全机器人不停跳冠状动脉旁路移植术的麻醉管理

Anesthesic management in telerobotic totally endoscopic coronary artery bypass grafting

目的探讨使用daVinciS手术系统行不停跳冠状动脉旁路移植手术的麻醉管理策略。方法2007年1月至2009年5月我院共完成全机器人不停跳冠状动脉旁路移植术16例。所有患者均在麻醉诱导后插入左侧双腔支气管导管,术中采用右侧单肺通气,使用机器人游离左侧乳内动脉后与前降支吻合。术中分别记录麻醉诱导后(T1)、开始单肺通气(T2)、开始游离左侧乳内动脉(T3)、开始放置心脏稳定器(T4)及血管吻合后(T5)各时点的血流动力学参数及左心室功能变化。结果平均动脉压在T2、T3、T4时点明显低于T1(P<0.05);平均肺动脉压在T2、T3、T4时点,心率在T2、T3、T5时点,肺毛细血管楔压在T4时点及中心静脉压在T5时点均明显高于T1(P<0.05)。结论全机器人不停跳冠状动脉旁路移植术中单肺通气及手术操作对呼吸和循环系统的影响明显,通过调整呼吸参数并合理应用血管活性药物能够维持血流动力学稳定。

Objective To investigate the strategies for anesthetic management for totally endoscopic coronary artery bypass grafting with the da Vinci S surgical system.Methods Between January 2007 and May 2009,16 patients underwent off-pump coronary artery bypass grafting via a totally endoscopic approach.After anesthetic induction,a left-sided double-lumen endotracheal tube was positioned to allow single right-lung ventilation during intra-operative procedure.The left internal mammary artery graft was harvested and anastomosed with the anterior descending branch with robotic assistance.The hemodynamic status and left ventricular function of each patient were recorded immediately after the induction（T1）,after single right-lung ventilation（T2）,after dissecting the left internal mammary artery（T3）,after using the heart stabilizator（T4） and after the completion of the anastomosis（T5）.Results The mean arterial blood pressure at T2,T3,and T4 were significantly reduced as compared with that at T1（P〈0.05）,and the mean pulmonary artery pressure at T2,T3 and T4,the heart rate（HR） at T2,T3 and T5,the pulmonary capillary wedge pressure at T4 and the central venous pressure at T5 all increased significantly in comparison with those at T1（P〈0.05）.Conclusion Although the hemodynamics and the respiratory function in totally endoscopic coronary artery bypass grafting are both extremely unstable as a result of single right-lung ventilation and surgical procedure,the appropriate administration of vasopressors and adjustment of respiratory function in anesthesia can allow the completion of the procedure with acceptable hemodynamics.