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强直性脊柱炎极重度脊柱后凸畸形折叠人麻醉管理一例

2020-03-19 MedSci原创 MedSci原创

患者,男,36岁,ASAⅢ级,Mallampati IV级,因“双膝、双髋、腰背痛20余年,脊柱后凸伴活动障碍16年,身体屈曲折叠4年”入院。拟在全身麻醉下行“脊柱

患者,男,36岁,ASAⅢ级,Mallampati IV级,因“双膝、双髋、腰背痛20余年,脊柱后凸伴活动障碍16年,身体屈曲折叠4年”入院。拟在全身麻醉下行“脊柱后路截骨矫形植骨融合椎弓根螺钉内固定术”。术前体格检查:身高66 cm,臂展175 cm,体重35.5kg,呈胸腰背部过伸度屈曲体位,头部埋于双膝之间(图1),心肺听诊未闻及异常。下颌关节前伸受限,头颈活动受限,开口度约两横指,屏气试验约60s。
 
图1 患者术前全身照和影像图。注:A,患者全身照;B,患者冠状位CT图像;C,患者侧位X光片;D,患者三维重建图像
 
肺功能提示:极重度混合性通气功能障碍,大、小气道气流重度受阻,气道阻力异常增高,气道传导下降,重度肺气肿,弥散功能、通气储备功能重度降低,肺功能极重度受损。血常规提示轻度贫血,凝血常规正常,ECG正常。患者入室后常规监测HR、NIBP、SpO2及体温。术前NIBP130/80mmHg,HR80次/分,SpO2 99%。静脉给予患者戊乙奎醚0.3mg、甲基强的松龙40mg、羟考酮3mg,同时10min内静脉泵注右美托咪定负荷量0.5μg/kg,维持量0.2μg·kg-1·h-1。因患者右膝阻挡,故于患者左侧行超声引导下颈内静脉穿刺置管。同时行左桡动脉穿刺置管,行脉博轮廓连续心排量(pluse indicator continous cardiac output,PICCO)监测。
 
口咽部及环甲膜穿刺以1%丁卡因表面麻醉后,经纤维支气管镜引导下行气管插管,VT300~340ml,RR18~22次/分,新鲜气流量2L/min,FiO2 50%,维持PETCO2 35~45mmHg。麻醉维持为血浆靶控输注丙泊酚、瑞芬太尼及维持剂量右美托咪定,维持BIS值50~60,根据PICCO监测进行液体治疗及给予血管活性药物,采用保温毯对患者进行加温治疗,维持膀胱温36.0~37.0℃。同时监测患者体感诱发电位(SEP)及运动诱发电位(MEP)。
 
术中采用回收式自体输血治疗。手术采用侧卧位进行。当手术主要步骤结束后开始唤醒,此时停止输注丙泊酚及瑞芬太尼,仅静脉以右美托咪定维持。待BIS>75后进行唤醒,患者根据指令准确活动双下肢,唤醒时间约15min。术中总出血量4000ml、尿量900ml,输入晶体液2750ml,胶体液1100ml,红细胞14.5U,新鲜血浆900ml,自体血400ml。手术时间约330min,麻醉时间约460min,术中切口长约30 cm。
 
手术结束12min,患者恢复自主呼吸,30min意识、肌张力均恢复正常,40min拔除气管导管。术后给予患者静脉自控镇痛:羟考酮50mg+托烷司琼10mg+生理盐水100ml,无背景剂量,单次注射量4ml,锁定时间5min,4h锁定量20ml。
 
讨论
 
强直性脊柱炎(ankylosing spondylitis,AS)是一种以中轴关节慢性炎症为主要病变的慢性进展性风湿疾病。其特征为肌腱、韧带附着点风湿样改变,随着病情进展炎性病变由关节韧带逐步蔓延至关节,最终导致骨性强直,脊柱前屈、后伸、侧弯或旋转活动受限,晚期合并严重的脊柱胸腰椎后凸畸形,严重影响患者生活质量。对于AS患者的术前需要详细的病史采集和体格检查,评估重要脏器的功能,了解手术方式。
 
该例围术期麻醉管理总结经验如下:
 
(1)该患者入院后进行了长达6个月的术前准备工作,包括:逐日增加平地运动时间,吹气球训练,服用本院配置的营养套餐等,到术前1周,患者与入院时比较,体重已由30kg增加至35.5kg;
 
(2)在术前1d进行超声引导下颈内静脉穿刺,由于患者的双侧股静脉及右颈内静脉均无法暴露,仅左侧颈部可以暴露,但是超声探头的放置和穿刺针的进针方向均受限,第1次穿刺误伤动脉而失败,1周后第2次做了穿刺的改进:①放弃ARROW的穿刺针,改用20G的血管穿刺针,便于置管;②使用压力延长管接在穿刺针后再带注射器,避免穿刺针直接连接注射器而影响进针方向;③使用新生儿穿刺套件内的细钢丝作为引导导丝;④针对非血管正上方、斜轴的超声引导,穿刺前做了三维结构图并确定了穿刺点和进针角度,第2次穿刺顺利成功;
 
(3)右美托咪定+羟考酮程序镇静镇痛下配合表面麻醉纤支镜引导下气管插管,临床效果满意;
 
(4)术中监测包括有创动脉血压、心排量、每搏变异度、膀胱温、麻醉深度、体感诱发电位及运动诱发电位等,术中备两个体表加温仪及自体血回收机;
 
(5)全凭静脉麻醉避免恶性高热;
 
(6)靶控输注丙泊酚和瑞芬太尼维持麻醉保证唤醒质量;
 
(7)患者体重低,手术时间长,失血量较多,术前备血充分,术中备好血管活性药及抢救药,积极成分输血,术中监测凝血功能;
 
(8)唤醒过程,停用丙泊酚及瑞芬太尼,仅以右美托咪定维持,待BIS>75即可唤醒;
 
(9)严格计算麻醉药的用量,术后积极拔除气管导管。

综上所述,极重度脊柱畸形矫形手术的麻醉管理是一项极具挑战性的工作,术前详细的麻醉计划、术中全面的监测和调控以及必要的临床技能改进都是必不可少的。

 
原始出处:
 
李强,陈涛,周莹,张健,郑传东.强直性脊柱炎极重度脊柱后凸畸形折叠人麻醉管理一例[J].临床麻醉学杂志,2019(03):310-311.

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    2021-02-26 zywlvao
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