心尖入路经导管主动脉瓣植入术的麻醉管理

Anesthetic Management of Trans-apical Aortic Valve Implantation

目的探讨心尖入路主动脉瓣植入术的麻醉管理方法。方法2018年2月~2019年8月我院行心尖路径经导管主动脉瓣植入术36例,采用全凭静脉麻醉,Flotrac监测血流动力学,借助经食道超声进行术中指导与心功能监测,利用脑电双频谱指数监测麻醉深度。麻醉诱导气管插管后经右侧颈内静脉放置临时起搏器,观察术前、术中、术后血流动力学参数,记录术中出入量、手术时间、机械通气时间、监护室停留时间、住院时间、并发症和全因死亡情况。结果诱导前平均动脉压(95.7±11.2)mm Hg,显著高于诱导后15 min(86.1±7.8)mm Hg(P=0.000)和手术结束时(84.4±10.8)mm Hg(P=0.000),但诱导后15 min与手术结束时比较差异无显著性(P=1.000)。诱导前患者心率(82.2±15.3)次/min,显著高于诱导后15 min(74.3±15.7)次/min(P=0.000),手术结束时心率(87.4±15.5)次/min升至诱导前水平(P=0.576),但明显高于诱导后15 min(P=0.003)。诱导前患者心输出量(4.95±0.58)L·min^-1,显著高于诱导后15 min(4.25±0.31)L·min^-1(P=0.000)和手术结束时(4.76±0.29)L·min^-1(P=0.009),但诱导后15 min显著低于手术结束时(P=0.000)。诱导前患者心输出量指数(2.90±0.41)L·min^-1·m^-2,显著高于诱导后15 min(2.50±0.27)L·min^-1·m^-2(P=0.000)和手术结束时(2.80±0.34)L·min^-1·m^-2(P=0.024),且诱导后15 min显著低于手术结束时(P=0.000)。6例发生肝肾功能不全,2例发生低氧血症,2例发生心力衰竭,1例发生室颤,共3例死亡。结论心尖入路经导管主动脉瓣植入术需要严密术中监测以及仔细的血流动力学管理,从而有效保障患者安全度过手术期。

Objective To study the anesthetic management of trans-apical aortic valve implantation.Methods From February 2018 to August 2019,36 patients received trans-apical aortic valve implantation(TAAVI)under general intravenous anesthesia.The Flotrac was used to monitor the hemodynamic,the transesophageal echocardiography was used to monitor cardiac function and to guide the operation progress,and the bispectral index was used to monitor the depth of anesthesia.After the intubation,the temporary pacemaker was placed via the internal jugular vein.The hemodynamic parameters,operation time,extubation time,length of ICU stay and hospitalization days,liquid intake and output,complications and all-cause mortality before,during and after surgery were recorded and analyzed.Results The patient’s baseline mean blood pressure(MAP)was(95.7±11.2)mm Hg,higher than that 15 minutes after induction(86.1±7.8)mm Hg(P=0.000)and the end of the surgery(84.4±10.8)mm Hg(P=0.000),but there was no significant difference between 15 minutes after induction and the end of the surgery(P=1.000).The patient’s baseline heart rate(HR)was(82.2±15.3)beats per minute,higher than that 15 minutes after induction(74.3±15.7)beats per minute(P=0.000);HR at the end of surgery was(87.4±15.5)beats per minute,almost the same with the induction period(P=0.576)but still higher than 15 minutes after induction(P=0.003).The patient’s baseline cardiac output(CO)was(4.95±0.58)L·min^-1,higher than that 15 minutes after induction(4.25±0.31)L·min^-1(P=0.000)and the end of the surgery(4.76±0.29)L·min^-1(P=0.009),but CO at 15 minutes after induction was lower than the end of the surgery(P=0.000).The patient’s baseline cardiac index(CI)was(2.90±0.41)L·min^-1·m^-2,higher than that 15 minutes after induction(2.50±0.27)L·min^-1·m^-2(P=0.000)and the end of the surgery(2.80±0.34)L·min^-1·m^-2(P=0.024),but CI at 15 minutes after induction was lower than the end of the surgery(P=0.000).There were 6 cases of liver and kidney dysfunction,2 cases of hypoxemia,2 cases of heart failure,1 case of ventricular fibrillation and 3 cases of death.Conclusion During TAAVI,close monitoring and careful hemodynamic management can ensure the perioperative safety of patients.