恶性肿瘤患者全身热疗的麻醉处理

Anesthesia management of the patients with various malignancies undergoing whole body hyperthermia

晚期恶性肿瘤患者23例,ASAⅡ或Ⅲ级,在静脉全麻下采用红外线辐射体表加热实施全身热疗(WBH),包括升温期(食管下段温度达41．8℃)、恒温期(维持41．8℃恒温1 h)及降温期(开舱自然降温,体温降至38．5℃)。有创监测血液动力学、呼吸力学、肺氧合指标,测定电解质、血糖和尿量。升温期和恒温期心率、心脏指数、每搏指数、中心静脉压、平均肺动脉压、肺动脉楔压、肺内分流率和气道峰压升高,平均动脉压、动脉血二氧化碳分压、动脉血pH、BE、血钾和血糖下降,降温期逐渐恢复。恒温期和降温期低血压和肺水肿发生率较高。采用对循环干扰小的静脉复合全麻,有创监测血液动力学,呼吸支持,及时纠正内环境失衡,维持心肺功能稳定,保护重要脏器的功能,是WBH麻醉处理的关键。

Twenty-six total intravenous anesthesia was performed in 23 ASA Ⅱ or Ⅲ patients with various advanced malignancies undergoing whole body hyperthermia （WBH）. Their age ranged from 32 to 67 yrs and body weight between 42 and 77 kg. The patients had no hypertension, coronary artery disease or diabetes mellitus. Anesthesia was induced with midazolam 5-10 mg, fentanyl 0.1 mg, propofol 1.5-2.5 mg·kg^-1 and vecuronium 0.12 mg·kg^-1 and maintained with IV infusion of midazolam （0.08-0.16mg·kg^-1·h^-1 ）, remifentanil （0.05- 0.15μg·kg^-1·h^-1 ） and vecuronium （0.08-0.15mg·kg^-1·h^-1 ）. The patients were mechanically ventilated （VT = 8-12 ml·kg^-1 , RR = 10-18 bpm, FiO2 = 1.0） after tracheal intubation. PETCO2 was maintained at 35 mm Hg. ECG, MAP, HR, CVP, SpO2, PET CO2, peak airway pressure, VT, RR, minute ventilation （MV）, urine output, core temperature （lower esophageal and naso-pharyngeal ） and surface temperature were continuously monitored. Swan-Ganz catheter was placed in 15 patients. MPAP, PCWP and cardiac output （CO） were measured and Qs/Qt, cardiac index （CI） and stroke index （SI） were calculated. WBH was induced in an ultra-red radiation hyperthermic cabin （type ET-Space^TM-1 ） and was divided into 3 phases： Ⅰ warming phase （lower esophageal temperature increased gradually to 41.8℃ ）;Ⅱ hyperthermic phase （lower esophageal temperature was maintained at 41.8℃ for 1 h） and Ⅲ cooling phase （core temperature was gradually decreased to 38.5℃ without any cooling measures）. Blood samples were taken from artery and Swan-Ganz catheter 15 min after induction of anesthesia （baseline）, at 39℃ , 40℃ , 41℃ and 41.8℃ during warming phase, at the late hyperthermic phase and at 40℃ and 38.5℃ during cooling phase for blood gas analysis, determination of blood electrolytes and sugar. As the temperature was increasing, HR, CI, SI, CVP, MPAP, PCWP, Qs/Qt and peak airway pressure were gradually increased while MAP, PaO2, pHa, BE and blood glucose and K^＋ were decreasing during warming phase （ Ⅰ ）. These changes reached the peak levels at the late period of hyperthermic phase （ Ⅱ ） and then gradually returned to baseline during cooling phase （ Ⅲ ）. Vasoactive drugs and fluid infusion including crystalloid and colloid were needed to maintain hemodynamic stability in 69% patients. Acidosis had to be corrected in 54% patients. Severe hypotension and pulmonary edema occurred in 4 patients. Continuous hemodynamic monitoring, respiratory support, maintenance of circulatory stability and correction of acidosis and hypokalemia were the key factors in the management of patients during WBH.