慢性血栓栓塞性肺动脉高压患者的麻醉管理

Perioperative anaesthetic management of patients with chronic thromboembolic pulmonary hypertension

慢性血栓栓塞性肺动脉高压(CTEPH)是急性肺血栓栓塞后幸存者最严重的并发症,亦是惟一一种可通过肺动脉内膜切除手术(PEA)治愈的肺动脉高压类型。由于严重的肺动脉高压与右心功能不全,CTEPH患者的麻醉极具挑战。手术前多学科的讨论与充分的麻醉前评估至关重要。患者从清醒到体外循环转机阶段的麻醉总则是维持右心室-肺动脉的偶联。体外循环转机及深低温停循环阶段的麻醉总则是均匀降温、复温以及脑、心等重要器官的保护。体外循环脱机至离开手术室阶段的麻醉总则是恢复左心室泵功能与防治肺缺血再灌注损伤。文章围绕CTEPH患者病理生理的特殊性以及PEA手术特点,根据手术步骤对麻醉评估、右心功能管理、深低温停循环的安全实施、控制性低心排技术的应用以及肺内出血并发症的处理等核心麻醉技术进行总结和讨论。

Chronic thromboembolic pulmonary hypertension(CTEPH)is the most serious complication in survivors after acute pulmonary thromboembolism,and it is possibly can be cured by pulmonary endarterectomy(PEA).Because of the severe pulmonary hypertension and consequently right heart failure,anesthesia in CTEPH patients can be challenging.So perioperative collaboration of a multidisciplinary team and elaborate anesthesia evaluation is extremely important.The principle of anesthesia during the period from anesthesia induction to initiation of cardiopulmonary bypass(CPB)is to maintain right heart – pulmonary artery coupling.During CPB and deep hypothermia cardiac arrest,the principle of anesthesia is to cooling and rewarming the patient slowly and evenly,while important organ protection must be done.And then after weaning from CPB to transport patients to ICU,the anesthesia principle is to protect left heart function and managing lung ischemia-reperfusion injury.This article focused on the pathophysiological characteristics of CTEPH and the characteristics of PEA operation,and summarized the anesthesia techniques according to operation procedure,as well as right heart function management,safe implementation of deep hypothermia circulation arrest,application of controlled hypo-cardiac output and management of pulmonary hemorrhage after operation.