经食道超声心动图用于坐位神经外科手术的临床研究

Clinical research on transesophageal echocardiography(TEE) monitoring applied in sitting neurosurgery

目的观察经食道超声心动图(TEE)对卵圆孔未闭(PFO)判断的准确性及坐位神经外科手术中利用TEE对静脉空气栓塞(VAE)和反常空气栓塞(PAE)监测的有效性。方法 8例拟行坐位神经外科手术的患者术前行经胸心脏超声心动图和TEE,无PFO者行坐位手术。术中TEE双维四腔心界面和心房上腔静脉界面监测VAE和PAE及卵圆孔状态和中心静脉导管尖端的位置,采用Grade分级法行VAE和PAE分级,术中持续行胸前多普勒超声(PCD)、有创动脉血压、中心静脉压(CVP)、呼气末二氧化碳分压(PetCO2)监测。结果术前心脏超声对比观察中TEE发现1例PFO。7例患者坐位手术中TEE监测到VAE者6例(85.7%);监测到PAE者2例(28.6%),Grade级别为1,其VAEGrade级别为3,其中1例发现卵圆孔重新开放导致PAE的发生,另1例主动脉PAE发生在右房VAE消失后的手术过程中;PCD有明确信号者5例(5/7),1例PCD信号可疑;血压明显下降发生在VAEGrade3级的2例患者中,PetCO2下降≥5mmHg者5例(71.4%),术中抽吸到空气栓子的患者5例。结论 TEE是术前筛选PFO更敏感的手段,TEE在坐位手术中可以定量监测VAE和PAE的性质和严重程度。TEE应作为神经外科坐位手术必要的监测手段。

Objective To investigate the accuracy of preoperative diagnosis of patent foramen ovale （PFO） and the validity of transesophageal echocardiography （TEE） in venous air embolism （VAE） monitoring and paradoxical air embolism （PAE） in patients undergoing the sitting-position neurosurgery. Methods Trans-thoracic echocardiography and TEE test were performed preoperatively in eight patients scheduled for sitting-position neurosurgical procedures. Patients without PFO during transthoracic echocardiography and TEE preoperatively were scheduled for sitting-position neurosurgery. In- tra-operative TEE monitoring with four-cavity heart interfaces and atrium-superior vena interfaces were performed to de- tect VAE, PAE, status of foramen ovale and the position of central venous catheter tip. The severity of PAE and VAE was graded 0-3. When the intra-operative PAE and VAE incidents were founded, the precordial Doppler and ABP, CVP and PetCO2 were conducted. Results One case co-existing PFO with preoperative TEE screening was found. The VAE inci- dents in six of seven patients and PAE incidents in two of seven patients were encountered in sitting-position neurosurgery. Conclusions The TEE monitoring is more sensitive for preoperatively detecting PFO, and quantitating for the severity of PAE and VAE in sitting-position neurosurgery. TEE should be an obligatory monitoring method undergoing sitting-position neurosurgery.