急性升主动脉夹层手术期间麻醉管理策略

The anesthesia management strategies of patients with acute ascending aortic dissection surgery

目的总结分析急性升主动脉夹层手术患者的麻醉管理策略。方法收集、分析2009年5月至2014年3月47例急性升主动脉夹层手术患者的病历资料。其中，男40例，女7例；年龄22～72岁，平均（46．7±10．4）岁；体重46～115 kg，平均（77．5±15．3）kg。术前左心室射血分数41％～87％，平均（65．7±9．2）％。术中采用全凭静脉麻醉方法，连续监测上、下肢有创动脉压和肺动脉压。手术开始后使用冰袋行脑部降温和静脉滴注甲泼尼龙行脑保护。结果26例在深低温停循环下行全弓置换，21例行半弓置换。体外循环（226．7±73．1）min，主动脉阻断（160．2±62）min，术中鼻咽温降低到（19．5±2．8）℃时，深低温停循环时间为63．8 min（0～129 min），脑部停循环（27．1±13．6）min。停机后血制品使用包括红细胞（6．1±2．0）U，新鲜冰冻血浆（10．5±3．6）U，冷沉淀（11．2±6．1）U，血小板（1．9±0．4）U。术后呼吸机支持时间为64．9 h（5～215．8 h），监护室住院天数为（6．3±3．4）d。术后4例发生苏醒延迟，2例死亡。结论急性升主动脉夹层患者术前病情危重，手术及体外循环时间长，需深低温停循环和采取脑保护措施。科学合理的循环管理、脑保护和血液管理是该类手术患者麻醉管理的关键。

Objective To summarize the anesthesia management strategies for operative repair of acute ascending aortic dissection.Methods Clinical data about forty seven patients [40 males and 7 females,aged of 22 to 72（mean 46.7 ±10.4 ） years,weighting from 46 to 115（mean 77.5 ±15.3 ） kg] receiving operative repair of acute ascending aortic dissection from May 2009 to March 2014 were retrospectively analyzed.The left ventricular eject fraction was 41-87 （ mean 65.7 ±9.2 ）%.All received totally intra-venous anesthesia and continuous monitoring the upper and lower limbs invasive blood pressure and the pulmonary artery pressure during the operation.After start the operation,the head were packed with ice,and the methylprednisolone were applied through intravenous drip to protect the brain.Results Twenty six patients received total arch replacement and 21 patients received semi-arch replacement under deep hypothermic circulatory arrest .All patients were smoothly completed the surgery,the mean cardiopulmonary bypass time was （226.7 ±73.1）min,aortic cross clamping time was（160.2 ± 62）min.By reducing body temperature to（19.5 ±2.8）℃,the circulation was arrested and it was lasted 63.8 min （0-129 min）,and brain arrest circulation time was lasted （27.1 ±13.6） min who was carried out the total-arch replacement.The blood products transfusion included red blood cell （6.1 ±2.0） U,fresh frozen plasma （10.5 ± 3.6）U,cryoprecipitate（11.2 ±6.1）U and blood platelet（1.9 ±0.4）U during the operation.After the operation, the mechanical respiratory support was continued 64.9 h（5-215.8 h）,and the length of ICU stay was（6.3 ±3.4） d.There were 4 patients occurred delayed recovery and 2 patients died post-operatively.Conclusions The patients with the acute ascending aortic dissection have seriously condition before operation,longer operative and CPB time, and need the deep hypothermic circulatory arrest and brain protection .The reasonable circulation management ,brain protection and blood preserve strategy are the key points to ensure these patients peri -operative security and improve disease prognosis.