体外循环下小儿室间隔缺损修补术的麻醉处理

Anesthesia management of surgery repair of ventricular septal defect under cardiopulmonary bypass

目的通过对小儿室间隔缺损修补术麻醉过程的临床观察，探讨体外循环下小儿室间隔缺损修补术麻醉处理的正确方法。方法选择小儿室间隔缺损129例，ASAⅠ-Ⅱ级。本组患儿均在舒芬太尼静脉复合七氟醚吸入全身麻醉、低温体外循环下行室间隔缺损修补术。主动脉阻断前及主动脉开放前均应用甲泼尼龙及乌司他丁以预防体外循环中的炎症反应及心脏缺血／再灌注损伤。术中维持动脉血二氧化碳分压（PaCO2）30—35mmHg，中心静脉压（CVP）7—15mmHg。全组持续监测有创动脉压、CVP、ECG、脉搏氧饱和度（SpO2）、电解质、尿量、鼻咽温和肛温；动态监测激活全血凝固时间（ACT）、呼气末二氧化碳分压（PETCO2）及血气分析。结果本组患儿术中血流动力学稳定，体外循环转流时间36—76min，主动脉阻断时间12—48min。主动脉开放后，127例患儿心脏自动复跳，2例患儿出现心室纤颤，心内除颤后复跳，1例患儿心率偏慢，用药物后效果不佳，放置临时起搏器。所有患儿均顺利停止体外循环。术毕至拔管平均时间2—3h。所有患儿10天内均痊愈出院，无严重并发症。结论对于先天性心脏病室间隔缺损的患儿，平稳的麻醉诱导，适当的麻醉深度，有效的呼吸管理，完善的术中监测，积极防范处理术后并发症，可使患儿安全度过围麻醉手术期。

Objective To discuss the anesthesia management of the surgery repair of ventricular septal defect （VSD） under cardiopulmonary bypass （CPB）. Methods A total of 129 ASA Ⅰ-Ⅱ VSD child patients were included. They un- derwent general anesthesia through intravenous injection of sufentanil and inhalation of sevoflurane before surgical repair of VSD under hypothermic CPB. In order to prevent inflammatory reaction in CPB and ischemia/reperfusion injury in the heart, methylprednisolone and ulinastatin was administrated before occlusion and opening of the arteriae aorta. During the surgery, the arterial blood partial pressure of carbon dioxide （ PaCO2 ） was maintained between 30 to 35 mmHg. The central venous pressure （CVP） was kept between 7 to 15 mmHg. Their invasive blood pressure, CVP, electrocardiogram （ ECG）, pulse oxygen saturation （SpO2 ）, electrolytes, urinary volume, nasopharyngeal and rectal temperatures were continuously monitored. Meanwhile, their activated clotting time of whole blood （ACT） and end -tidal carbon dioxide partial pressure （PETC02） were dynamically monitored and blood gas analysis was performed. Results All patients showed stable hemody- namic results, with the time of CPB from 36 to 76 min and the time of occlusion from 12 to 48 min. After the opening of the arteriae aorta, 127 child patients resuscitated spontaneously, but 2 patients presented ventricular fibrillation. Among the 2 patients, one patient resuscitated immediately after defibrillation and the other one＇s heart rate was relatively slow, whose showed poor overcome and a temporary pacemaker was then implanted. CPB was successfully in all children. The average time from the end of the operation to tracheal extubation was 2 to 3 hours. All patients were discharged within 10 days and without severe complications. Conclusions During the operation of VSD, careful preparation before anesthesia, stable induced anesthesia, suitable anesthesia depth, effective respiratory management, improved surgery monitoring, and active approaches to prevent complication can guarantee the safety of child patients during intraoperative anesthesia.