妊娠合并重度特发性肺动脉高压患者行剖宫产术的麻醉处理

Anesthesia management of cesarean section in pregnant women with severe idiopathic pulmonary arterial hypertension

目的探讨妊娠合并重度特发性肺动脉高压患者行剖宫产术的麻醉处理。方法回顾性分析2006年1月至2016年3月于首都医科大学附属北京安贞医院行剖宫产术的妊娠合并重度特发性肺动脉高压9例患者的临床资料。其中8例患者采用连续硬膜外阻滞麻醉，1例患者因不能配合而采用全身麻醉。监测患者心输出量、中心静脉压（CVP）、平均肺动脉压（MPAP）、平均动脉压（MBP）、心率和肺毛细血管楔压（PCWP）；并计算心指数、体循环血管阻力（SVR）和肺循环血管阻力（PVR）；分析患者液体量变化和不良事件发生情况。结果8例行连续硬膜外麻醉患者麻醉操作均顺利，麻醉效果平面确切，麻醉平面为T8～S5；1例行全身麻醉患者采用快速麻醉诱导，麻醉操作过程顺利，患者术中血流动力学参数较平稳，手术顺利。治疗过程中3例患者因发生肺动脉高压危象而死亡，该3例数据剔除。胎儿娩出后和初始麻醉后患者心输出量、CVP、MPAP、MBP、心率、心指数、SVR和PVR与麻醉前比较，差异均无统计学意义（均P〉0．05）。患者总液体输入量为110～1000ml，中位总液体输入量为310ml，晶体液与胶体液容积比为2：3；出血量为100～800ml，中位出血量为250ml；尿量为30～1000ml，中位尿量为200ml。6例患者术后病情稳定，均顺利出院。结论妊娠合并特发性肺动脉高压患者在剖宫产围术期容易发生肺动脉高压危象甚至死亡，在辅助措施协助下硬膜外麻醉是较合适的选择。

Objective To investigate anesthesia management of cesarean section in pregnant women with severe idiopathic pulmonary arterial hypertension （IPAH）. Methods Clinical data of 9 pregnant women with - severe IPAH who had cesarean section from January 2006 to March 2016 in Beijing Anzhen Hospital, Capital Medical University were retrospectively analyzed. Eight women had continuous epidural anesthesia and one woman had general anesthesia. Cardiac output（CO） , central venous pressure（CVP） , mean pulmonary artery pressure（MPAP）, mean arterial pressure（MAP）, heart rate（HR） and pulmonary capillary wedge pressure （PCWP） were recorded. Cardiac index （CI）, systemic vascular resistance （SVR） and pulmonary vascular resistance（PVR） were calculated. The volume of fluid transfusion and occurrence of adverse reactions were analyzed. Results Epidural anesthesia in 8 cases was effective, level of anesthesia T8-S5; hemodynamic parameters in 1 case who had general anesthesia was stable. Three patients died of pulmonary hypertension crisis. CO, CVP, MPAP, MAP, HR, CI, SVR, PVR in 6 patients after anesthesia and after delivery had no significant differences compared to those before anesthesia（ P 〉 0. 05 ）. The total volume of fluid transfusion was 110-1 000 ml; the mean volume of fluid transfusion was 310 ml; the volume ratio of crystalloid/eolloid was 2 ： 3. The total blood loss was 100-800 ml; the mean blood loss was 250 ml; the total urine volume was 30-1 000 ml; the mean urine volume was 200 ml. Disease conditions in 6 patients were stable after operation. Conclusion Patients with IPAH have high risk of pulmonary hypertension crisis and death during perioperative period of cesarean section; epidural anesthesia is a reasonable option.