子宫外产时处理手术胎儿的呼吸管理经验——附20例病例总结

The experience of respiratory management in 20 cases of fetuses undergoing ex utero intrapartum treatment surgery

目的总结20例产前诊断存在畸形的胎儿行子宫外产时处理(ex utero intrapartum treatment,EXIT)手术的呼吸管理经验。方法2016至2018年我院收治的20例行EXIT手术的胎儿,其中颌面部淋巴管瘤5例,颈部畸胎瘤4例,肺囊腺瘤3例,胸腔积液5例,隔离肺3例。对其采用母体胎盘途径麻醉,胎头娩出后,维持胎盘循环下,全部病例均采用可视喉镜行气管插管对胎儿进行人工气道建立,记录插管前后胎儿的血氧饱和度、胎心率,待插管成功后断脐,并抽取胎儿动脉血气。随即于产房内进行新生儿外科手术治疗,给予3~5 cmH2O(1 cmH2O=0.098 kPa)PEEP支持,术中抽取血气分析,新生儿手术结束后转至NICU。结果(1)20例胎盘维持下胎儿处于麻醉状态,母体1.5 MAC七氟醚吸入麻醉,瑞芬太尼泵入,胎儿血氧饱和度可维持在(51.5±4.7)%,胎心率(155.3±11.34)次/min;(2)20例胎儿的气管插管完成时间(24.20±3.43)s,声门暴露时间(3.20±1.12)s,1次插管成功率90%(18/20),其中2例声门暴露困难,行2次气管插管后成功;(3)使用3~5 cmH2O PEEP支持下高频正压通气模式,可为新生儿手术期间提供良好氧合[SpO2(92.10±3.34)%],胎儿平均住院时间(15.0±3.2)d,呼吸机维持时间(3.0±1.2)d,术后并发肺炎4例,肺不张2例。结论(1)避免母体过深麻醉,有效维持胎盘循环,可提供人工气道建立前的良好氧合,为胎儿提供有效麻醉;(2)可视喉镜缩短了插管时间,声门暴露良好,可提高断脐后新生儿的氧合指数;(3)使用PEEP支持下高频通气模式,为新生儿手术期间提供良好氧合。

Objective To summarize the experience of respiratory management in 20 cases of fetuses diagnosed with prenatal malformations undergoing ex utero intrapartum treatment(EXIT)surgery.Methods From 2016 to 2018,20 cases of fetuses undergoing EXIT surgery were admitted to our hospital,including five cases of maxillofacial lymphangioma,four cases of cervical teratoma,three cases of lung cystadenoma,five cases of pleural effusion,and three cases of isolated lung.The fetal anesthesia was through maternal anesthesia.After the fetal head was delivered,the placental circulation was maintained.All cases were established with artificial laryngoscopy by visual laryngoscopy and tracheal intubation.The blood oxygen saturation and heart rate of the fetuses were recorded before and after intubation.After successful intubation,the umbilical cord was broken and the fetal arterial blood gas was drawn.Immediately,the neonatal surgery was performed in the delivery room,with 3 to 5 cmH2O(1 cmH2O=0.098 kPa)PEEP for respiratory support,and blood gas analysis during the operation were collected.After surgery,newborns were transferred to NICU.Results(1)The 20 cases of fetal anesthesia under placenta maintenance,maternal 1.5 MAC sevoflurane inhalation anesthesia with remifentanil pumping,fetal oxygen saturation can be maintained at(51.5±4.7)%,fetal heart rate(155.3±11.34)times/min;(2)The completion time of tracheal intubation of 20 fetuses was(24.20±3.43)s,the time of glottal exposure was(3.20±1.12)s,and the success rate of one intubation was 90%(18/20),of which two cases were exposed to glottis difficult,successful after two tracheal intubation;(3)The use of 3 to 5 cmH2O PEEP to support the high-frequency positive pressure ventilation mode can provide good oxygenation[SpO2(92.10±3.34)%]during the neonatal surgery,the length of hospital stay of the fetus was(15.0±3.2)d,and ventilator duration time was(3.0±1.2)d.Postoperative complications included four cases of pneumonia and two cases of atelectasis.Conclusion(1)Avoiding excessive deep anesthesia of mother,maintain the placental circulation effectively,providing good oxygenation before artificial airway establishment and providing effective anesthesia for the fetus are important in EXIT;(2)The visual laryngoscope shortens the intubation time,and the glottis is well exposed,which can increase the oxygenation index of the newborn after the umbilical cord is broken;(3)The high-frequency ventilation mode supported by PEEP can provide good oxygenation for newborns during surgery.