婴儿心脏瓣膜置换手术的麻醉处理

Anesthetic management of operation for infants cardiac valvular replacement

目的研究婴儿心脏瓣膜置换手术的麻醉处理。方法选择1998-07～2009-12接受心脏瓣膜置换手术者9例,男5例,女4例;年龄3～11个月;体重4.5～8.5 kg。病种:矫正性大血管转位合并Ebstein畸形、完全性房室间隔缺损、房缺室缺动脉导管未闭合并二尖瓣发育不良、二尖瓣黏液样退行性变各1例,室缺二尖瓣脱垂并二尖瓣瓣叶发育不良5例。术前均有明显的活动后气促,心功能Ⅲ级4例、Ⅳ级5例,其中1例二尖瓣黏液性变患者,11个月时置换19号双叶机械瓣,7岁时出现置换瓣相对狭窄,且三尖瓣亦发生黏液性变,遂用25、27号双叶机械瓣分别置换二、三尖瓣。术前镇静采用在术前30 min口服咪达唑仑糖浆0.5 mg/mg,入睡后进手术室行ECG、SpO2及无创血压监测,静脉通道开放后静脉注射芬太尼+肌松剂+镇静剂进行麻醉诱导,行鼻腔内气管插管,PCV压力模式控制呼吸,深静脉穿刺置双腔管行CVP监测,桡动脉穿行血压监测以及血气、温度、红细胞压积(HCT)、胶体渗透压(COP)等监测,体外循环前循环难以控制给多巴胺、肾上腺素正性肌力药支持,维持容量平衡,纠正酸血症,心内手术结束后继续泵入正性肌力药支持心脏,增加强心和扩血管药支持,维持有效心率和心输出量。结果全组患者麻醉顺利,无神经系统并发症,无麻醉死亡。其中2例分别于手术后2、4 d发生室性早搏,经治疗后恢复窦性心律,平均术后4～6 h麻醉清醒,带管时间平均48～54 h,顺利脱离呼吸肌,平均15～23 d出院。随访2～8年,无远期病死,心功能Ⅰ级4例,Ⅱ级5例。结论注意维持术中循环稳定,把握婴儿麻醉特点,注意个体化麻醉方式,加强监测手段合理用药,是保证手术顺利进行麻醉处理的关键。

Objective To investigate the anesthetic management of valve replacement operation in infants.Methods From July,1998 to December,2009,infants（5 male and 4 female,aged from 3 to 11 months,weighted from 4.5 to 8.5 kg） to be received cardiac valvular replacement operation were selected.Their diseases included CTGA-Ebstein,CAVSD,MV hypogenesis,MV myxomatosis,MV prolapse combined with hypogenesise.Before the operation,all the infants had panting after activity.The heart function of four cases was Ⅲ class and five was Ⅳ class.Midazolam was taken 0.5 mg/kg orally half an hour before operation and the ECG,SpO2 and non-invasive monitoring blood pressure were inspected after sleeping.After the opening of vein passage,fentanyl,Skelaxin and sedative were administered in vein and the tracheal tube was plugged via nasal cavity after anesthesia induction.Mechanical ventilation was set to PCV mode and one double-current central venous catheter was introduced by right central vein puncture to inspect the CVP.Invasive monitoring blood pressure,blood gas,Hct,and COP were inspected through radial artery.Before and after the cardiopulmonary bypass（CPB）,acidosis was corrected in time and the circulation was managed with cardiovascular active drugs such as dopamine,adrenalin and so on.All the steps were adopted to make sure of the effect HR and cardiac output.Results During the anesthesia,there was not nerves system syndrome or death and the anesthesia of the operation was calm and favoring.PCV happened in two of the infants later 2 days and 4 days after the operation and the sinus rhythm of the heart recovered through active therapy.The patients′ consciousness recovered within 4 to 6 hours after the operation.The mechanical ventilation was withdraw after the 48-54th hour.They left hospital at 15 to 23 days then.There was not death in subsequently follow-up of 2-8 years.The heart function of the four cases was up to Ⅰclass and five was Ⅱclass.Conclusion To maintain the stability of circulation is important.According to the characteristics of the infants,it is very important to the successful surgical operations by rationalization of drug administration,individual application of anesthesia and continuous inspection.