微创非体外循环下冠状动脉旁路移植术的麻醉管理

摘要

Objective To summarize our experience of anesthetic management in patients undergoing video-assisted coronary artery bypass grafting (VACAB). Methods Totally 15 patients, who were undergoing VACAB, were given combined intravenous and inhalation anesthesia with a double-lumen endobronchial tube. All the patients were monitored with a FloTrac/Vigileo system. Hemodynamic data including cardiac index (CI) and stroke volume variability (SVV) were recorded. One lung ventilation (OLV) was used during the internal mammary artery (IMA) harvesting with video-assisted thoracoscopy and subsequent vascular anastomosis. Results The total operation time was (247.4 ±44. 1 ) min. The IMA harvesting time and OLV time were (70. 5 ± 13. 3) min and (185.2 ±29.5) min, respectively. The volume of autologous packed red blood cells reabsorbed intraoperatively was (110.3 ±25.6) ml and the volume of blood loss was (238. 7 ± 50. 1 ) ml. No patient received allogeneic blood transfusion. CI in T1 and T2 were (2. 4 ±0.3) L · min-1 · m-2 and (2. 9 ± 0. 6) L · min-1 · m-2 , respectively (t =6. 220, P =0.000) . SVV in T1 and T2 were (17.0 ±3.5) % and (12.3 ±2.6) % (t = -10.540, P =0.000). SpO2 dropped in 3 patients at the beginning of OLV, and then recovered after blowing oxygen into the left lung and adding 5 cm H2O positive end-expiratory presure ( PEEP) in the right lung. The patients were extubated (6.9 ±3. 5) h after operation in the ICU. All the patients were discharged from hospital and the length of stay was (7. 2 ±2. 3) d. There were no anesthesia-related complications occurred perioperatively. Conclusions Special attention should be paid to the particularity of circulatory and respiratory management during VACAB. Good hemodynamic stability and oxygen delivery consumption balance during OLV are necessary to ensure the perioperative safety of the patients.%目的 总结胸腔镜辅助下小切口非体外循环冠状动脉旁路移植术(video-assisted coronary artery bypass grafting,VACAB)的麻醉处理经验. 方法 2012年2～11月15例接受VACAB,采用双腔支气管内插管静吸复合全麻,术中采用FloTrac/Vigileo监护仪监测心脏指数(cardiac index,Ci)和每搏量变异度(stroke volume variation,SVV)等指标.胸腔镜辅助下获取乳内动脉(internal mammary artery,IMA)以及行血管吻合时,采取右侧单肺通气(one-lung ventilation,OLV). 结果 手术时间(247.4±44.1)min,其中游离IMA时间为(70.5±13.3)min,OLV时间为(185.2±29.5)min.术中回收自体浓缩红细胞(110.3 ±25.6)ml,术中出血量(238.7±50.1)ml,术中均未使用库血.T1时点(胸腔镜辅助下获取IMA时)和T2时点(关胸时)CI分别为(2.4±0.3)L·min-1·m-2和(2.9±0.6)L.min-1·m-2,二者比较有统计学差异(t =6.220,P=0.000)；T1时点和T2时点SVV分别为(17.0±3.5)％和(12.3±2.6)％,二者比较有显著性差异(t=-10.540,P=0.000).3例在OLV刚开始时出现Sp02下降,经左肺持续吹入氧气2 L/min及右肺加用5 cmH2O呼气末正压通气等处理后Sp02升至97％以上.在ICU的带管时间为(6.9±3.5)h.全部患者均顺利出院,住院时间(7.2士2.3)d,围术期无麻醉相关并发症. 结论 充分重视胸腔镜下手术时循环和呼吸管理的特殊性,维护好OLV期间血流动力学平稳和氧供需平衡,以保证患者围术期安全.