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心功能III级扩心病患者腹腔镜胆囊摘除术麻醉处理一例

2018-10-29 方超 临床医药文献电子杂志

患者,女,58岁,体重55kg。因“阵发性胸闷气短4个月伴间断右上腹痛1个月”入院。胸部DR及核磁检查提示扩张型心肌病,胆囊多发结石,全心扩大,心胸比0.73。ECG检查提示窦性心律频发室早,st-t改变。超声所见:全心扩大,左室壁运动减低,双侧胸腔积液,胆囊结石,EF28%,左心室舒张末前后径64mm。心脏CT检查:冠状动脉粥样硬化。既往无家族史、无遗传史。实验室检查:NT—proBNP1547

患者,女,58岁,体重55kg。因“阵发性胸闷气短4个月伴间断右上腹痛1个月”入院。胸部DR及核磁检查提示扩张型心肌病,胆囊多发结石,全心扩大,心胸比0.73。ECG检查提示窦性心律频发室早,st-t改变。超声所见:全心扩大,左室壁运动减低,双侧胸腔积液,胆囊结石,EF28%,左心室舒张末前后径64mm。心脏CT检查:冠状动脉粥样硬化。既往无家族史、无遗传史。实验室检查:NT—proBNP1547pg/mL。

入院诊断为:①充血性心力衰竭、扩张型心肌病、心脏扩大、心功能III级;②胆囊结石伴胆囊炎,在心内科给予强心利尿扩血管抗心律失常治疗3周后,可以下地平走,无心衰症状。复查心脏超声:左心房室扩大、左心室壁运动减低、左心功能减低、EF32%。实验室检查:谷丙转氨酶53U/L,NT—proBNP298pg/mL,血尿常规、肾功、血糖、血脂、电解质等检查均正常。24小时动态心电检查窦性心律偶发室早。NYHA分级III级。后转入肝胆外科拟于全麻下腹腔镜摘除胆囊术。
 
患者入手术室后,局麻下行桡动脉穿刺监测有创BP155/95mmHg,HR101次/分,SpO2 95%。面罩吸氧,BIS监测,开放静脉通路,全麻诱导,静注地塞米松10mg,盐酸戊乙奎醚1mg,依托咪酯15mg,顺苯磺酸阿曲库铵12.5mg,舒芬太尼30ug,顺利气管插管,机械通气潮气量10mL/kg,频率12次/分,Paw17mmH2O,右颈内静脉穿刺置入中心静脉导管,CVP7mmHg,插管后患者血压105/72mmHg,HR75次/分,SpO2 100%,PETCO2 33mmHg。麻醉维持1.5%七氟醚持续吸入,顺苯磺酸阿曲库铵0.1mg/kg间断静脉推注,经中心静脉导管栗注丙泊酚3mg?kg-1?h-1、瑞芬太尼2ug.kg-1·min-1。气腹后,BP升高190/105mmHg,HR77次/分,PETCO2 45mmHg,Paw27mmH2O,BIS值50。患者ECG开始出现频发室早二联律,马上加深麻醉,效果不明显,急查血气,各项指标在正常范围。给予乌拉地尔5mg,利多卡因100mg,BP恢复到140/80mmHg,心律恢复到正常节律。手术历时1.5小时,术中晶体液400mL,胶体液300mL,失血100mL,尿量300mL。术后生命体征平稳,拔出气管插管,送回病房。
 
讨论:
 
扩张性心肌病(DCM)是一种比较常见的心肌疾病,其病程具有进展性,常伴发心脏电生理改变,并继发左室形态和功能的持续改变。DCM见于双心室扩张主要见于左心房室扩张为主并且收缩功能减低,主要表现为进行性心力衰竭、恶性心律失常、血栓栓塞、心脏骤停、猝死。扩张性心肌病在病理上来说心肌细胞肥大,细胞核变异,心内膜中胶原纤维以及弹性纤维增加,心肌细胞产生一系列不可逆的改变。
 
临床上,扩张性心肌病的发病率逐年上升,发病到一定阶段,患者会出现心力衰竭,对患者的生命安全构成了严重的威胁,不利于患者的预后。几乎所有心脏病在其发展的过程中,当心脏超负荷工作达到一定程度,进人失代偿的阶段,心力衰竭是其必然发展的一个过程。对于扩张性心肌病来说,双心室扩大、充血性心力衰竭、心律失常这些临床症状是必然显现的,对于扩张性心肌病的治疗,主要目的是对心力衰竭进行控制,并对心功能进行改善。临床治疗需要结合患者的实际情况落实到综合治疗,从而提高患者的生存率。
 
近年来,随着腹腔镜技术的发展,手术指征的逐渐扩大,越来越多的患者接受腹腔镜手术,并且对于手术后的疗效给予认可。手术中的气腹对于手术中血流动力学的影响,也引起了一些学者的关注。理论上讲,腹内高压情况下,机体心率(HR)代偿性加快、心舒张期缩短和CO减少等因素,均会导致心肌血供受损。气腹对于机体血管系统的影响机制十分复杂,如果身体状况良好的病人,一般来说是可以耐受的,而对于术前有心力衰竭的患者来说,则会造成急性心力衰竭和恶性心律失常。因此气腹压应尽量控制在合理水平,当患者血流动力学难以控制的时候,应放弃气腹,开腹完成手术。
 
术前评估:该患者既患有心脏病又伴有胆囊疾病,这一类病人属于心脏病病人行非心脏手术,麻醉与手术并发症及死亡率会明显高于无心脏病患者。这是由于麻醉和手术可以影响心脏功能与血流动力学,患者自身的心脏功能储备较差,经过手术和麻醉的双重打击,会进一步加重心血管系统负担。这些不但影响着手术后的恢复,而且还会影响着术后1-2年甚至更长时间的转归。对于这种术前已有心功能不全表现的患者,手术中是极易发生心律失常和心力衰竭,必要时可以给予强心、利尿、扩血管药物治疗。
 
术前患有心力衰竭患者,经过一段时间治疗,麻醉医生访视患者对于心功能的评估,看是否符合麻醉适应症,这显得尤为重要。扩心病患者心功能的评估主要依据MRI、心脏彩超、BNP、临床症状改善。因要求患者尽量减少下地走动,未做步行6分钟试验检测。MRI对于患者术前心功能的评估,具有独特的优势,它能在病人静息的状态下进行检查,无辐射,而且可以评估DCM病人心肌组织纤维化的程度以及心脏形态、功能、心肌灌注的改变。MRI对于早期明确心脏功能是否失调可以避免心室重构给病人带来的风险,有着十分重要的价值。
 
B型脑钠肽(BNP)释放与心室容积扩张和心室压力超负荷直接相关,可反映患者心功能受损情况,是心室功能障碍时特异且敏感的检测指标。B型脑钠肽的检测应用于心力衰竭的诊断及疗效评估,其时效性与准确性已被重视与认可。BNP已经被广泛用于高危患者心功能的评估。
 
心脏彩超是目前临床上应用较多的检查方法,它是目前临床唯一一种可直观、动态显示患者心脏内结构、血流状况的无创检查仪器,其结合患者的心功能分级情况则可有效反应患者病情进展程度,对于心力衰竭诊断准确性具有重要意义。
 
麻醉前准备:患者人手术室之后,常规检测ECG、SpO2,面罩吸氧,有创动脉监测,深静脉置人监测CVP,术中给予BIS监测,必要时TEE监测心功能,麻醉前做好充分准备,备好抢救药品和血管活性药物,术中尽量维持患者血流动力学平稳。
 
麻醉方式选择,对于术前心功能不全的扩心病患者腹腔镜手术尽量考虑全身麻醉,全麻对于患者术中麻醉效果确切,生命体征平稳便于控制,可以消除患者紧张情绪,可以抑制住患者应激反应,方便术者操作,充分保证氧合,减少心律失常和低血压的发生。
 
综上所述,患有心力衰竭症状的扩心病患者腹腔镜手术对于术前心功能的评估,适当的麻醉方式,严密的监测手段,气腹情况下维持稳定的血流动力学,可以保证扩心病患者腹腔镜患者术中麻醉的安全。
 
原始出处:

方超. 心功能III级扩心病患者腹腔镜胆囊摘除术麻醉处理一例[J]. 临床医药文献电子杂志, 2017, 4(4).

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    2019-07-11 楚钟
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    2019-08-15 juliusluan78
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    2018-10-29 changjiu

    学习一下,谢谢分享。

    0

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    2018-10-29 医者仁心5538

    学习了

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