高龄危重患者手术麻醉方法和管理

Anesthesia and perioperative management of very old patients undergoing major operation

目的探讨合并多个脏器功能异常、年龄逾90岁患者手术麻醉方法和管理的特点。方法总结近3年年龄超过90岁手术患者16例次，其中开腹手术6例次，人工髋关节置换术10例次，术前依据病史有针对性检查各重要脏器的功能，并作相应的积极准备，依手术种类和病情特点选择麻醉方法，应用Hemosonic TM100食道超声多普勒监测血流动力学、A-Line自动回归指数（AAL）监测麻醉深度以及4个成串刺激（TOF）指导追加肌肉松弛剂。结果全组患者术前均伴有2～4个脏器功能异常，且以循环、呼吸和内分泌系统改变较为常见；控制血压、营养心肌、抗心律失常、降血糖和抗感染是术前准备常用且有效的方法；开腹手术以全麻为主，追加维库溴铵间隔时间（87±16）min；人工髋关节置换术全部选择硬膜外阻滞，首次剂量1％利多卡因（7．6±0．9）ml，追加间隔时间（63±17）min。用6％羟乙基淀粉按10ml／kg静输后15min，患者每搏输出量、心输出量、心脏指数和主动脉内血流量（ABF）均分别较扩容前平均增加17％、11％、14％和15％，外周血管阻力和心率分别下降16％和9．6％。术中维持AAI 50～60，术毕出现咳嗽（吞咽）和清醒应答时AAI分别为73±9．4和81±7．3，随访术后无知晓。结论重视术前准备和术中监测；硬膜外阻滞应选用低浓度、小容量局麻药，6％羟乙基淀粉适合用于人工髋关节置换术；分次、小剂量应用静脉麻醉药，间隔更长时间再加肌松剂和维持相对较高AAI，是开腹手术实施全麻应遵循的原则。

Objective To investigate the anesthesia and perioperative management of very old patients undergoing major operation. Methods The anesthesia and perioperative management of 16 elderly patients over 90 years old undergoing operation, including abdominal operation （6 cases） and artificial hip joint surgery （10 cases）, were retrospectively reviewed. According to patients＇ history, the functions of major organs were pertinently examined and active preoperative preparation was carried out before operation. The anesthetic technique was selected in the light of the category of operation and characteristics of the diseases. The hemodynamics was monitored by a transesophageal echo-Doppler （HemosonicTM 100） and the depth of anesthesia was monitored by an A-Line autoregressive index （AAI）. The additional muscle relaxants were administered under stimulation with train-of-four （TOF）. Results Disorder of two to four major organs, mainly in circulatory, respiratory and endocrine system, were found in all patients before operation. Blood pressure control, myocardium nutrition, anti-arrhythmia, blood sugar control and antiinfection were necessary and were effective methods for preoperative preparation. General anesthesia was selected as the major anesthesia method for patients undergoing abdominal operation, supplemented with vecuronium at an interval time of （87± 16） min. Epidural anesthesia was applied in patients undergoing artificial hip joint surgery. The first dose of local anesthetic was 1% lidocaine （7.6 ±0.9） ml, additional local anesthetic was used after （63 ± 17） rain. Fifteen minutes after intravenous infusion of 6 % hydroxyethyl starch （10ml/kg）, strock volume （SV）, cardiac output （CO）, cardiac index （CI） and aorta blood flow（ABF） were increased by 17%, 11%, 14% and 15% respectively,while the peripheral vascular resistance （SVR） and heart rate （HR） were decreased by 16% and 9.6% respectively. The value of AAI was maintained at 50-60 during the operation. At the end of operation, and the timepoint when the patients began to cough or swallow and answer questions clearly, the value of AAI was 73±9.4 and 81±7.3 respectively. No patient had awareness during operations. Conclusion Effective preoperative preparation and intraoperative monitoring are very important. Epidural anesthesia with low concentration and low volume of local anesthetics, and intravenous infusion of 6% hydroxyethyl starch should be adopted in elderly patients undergoing artificial hip joint surgery. While general anesthesia should be selected in elderly patients undergoing abdominal operation, the principles should be followed including intravenous administration of anesthetics at low dose, prolonging time interval for adding muscle relaxant, and maintaining AAI value at a high level.