小儿喉乳头状瘤重度气道梗阻手术的围术期管理

Perioperative management for pediatric recurrent laryngeal papillomatosis with severe airway obstruction

目的总结小儿喉乳头状瘤重度气道梗阻手术的围术期管理方法。方法选取复旦大学附属眼耳鼻喉科医院于2005年7月-2009年3月收治的70例Ⅲ度和Ⅳ度喉梗阻的喉乳头状瘤患儿,记录麻醉诱导前、手术开始时及手术开始后5、10 min以及手术结束时的平均动脉压(MAP)、心率(HR)、脉搏血氧饱和度(SpO2)、呼气末二氧化碳(PETCO2)。从麻醉诱导、麻醉维持、术中通气方式、拔管期和拔管后处理等一系列环节分析围术期的管理效果。结果手术时间为5～35 min,术后5～20 min拔管送苏醒室。手术结束时MAP为(66±6)mmHg(1 mmHg=0.133 kPa)、HR为(138±11)次/min,与麻醉诱导前的(69±8)mmHg、(155±10)次/min的差异均无统计学意义(P值均>0.05)。手术结束时SpO2为(98.3±1.2)%、PETCO2为(44.8±3.8)mmHg,均较麻醉诱导前的(91.9±2.3)%、(68.1±11.8)mmHg明显改善,差异有统计学意义(P值均<0.05)。在合理的围术期管理下,患儿麻醉诱导平稳,麻醉效果满意,血流动力学稳定,均顺利完成手术,安全度过围术期。结论小儿喉乳头状瘤重度气道梗阻手术围术期管理的关键是充分的术前评估和谨慎使用肌松药,合理选用气管导管及气管插管的方法,术中维持足够的麻醉深度,根据手术需要采取相应的通气方式,尽量避免气管切开,拔管期和拔管后密切监测呼吸循环功能,保护气道避免误吸。

Objective To summarize our experience on perioperative management for pediatric recurrent laryngeal papillomatosis with severe airway obstruction. Methods The data of 70 children （July 2005 to March 2009） with recurrent papillomatosis and Ⅲ - Ⅳ laryngeal obstruction were analyzed. The mean arterial pressure （MAP）, heart rate （HR）, SpO2 and end-tidal carbon dioxide （PETCO2） were recorded before induction of anesthesia, at beginning of operation, 5 min after operation, 10 min after operation, and at the end of operation. The outcomes of perioperative management were analyzed from the aspects of anesthesia induction, anesthesia maintenance, ventilation technique during operation, intra-extubation and post-extubation treatment. Results The operation time was 5- 35 min and extubation was done 5- 20 min after operation. At the end of the operation the MAP was （66±6） mmHg（1 mmHg = 0. 133 kPa）, HR was （138± 11）/min, which were similar to those before anesthesia induction （[69±81 mmHg, [155±101/min, P〉 0.05）. At the end of operation the SpO2 was （98.3±1.2） % and PET 002 was （44.8±3.8） mmHg, which were significantly improved compared with those before anesthesia induction （[91.9± 2.31%, [ 68.1± 11.81 mmHg, P〈 0.05）. With appropriate perioperative management, stable anesthesia was achieved in all children and they underwent successful operation with improved hemodynamics. Conclusion The key points of the perioperative management for pediatric laryngeal papillomatosis with severe airway obstruction include： sufficient preoperative airway evaluation, cautious use of muscle relaxants, proper choice of endotracheal tube and method of intubation, suitable anesthesia depth, proper ventilation technique, avoidance of tracheotomy, intensive monitoring during extubation and after extubation, and protection of airway from aspiration. （Shanghai Med J, 2009, 32： 966-969）