胸腔镜辅助微创单支冠状动脉旁路移植术的麻醉处理

Anesthetic management in patients with thoracoscope assisted minimally invisive single coronary artery bypass grafting

目的总结胸腔镜辅助微创单支冠状动脉旁路移植术的麻醉处理。方法8例冠心病患者,术前心功能NYHA分级Ⅰ～Ⅱ级。采用单腔气管内插管静吸复合全麻,术中行有创动脉血压、心电图、脉搏氧饱和度、呼气末二氧化碳、中心静脉压、尿量、温度(鼻温、直肠温)监测,并间断进行动脉血气、电解质监测。游离乳内动脉过程中采用低潮气量,增加呼吸频率,以避免肺过度膨胀影响手术操作。术中持续泵入硝酸甘油,预防围术期发生心肌缺血及控制血压。结果全组患者术中血流动力学平稳,6例患者术后当日拔除气管插管,1例术后第1日拔除,1例因术后肺部感染延迟至术后69h拔管。全部患者均顺利出院,无围术期心梗及死亡。结论胸腔镜辅助微创单支冠状动脉旁路移植术手术,术中合理选择麻醉药物、加强呼吸管理将有助于患者术后早期拔管,减少肺部并发症,缩短监护室的停留时间,利于患者的术后恢复及减少医疗费用。

Objective To summarize the experience of anesthetic management in patients with thoracoscope assisted minimally invisive single coronary artery bypass grafting. Methods 8 patients with coronary artery disease, New York Heart Association（NYHA ） function class Ⅰ and Ⅱ , underwent thoracoscope assisted minimally invisive single coronary artery bypass grafting. Anesthesia was induced with etomidate 0.3 mg/Kg, Atracurium 0.8 mg/kg, fentany 8 μg/kg, and single lumen tracheal intubation was inserted. 7F double lumen catheter was inserted into internal jugular vein and subclavian vein to transfusion and monitor of central venous pressure （CVP）. Small dose of fentany and Atracurium iv, propefol iv by pump and inhalation of isoflurane were used to maintain depth of anesthesia. Invasive blood pressure （IBP）, electrocardiogram （ECG）, saturation of pulse oxygen （SPO2）, partial pressure of carbon dioxide in endexpiratory gas（PETCO2）,central venous pressure （CVP）, urinary volume, nasopharyngeal and rectum temperature were monitored continually and arterial blood gas and electrolytes analysis was done intermittently. Low tidal volume and higher breathing frequency were used when internal mammary artery was harvested. Nitroglycerin was iv by pump continually to avoid myocardial ischemia and to control IBP. Results Hemodynamics of all patients during operatiom were stable.6 cases have tracheal extubation in 0 postoperative day, 1 case in 1 postoperative day and 1 case who have postoperative pulmonary infection in postoperative 69 hours. All patients have no myocardial infarct and postoperative death and discharge successfully. Conclusion During thoracoscope assisted minimally invisive single coronary artery bypass grafting operation, reasonable election of anesthetic drugs and intensive breathing management can reduce lung complications,time of ICU stay, medical cost and be helpful to early tracheal extubation and recover of patients.