儿童肾上腺皮质癌切除术的麻醉管理

Anesthesia management for resection of adrenal cortical carcinoma in children

收集2012年1月至2019年1月本院行肾上腺皮质癌切除术的11例患儿的病历资料,分析及讨论儿童肾上腺皮质癌切除术的麻醉管理经验。麻醉诱导:静脉注射阿托品0.01 mg/kg、地塞米松2~5 mg、丙泊酚2~3 mg/kg、舒芬太尼0.3~0.5μg/kg或芬太尼1~2μg/kg、罗库溴铵0.5 mg/kg或顺式阿曲库铵0.1~0.2 mg/kg。超声引导下行桡动脉穿刺置管术和股静脉穿刺置管术,持续监测动脉血压。置入食管测温探头持续监测体温,置入尿管监测尿量。气管插管术后行间歇正压通气,吸入氧浓度60%~100%,氧流量2~3 L/min,潮气量7~10 ml/kg,通气频率20~26次/min,吸呼比1∶(1.5~2.0),气道压16~20 cmH_(2)O,维持P_(ET)CO_(2)35~45 mmHg。麻醉维持:吸入2%~4%七氟烷和/或静脉输注丙泊酚0.10~0.15 mg·kg^(-1)·min^(-1),静脉输注瑞芬太尼0.2~0.5μg·kg^(-1)·min^(-1),术中维持血流动力学在正常范围内波动,维持BIS值40~60。结扎肿瘤周围血管至完整切除肿瘤前,静脉输注氢化可的松琥珀酸钠5~10 mg/kg。术毕持续静脉输注舒芬太尼0.75~1.00μg·kg^(-1)·d^(-1)或芬太尼7.5~10.0μg·kg^(-1)·d^(-1)镇痛至术后48 h。所有患儿麻醉过程平稳,术后顺利拔除气管导管,均存活至今。儿童肾上腺皮质癌切除术的麻醉管理需要熟知儿童肾上腺皮质癌的临床特征及病理生理特点,关注围术期激素水平变化并及时调整患儿内环境,维持麻醉平稳,减少应激反应是麻醉管理的关键。

The medical records of 11 pediatric patients undergoing resection of adrenal cortical carcinoma from January 2012 to January 2019 in our hospital were collected.Anesthesia management for resection of adrenal cortical carcinoma in children was analyzed and investigated.Anesthesia was induced by intravenously injecting atropine 0.01 mg/kg,dexamethasone 2-5 mg,propofol 2-3 mg/kg,sufentanil 0.3-0.5μg/kg or fentanyl 1-2μg/kg,rocuronium 0.5 mg/kg or cis-atracurium 0.1-0.2 mg/kg.Radial artery catheterization and femoral vein catheterization were performed under ultrasound guidance.Arterial blood pressure was continuously monitored.The esophageal thermometers probe was placed to continuously monitor body temperature.The catheter was placed to monitor urine volume.Intermittent positive pressure ventilation was performed after endotracheal intubation with the inspiratory oxygen fraction set 60%^(-1)00%,oxygen flow rate 2-3 L/min,tidal volume 7^(-1)0 ml/kg,ventilation frequency 20-26 times/min,inhalation/respiration ratio 1∶(1.5-2.0)and airway pressure 16-20 cmH2O,and the end-tidal pressure of carbon dioxide was maintained at 35-45 mmHg.Anesthesia was maintained by inhaling 2%-4%sevoflurane and/or intravenously infusing propofol 0.10-0.15 mg·kg^(-1)·min^(-1),and continuously infusing remifentanil 0.2-0.5μg·kg^(-1)·min^(-1).Hemodynamics was maintained within the normal range,and the bispectral index was maintained at 40-60 during the surgery.Before the tumor was completely removed,5^(-1)0 mg/kg sodium hydrocortisone succinate was intravenously infused.At the end of the operation,sufentanil 0.75^(-1).00μg·kg^(-1)·d^(-1) or fentanyl 7.5^(-1)0.0μg·kg^(-1)·d^(-1) was continuously infused for postoperative analgesia until 48 h after operation.Operation was smoothly completed with stable anesthesia in all the pediatric patients.The tracheal tube was removed successfully after the operation.All children in this group were discharged from hospital and no death occurred.Anesthesia management for resection of adrenal cortical carcinoma required an appreciation of the clinical characteristics and perioperative pathophysiological changes.Paying attention to the changes in hormone levels during perioperative period and timely adjusting the children′s internal environment to maintain the stability of anesthesia and reduce the stress response were the keys to anesthesia management.