宫腔镜手术中血流动力学变化对循环气栓的预测价值

摘要

目的：探讨宫腔镜手术中血流动力学变化对循环气体栓子（气栓）的预测价值。方法择期全身麻醉下行宫腔镜手术的患者120例，其中宫腔粘连41例、子宫内膜息肉35例、子宫黏膜下肌瘤28例、子宫纵膈9例、胚物残留7例。术中用彩色多普勒超声持续监测患者髂总静脉、上、下腔静脉及心脏中气栓的发生情况。无创血流动力学监测仪连续监测血流动力学指标；多功能监护仪监测ECG、SpO2、PET CO2。记录手术时间、出血量、气栓出现时间、气栓高峰时间及气栓高峰时间HR上升（较基础值升高30％或＞120次/min）、PET CO2下降（较基础值降低10％或降低≥3 mmHg）情况。记录气栓出现时（ T1）、气栓高峰（ T2）、HR上升时（ T3）、PET CO2下降时（ T4）、气栓消失时（T5）的HR、MAP、SpO2、PETCO2、SV/SVI、CO/CI、SVR/SVRI、TFC、VI、ACI、PEP、LVET、STR、LCW/LCWI。观察手术并发症发生情况。结果超声监测显示120例术中有76例（63．3％）无气栓出现（A组），44例（36．7％）出现气栓，其中少量气栓（B组）27例（22．5％），中量气栓（C组）10例（8．3％），大量气栓（D组）7例（5．8％）。 D组手术时间、出血量高于其他三组（P均＜0．05）。各组气栓出现时间、HR上升情况、PET CO2下降情况、MBP、SpO2、PET CO2、SV/SVI、CO/CI、SVR/SVRI、TFC、VI、ACI、PEP、LVET、STR、LCW/LCWI差异无统计学意义。对出现气栓患者予暂停手术、头低左侧卧及对症处理。120例患者未出现气体栓塞导致的死亡或伤残。结论超声监测可及时发现宫腔镜手术中循环气栓，无创血流动力学监测对气栓发生的诊断无明显特异性。%Objective To explore the value of noninvasive hemodynamic monitoring in predicting the gas embolus dur -ing hysteroscopic surgery .Methods A total of 120 patients, undergoing hysteroscopic surgery under general anesthesia were involved in this study (41 intrauterine adhesion , 35 endometrial polyp , 28 submucous uterine myoma , 9 uterus medi-astinum , 7 trophoblastic residual ) .Gas embolus in the common iliac vein , superior vena cava , inferior vena cava and heart cardiac were continuously monitored by using color Doppler ultrasonic imaging .The haemodynamic indexes were monitored by noninvasive hemodynamic monitoring.ECG, SpO2, PET CO2 were monitored as well.The operation time, blood loss, the appearance time of gas embolus , the appearance time of highest gas embolus and then the change of HR ( when HR >120 bpm or increased 30%compared with baseline ), PETCO2(when it was reduced more than10%compared with baseline or 3 mmHg) were recorded.The HR, MBP, SpO2 , PET CO2 , SV/SVI, CO/CI, SVR/SVRI, TFC, VI, ACI, PEP, LVET, STR, LCW/LCWI were recorded when appearance of the gas embolus (T1), the highest gas embolus appeared (T2), and the HR rise(T3), and when the PETCO2 decline (T4),the gas embolus disappeared(T5).Results Gas embo-lus donn't appeared(group A) in 76 patients of all the 120(63.3%).Gas embolus appeared in 44 patients(36.7%).A small number of gas embolus occurred in 27 cases(group B, 22.5%).A moderate number of gas embolus occurred in 10 cases(group C, 8.3%).A large number of gas embolus occurred in 7 cases(group D, 5.8%).The blood loss and opera-tion time of group D were significantly higher than the other groups (all P<0.05).There was no statistical differences in four groups at the appearance time of gas embolus , HR, PET CO2 , MBP, SpO2 , PET CO2 , SV/SVI, CO/CI, SVR/SVRI, TFC, VI, ACI, PEP, LVET, STR, LCW/LCWI.When the patients developed gas embolus , the operation were suspend , simultaneously, the left-Rlateral and head-Rdown position should be taken to avoid serious complications ( dead or disabli-ty) because of gas embolism .Conclusion There were no value of noninvasive hemodynamic monitoring in predicting the gas embolus during hysteroscopic surgery .But the ultrasonography can monitoring the gas embolus during hysteroscopic sur -gery immediately.