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常温非心肺转流下全胸腹主动脉置换术麻醉处理一例

2019-01-15 方斌 李金宝 黄施伟 临床麻醉学杂志

患者,男,33岁,183 cm,86kg,4年前因主动脉夹层行升主动脉及主动脉瓣置换术、主动脉弓支架植入术,术后恢复良好。3个月前复查血管造影提示“胸腹主动脉夹层(Debakey Ⅲ型)”,近1个月来BP明显波动,入院拟行手术治疗。术前检查:ECG:窦性心律;心脏超声:EF71%。术前1d行L2~3蛛网膜下腔穿刺置管,用于术中脑脊液测压及引流。

患者,男,33岁,183 cm,86kg,4年前因主动脉夹层行升主动脉及主动脉瓣置换术、主动脉弓支架植入术,术后恢复良好。3个月前复查血管造影提示“胸腹主动脉夹层(Debakey Ⅲ型)”,近1个月来BP明显波动,入院拟行手术治疗。术前检查:ECG:窦性心律;心脏超声:EF71%。术前1d行L2~3蛛网膜下腔穿刺置管,用于术中脑脊液测压及引流。
 
置管后2h患者出现头痛伴发热(耳温38.5℃),无头晕呕吐等不适,无颈项强直,脑脊液常规示:WBC12×109/L。予拔除导管,抗炎治疗。3d后体温恢复正常。放弃置管。入室后心电监护,静注咪达唑仑1mg、舒芬太尼5μg镇静。局麻下右桡动脉、右足背动脉穿刺测压。
 
全麻诱导:咪达唑仑5mg、舒芬太尼70μg、丙泊酚70mg、哌库溴铵10mg,插入双腔气管导管。右颈内静脉穿刺,测鼻咽温,贴体外除颤电极片。术中采用血液回收技术:手术视野出血吸至储血机,适时经股动脉回输。麻醉维持采用持续吸入七氟醚,间断静注咪达唑仑3mg、舒芬太尼10~20μg、哌库溴铵2mg。
 
手术步骤与麻醉调控:(1)肝素化后将四分叉人工血管中的两支分别与双侧髂动脉端-侧吻合。(2)左进胸后,右侧单肺通气。自然降温至浅低体温水平(鼻咽温34.6~35.0℃)。静注甲强龙40mg,静滴20%甘露醇250ml。硝普钠泵注降压至80/50mmHg后阻断降主动脉,将人工血管主干与降主动脉近心端行端-端吻合。阻断后BP最高升至173/85mmHg,间断静注佩尔地平0.5mg,BP控制在130~100/70~55mmHg,开放前静滴5%碳酸氢钠100ml纠正酸中毒,17min后近端阻断钳缓慢开放,同时予股动脉灌注及静脉补液扩容,BP最低降至82/42mmHg。(3)远端阻断钳移至腹腔干上方,修整肋间动脉开口及周围外膜,与人工血管一分支行端-侧吻合,阻断37min(即脊髓缺血37min)。(4)将阻断钳下移至肾动脉下方,将腹腔干动脉、肠系膜上动脉、右肾动脉开口的腹主动脉壁游离,与人工血管远端行端-端吻合,左肾动脉与人工血管一分支行端-端吻合,左侧副肾动脉与右髂总动脉的人工血管行端-侧吻合,肾动脉下3 cm处缝闭腹主动脉断端。开放左肾动脉后静注呋塞米20mg。腹腔脏器及右肾缺血47min,左肾缺血63min。(5)血管吻合完毕,鱼精蛋白中和肝素。
 
改用普通血液回收机,共回输1700ml自体血。维持鼻咽温在35.3~35.8℃。输血小板2U、冷沉淀20U、血浆14U、人纤维蛋白原2g、人凝血酶原复合物1200IU加强凝血,输红细胞7U纠正贫血。术中失血约3500ml,共输晶体液3900ml、胶体液2000ml,尿量2500ml。
 
出室前动脉血气:pH7.43,K+3.72mmol/L,Hb 96g/L,BE3.1mmol/L。手术时间12h,安送ICU。次日上午自主呼吸恢复较好,神志清醒,血流动力学平稳,遂拔除气管导管,无截瘫、术后认知功能障碍、肾功能障碍等并发症,术后3周痊愈出院。
 
讨论 
 
胸腹主动脉瘤具有潜在破裂风险,手术是唯一的有效治疗方式。常温非心肺转流(CPB)下行全胸腹主动脉置换术可明显缩短手术时间、拔管时间及住院时间,同时减少术中出血量、血制品用量及术后并发症。截瘫是此手术的严重并发症,脑脊液测压引流能有效降低其发生率。
 
本例患者置管后出现发热,遂放弃。术中采用浅低体温,输注甲强龙、甘露醇,维持血流动力学平稳,控制适当的血容量,以保护脊髓、肾脏等重要脏器功能。术中阻断与开放主动脉时会出现剧烈的血压波动,即(1)阻断期间血压升高、心率减慢。此期心脏后负荷增加导致左室充盈压及左室舒张末容积明显增加;阻断后会引起静脉弹性回缩和儿茶酚胺的释放,使阻断部位以下静脉回心血量增加,心脏前负荷亦增加。因此,阻断前须做好降压准备:限制液体入量、加深麻醉、使用血管扩张药。(2)开放后外周血管阻力降低和血压下降,血容量严重不足。此期左室后负荷降低,阻断平面以下血管缺血性扩张,血管平滑肌暂时性麻痹,同时大量酸性代谢产物入血,使静脉回心血管减少,心输出量降低,进一步加重低血压,甚至出现“松钳性休克”。
 
开放前停用降压药,备好血管活性药物,提醒术者开放时缓慢松钳。全胸腹动脉置换采取分段阻断置换,需多次夹闭及开放主动脉,除非血压过低或低血压持续时间过长,应避免应用大剂量的血管收缩药,以防止再次钳闭动脉时出现“反跳性”高血压。开放后低血压的处理应首先补充血容量,本例静脉快速补液联合股动脉灌注可迅速补充血容量,效果满意。
 
原始出处:

方斌,李金宝,黄施伟,唐李隽.常温非心肺转流下全胸腹主动脉置换术麻醉处理一例[J].临床麻醉学杂志,2018,34(05):520.

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    2019-03-09 yxch48
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    2019-03-20 aids222
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