经胸微创封堵术治疗先天性心脏病的麻醉处理

Anesthesia management in minimally invasive surgery for congenital heart disease

目的总结经胸微创封堵术治疗先天性心脏病的麻醉处理特点。方法回顾性分析上海交通大学附属胸科医院近期连续收治的328例择期行经胸微创封堵术的患者,其中39例在术中转为体外循环手术(体外循环组),289例于非体外循环下成功实施手术(非体外循环组)。记录非体外循环组的麻醉诱导方式、气管插管方式、应用阿片类药物情况、术中平均动脉压(MAP)变化、术后去向、术后镇痛方式。比较非体外循环组与体外循环组手术时间、术中液体出入量、肝素用量、激活凝血时间(ACT)的差异。结果非体外循环组中,行静脉麻醉诱导209例(72.3%),七氟烷吸入麻醉诱导69例(23.9%),氯胺酮肌内注射麻醉诱导11例(3.8%);经口气管插管280例(96.9%),经鼻气管插管9例(3.1%);应用芬太尼265例(91.7%),应用舒芬太尼10例(3.5%),联合应用芬太尼及瑞芬太尼14例(4.8%),芬太尼的平均用量为(14.11±7.25)μg/kg,舒芬太尼的平均用量为(1.43±0.29)μg/kg,瑞芬太尼的平均用量为(4.17±1.30)μg/kg;术后进入重症监护病房231例(79.9%),进入麻醉后恢复室58例(20.1%);术后未用镇痛泵273例(94.5%),应用患者静脉自控镇痛16例(5.5%)。非体外循环组中行静脉麻醉诱导和吸入麻醉诱导患者的MAP均在手术开始时降至最低,均显著低于麻醉诱导后(P值均<0.05),而后逐渐恢复,手术30min时恢复至基线水平。体外循环组的肝素用量显著多于非体外循环组(P<0.01),ACT和手术时间均显著长于非体外循环组(P值均<0.01)。非体外循环组的术中出血量、输血量、尿量和输液量均显著少于体外循环组(P值均<0.05)。所有患者术后均康复出院。结论经胸微创封堵术治疗先天性心脏病术中出血少、时间短,适用快周转的围术期处理方式,虽然麻醉处理仍可采用传统的中剂量芬太尼麻醉和术毕转入重症监护病房的方式,但七氟烷吸入麻醉诱导、术中静脉注射舒芬太尼或瑞芬太尼维持麻醉及在麻醉后恢复室内拔除气管导管也不失为一种合理的选择。

Objective To review the characters of anesthesia in minimally invasive surgery for congenital heart disease. Methods A total of 328 intaoperative device closure of congenital heart disease using minimally invasive surgical technique in Shanghai Chest Hospital were retrospectively analyzed. There were 39 cases with cardiopulmonary bypass and 289 without cardiopulmonary bypass. The anesthesia managements such as the induction, intubation, opiod drugs, intraoperative mean arterial pressure （MAP）, postoperative transport direction and analgetic methods were recorded. The operating time, liquid intake and output volume, heprin dosage and activated clotting time （ACT） were compared between bypass group and non-bypass group. Results In the non- bypass group, the patients were induced with intravenous anesthesia （ n = 209, 72.3 % ）, sevoflurane inhalation （n = 69, 23.9 % ） and intramuscular ketamine （n = 11, 3.8 % ）, respectively. There were 280 patients （96.9 % ） undergoing intubation by mouth while only 9 patients by nose （3. 1% ）. For the use of intraopertive opiods, there were265 patients （91.7%） with fentanyl （[14. 11 ±7. 25] μg/kg）, 10 （3. 5%） with sufentanil （[1.43± 0. 29]μg/kg） and 14 （4.8 % ） with fentanyl plus remifentanil （[4.17±1. 30] μg/kg）. After surgery, 231 patients （79.9%） were sent to intensive care unit （ICU） and 58 （20.1%） were sent to postanesthetic care unit （PACU）. Patient controlled intravenuos analgesia （PCIA） was performed only in 16 patients （5.5 % ）, the other 273 patients （94.5%） required no PCIA. The MAP of the non-bypass group was reduced after induction, reached the lowest level at the beginning of the operation, and restored the baseline 30 min after the start of operation. The heprin dosage, ACT and operation time in the bypass group were greater than those in the non-bypass group （all P〈 0.01）. However, the volume of blood loss, blood transfusion, urinary production and fluid intake in the non-bypass group were significantly lower than those in the bypass group （all P〈0.05）. All the patients were discharged after recovery from surgery. Conclusion Minimally invasive surgical technique appears to be a safe and quick treatment for congenital heart disease. Although traditional anesthesia （medium dosage of fentanyl and direct transport to intensive care unit after surgery） has been used, sevenflorane inhalation combined with low dose sufentanil or rimifentanil and early extubation in the PACU seems to be a good alterative anesthetic management in minimally invasive surgery for congenital heart disease.