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扩张型心肌病全心衰竭合并重度睡眠呼吸暂停综合征患者麻醉处理1例

2019-11-15 黄秀丽 崔旭蕾 广东医学

患者,男,57岁,因间断气短、憋气4年余,加重半年余于2015年4月入院。4年前诊断为扩张型心肌病、心力衰竭,本次入院诊断重度睡眠呼吸暂停综合征(OSAHS)。体格检查:听诊双肺呼吸音清,心界向左扩大,律不齐,心音低钝,心尖区可闻及2/6级收缩期杂音。

患者,男,57岁,因间断气短、憋气4年余,加重半年余于2015年4月入院。4年前诊断为扩张型心肌病、心力衰竭,本次入院诊断重度睡眠呼吸暂停综合征(OSAHS)。体格检查:听诊双肺呼吸音清,心界向左扩大,律不齐,心音低钝,心尖区可闻及2/6级收缩期杂音。
 
心电诊断:心率74次/min,心室内传导阻滞,QT间期延长(0.45s),ST-T段异常,QRS≥0.12s。胸片示:心影增大,双侧肺纹理增粗。心脏彩超:心肌病变(左室下壁、后壁、侧壁及心尖部心肌变薄无运动);全心增大;二尖瓣轻至中度关闭不全;左室收缩功能减低,EF:31%;中度肺动脉高压(65mmHg)。患者术前Cr、Urea、ALT均有不同程度的升高,考虑为心力衰竭导致的肝肾功能损伤所致。患者11d前曾尝试于局麻下行心脏再同步化并植入心脏复律除颤器(CRTD)术。
 
手术开始40min时患者因心力衰竭发作而终止手术。术后多科会诊,拟行再次手术,考虑到该患者清醒状态下难以耐受较长时间手术刺激,遂决定于全麻下完成再次CRTD术。患者此次入室后常规行血氧饱和度、心电图、无创血压监测,并迅速建立有创血压监测。血压112/70mmHg,心率81次/min,呼吸14次/min,SpO2 97%。给予面罩吸氧,床头高脚低15°角。依托咪酯0.15mg/kg,舒芬太尼0.15μg/kg,咪达唑仑3mg,罗库溴铵0.6mg/kg诱导。
 
患者入睡后,置入4#Supreme喉罩(LaryngealMask有限公司,马来西亚)。诱导后患者血压略有下降,予以去氧肾上腺素0.38μg/(kg·min)速度泵入,术中血压波动在80~100/50~60mmHg,心率波动在50~60次/min。术中靶控输注丙泊酚,设置血浆效应室浓度0.5μg/mL,同时给予顺式阿曲库铵5mg/h泵入,舒芬5μg间断静脉推注。手术时长160min,入晶体液700mL,手术结束5min自主呼吸完全恢复后拔除喉罩,15min后患者生命体征平稳返回病房。术后第4天出院。
 
讨论
 
中重度慢性心力衰竭的重要治疗手段之一是在最佳药物治疗的基础上行心脏再同步化治疗(CRT)或CRTD术。在45~90岁的人群中,年龄每增加10岁,心力衰竭的发病率会相应增加2倍。在老年慢性心力衰竭患者中,OSAHS的发生率高达60.3%。然而,关于心力衰竭合并OSAHS患者的麻醉却鲜有报道。
 
扩张型心肌病全心衰竭合并OSAHS患者麻醉风险极高。患者心功能失代偿,是心脏的极度高危状态,既要避免使用镇静、镇痛药时心肌抑制导致的低血压,同时还要避免交感神经兴奋、心肌耗氧增加导致急性心力衰竭。患者代偿能力差,应避免低氧血症和高碳酸血症。然而该患者存在明确的重度OSAHS,麻醉诱导及恢复过程极易出现缺氧而诱发心力衰竭。除患者自身因素外,CRTD术本身风险极高,易出现各种严重并发症,如冠状静脉窦夹层、穿孔、心包积血,严重心律失常等。故麻醉时应该充分考虑患者所面临的各种风险,加强监测,并与外科大夫进行良好沟通。
 
扩张型心肌病全心衰竭患者麻醉管理原则是保持心肌氧供和氧需之间的平衡。具体措施如下:(1)患者入室后,避免对其的各种刺激,操作前提前做好解释工作;术中预防血压剧烈波动,避免容量过负荷;(2)升压药首选去氧肾上腺素,升高血压同时反射性兴奋迷走神经,使心率减慢,从而降低心肌氧耗;(3)诱导用药选择对心血管功能影响轻微的依托咪酯,避免诱导期血流动力学剧烈波动;(4)选择起效快、镇痛作用强、对血流动力学影响小的舒芬太尼(与芬太尼相比)进行完善镇痛。OSAHS患者围术期最主要的风险是呼吸道梗阻导致的严重缺氧和二氧化碳蓄积,从而引起心脑等重要脏器损害,甚至死亡。
 
该类患者围术期管理要点如下:(1)术前采用无创正压通气治疗,纠正低氧血症改善重要脏器氧供,提高麻醉安全性;(2)重点评估困难气道的程度,精心设计气道管理方案,麻醉前准备好气道管理工具,并拟定备选方案;(3)避免过量应用阿片类药物和镇静药,以免发生过度镇静而致呼吸道梗阻;(4)术后严格掌握拔管指征,拔管前充分拮抗肌松,并常规做好再次插管的准备。
 
回顾文献,CRTD通常于局麻或镇静下完成,较少需要全麻。本例患者易紧张,第一次局麻下手术术中发生急性心衰。故此次麻醉应避免单纯局麻,而给予适当的镇静。然而患者存在明确的重度OSAHS,镇静麻醉状态下患者嗜睡易诱发气道梗阻、通气不足。因而,本例患者选择了全麻。全麻不仅为患者提供了完善的镇静、镇痛,降低患者术中应激;而且全麻下置入喉罩行机械通气可确保气道通畅,避免OSAHS患者单纯镇静下舌后坠引起的上气道梗阻,为手术创造了良好的条件。
 
该患者选择喉罩而非气管导管用于全麻术中通气的原因在于,相对于后者维持喉罩稳定所需的麻醉深度较浅,麻醉药量也较少;并且喉罩可显著减轻气管导管插、拔管期间所致的心血管反应,降低患者苏醒期躁动发生率,有利于患者平稳舒适苏醒,更适用于本例患者。此外,维持适宜的麻醉深度和完善的肌松对于该例患者术中管理也至关重要。
 
麻醉过深易致血压降低,影响心肌灌注。麻醉过浅或肌松不足可能会导致喉罩耐受不良,存在发生喉痉挛的潜在风险。本例患者因合并肝肾功能不全,术中肌松维持选择了主要经Hofmann清除而降解的顺式阿曲库铵,避免术毕肌松残余引起的拔管困难。综上所述,心力衰竭合并OSAHS患者若局麻无法满足CRTD术,可尝试行全身麻醉,但此类患者麻醉管理对于麻醉医生是一种挑战,尤其应注重麻醉个体化。此外,条件允许的情况可行麻醉深度及肌松监测,危重患者更需精准麻醉。
 
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  4. 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  5. 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time=2019-11-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1622420, encodeId=853016224201f, content=<a href='/topic/show?id=b9578094833' target=_blank style='color:#2F92EE;'>#肌病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=75, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80948, encryptionId=b9578094833, topicName=肌病)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Sun Nov 17 05:18:00 CST 2019, time=2019-11-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=375308, encodeId=b4d73e530889, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=107, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Fri Nov 15 20:50:27 CST 2019, time=2019-11-15, status=1, ipAttribution=)]
    2020-07-30 lsj637
  6. 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    2019-11-15 天地飞扬

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