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胆道镜下钬激光碎石术治疗复杂肝内胆管结石麻醉误吸1例

2018-04-17 陈佩军 陈亚男 何海平 南京医科大学学报

患者,女,58岁,体重60kg,身高150cm,因“胆总管结石术后结石残留”入院

【一般资料】

患者,女,58岁,体重60kg,身高150cm,

【主诉】

因“胆总管结石术后结石残留”入院

【现病史】

,B超、CT提示:左肝管结石。患者4个月前曾行“腹腔镜下胆囊切除术、胆总管切开取石术及T管引流术”,术后3个月内有2次“经腹壁窦道胆道镜下取石术”史。

【既往史】

既往体健,一般情况尚可,1周前患“上呼吸道感染”,未作治疗,目前偶有咳嗽,无咳痰,无畏寒和发热。

【体格检查】

术前各项常规检查基本正常。

【治疗】

拟在全身麻醉下行“胆道镜下钬激光碎石取石术”,术前禁食8h、禁饮6h。患者上午8:30入室,体温36.5℃、心率90次/min、呼吸15次/min、血压147/85mmHg,SpO295%,心电监护。9:00静脉依次推注咪唑安定2mg、芬太尼0.2mg、丙泊酚120mg、顺式阿曲库铵10mg诱导,顺利置入4号喉罩。胸廓起伏良好,无气体从口咽部漏出,呼气末二氧化碳波形图正常,气道峰压在正常范围,听诊双肺呼吸音清晰对称,固定喉罩,连接麻醉机行机械通气。潮气量450mL、呼吸频率12次/min、气道峰压12cmH2O、呼气末二氧化碳36mmHg,全程2%七氟烷吸入,持续静脉泵注顺式阿曲库铵维持全麻。9:20手术开始,10:55结束,共95min,胆道镜顺腹壁窦道进入胆总管,查无结石,逐级检查肝内胆管,在左肝管Ⅱ级分支处有两处结石嵌顿,尝试取石篮取石未果。使用德国Lumenis公司钬激光器(Holmium),输出功率1.5~3.0W,脉冲能量1.5J/P(焦耳/脉冲),脉冲率10P/s(脉冲/s),光纤对准结石中心接触照射碎石,直至结石碎裂变小,用取石篮分次取出稍大结石,小的碎石采用高压泵冲洗,由窦道处冲出,最后检查上下胆管通畅,仅少量小结石残留,重新置入T型引流管并固定,外接引流袋。术中无明显手术出血,灌洗生理盐水用量达3000mL。术毕前10min,停麻醉,术毕5min,患者有皱眉和吞咽反应,同时见患者鼻腔、口腔涌出大量微浑浊液体,气道峰值压报警,立即将患者头偏向一侧,并置于头低位,液体涌出速度加快,充分吸引口腔内反流液。立即静脉推注丙泊酚、顺式阿曲库铵,助手按压患者环状软骨(Sellick手法),拔除喉罩,尽可能“吸净”口腔内残留液体后,插入管腔内径7.0mm气管导管,经气管导管吸引出少许微浑浊液体后,进行机械通气,潮气量480mL、呼吸频率12次/min,经右鼻孔留置胃管,连接胃肠减压器。听诊满肺哮鸣音,气道峰压28~30cmH2O,静注150mg氢化可的松,氨茶碱0.25mg/h持续泵注,同时经气管导管依次揿入沙丁胺醇、异丙托溴铵、布地奈德气雾剂,纤支镜下见支气管黏膜轻度水肿,未见明显误吸物,增加呼气末正压通气5cmH2O保持气道内正压,防止肺不张。肺部哮鸣音略微减轻,气道峰压28cmH2O,静注甲强龙40mg,经气管导管再次揿入沙丁胺醇、异丙托溴铵、布地奈德气雾剂。为降低和预防误吸造成的后果,静脉滴注左氧氟沙星0.3g(患者术前未行头孢类抗生素皮试),氨溴索60mg静脉滴注祛痰,奥美拉唑40mg保护胃黏膜。查血气分析:pH7.35、PaCO249.5mmHg、PaO2129.6mmHg、Lac1.0mmol/L、BE0.56mmol/L。肺部听诊呼吸音粗,仅两下肺稍许散在哮鸣音,患者逐步清醒,能配合医生做眨眼、握拳等动作,自主呼吸潮气量400mL左右,呼吸频率15次/min左右,准备拔管。清除口腔内分泌物后,拔除气管导管,嘱患者深吸气,经口依次揿入沙丁胺醇、异丙托溴铵、布地奈德气雾剂,面罩供氧,肺部听诊同拔管前。协助患者取坐位,拍背嘱其咳嗽排痰,咳出少许白黏痰,拍背咳嗽3次后取平卧位,观察30min,患者无明显呼吸困难及其他不适,吸空气下指端SPO295%~96%,肺部听诊同前,遂护送至病房。术后继续全身抗炎解痉、气道雾化吸入、拍背排痰及对症处理,连续3d观察无发热、呼吸困难等症状,肺部听诊呼吸音略粗,无明显干湿啰音,术后第5天出院,随访无不适。

【讨论】

本病例是典型的术中反流误吸案例。术中发生反流误吸有5个条件:①饱胃(有食物或液体);②食道括约肌松弛,胃内容物反流到口腔;③吞咽反射受到抑制,不能将反流的胃内容物咽回消化道;④人工呼吸将食物(胃液)挤入呼吸道内;⑤不能立刻将异物咳嗽清理出呼吸道(咳嗽反射)。麻醉过程中是否发生反流,主要取决于胃与咽喉部之间的压力差,本病例患者处于全身麻醉下,吞咽和咳嗽反射抑制,贲门括约肌松弛,胃肠蠕动减弱,胃内容物极易反流进入口腔和气道。3000mL的高压冲洗液(周东海等建议手术冲洗液不超过2000mL),一部分经窦道流出体外,一部分经十二指肠大乳头进入肠腔,当冲洗的速度和压力远远超过患者肠腔蠕动排泄能力时,冲洗液便逆流至胃形成“饱胃”,再逆流至食道、口腔、鼻腔。当麻醉减浅,患者吞咽反射开始恢复时,胃内容物便从移位的喉罩,借助机械正压通气,挤入气道。麻醉方式选择不当。胆道镜下钬激光碎石术治疗复杂肝内胆管结石麻醉为我院首例手术,尽管由富有胆道镜操作经验的普外科医生和熟练掌握钬激光使用技术的泌尿外科医生联合手术,但均缺乏此类手术经验,本例复杂肝内胆管结石嵌顿难取,手术时间长,冲洗液量明显偏大。麻醉医生没有意识到该病例极易发生术中反流误吸风险,仅仅考虑到患者近期有上呼吸道感染可能,为尽量减少气道高反应性,错误地选择了喉罩通气方式,造成了误吸的发生,而应用喉罩患者的胃内容物反流发生率可高达33%。围术期误吸胃内容物会引起严重的Mendelson综合征,患者迅速出现心率加快、血压下降、呼吸困难、甚至肺水肿和ARDS,病死率超过5%。尽管误吸物中含有胃液,但其已被大量冲洗液稀释,盐酸浓度大大降低,pH值增高,误吸后的严重程度相对减轻(术中纤支镜下仅见支气管黏膜轻度水肿,未见明显误吸物),加上处理及时,包括:体位引流、吸引、插管、药物治疗等。术中适当增大呼气末正压通气参数值,充分清醒后拔管,鼓励患者咳嗽,最大程度地减少肺不张的可能。β2肾上腺素能受体激动剂、抗胆碱能药物和糖皮质激素的应用,旨在达到局部抗炎、减少渗出、扩张支气管、降低气道高反应性的作用,具有起效快、用药量少、局部药物浓度高、全身不良反应少等优点。另外,采取小剂量激素全身治疗抑制肺部炎症反应,减轻肺损伤,同时早期给予抗生素预防感染。尽管本次医源性误吸未对患者造成明显不良后果,但延长了患者住院时间,增加了住院费用。对于围术期可能发生误吸的高危因素(急诊手术、困难气道、麻醉深度不足、截石位、自主神经病、胰岛素依赖型糖尿病、妊娠、情绪低落、肥胖等),麻醉医生应:①高度重视,以预防为主;②术前充分评估误吸的风险,可借助B超测量胃窦部的横截面积(crosssectionalarea,CSA)评估胃内容物;③高反流、误吸风险患者,术前行胃肠减压;④采取抗反流的麻醉诱导方法;⑤熟练掌握预防和处理误吸的方法,尽量避免严重并发症的发生。

原始出处:

陈佩军, 陈亚男, 何海平,等. 胆道镜下钬激光碎石术治疗复杂肝内胆管结石麻醉误吸1例[J]. 南京医科大学学报, 2017(11):1541-1542.

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    2018-04-19 oliver169
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    2018-04-18 青山颖钰

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