心脏双束支传导阻滞患者的麻醉处理

心脏双束支传导阻滞患者的麻醉处理沈通桃，陆文娟近年我院为８例双束支传导阻滞患者行９次手术。现就其麻醉处理报告如下。临床资料全组男７例，女１例，年龄６１～７９岁，均为右束支阻滞＋左前分支阻滞。术前心功能Ｉ级２例，Ⅱ级６例，伴高血压４例，冠心病、肺气肿各...     

临时心内起搏器在手术中的应用

在手术的麻醉诱导、手术牵拉及苏醒过程中,房室传导阻滞及束支传导阻滞易出现心脏骤停,常给麻醉及手术造成很大威胁。我院1999年1月～2000年12月,对19例房室传导阻滞及束支传导阻滞的病人,术前予置临时心内起搏器并接按需心脏起搏,使19例病人度过麻醉手术关。     

术前患者心腔心电图引导临时心脏起搏器放置的可行性

目的评价术前患者心腔心电图引导临时心脏起搏器放置的可行性。方法 72例心脏起搏或传导功能障碍、需行外科较大手术的患者,ASA Ⅰ-Ⅲ级,年龄42-89岁,术前心电图显示对阿托品无反应的严重心动过缓;Ⅱ度Ⅱ型房室传导阻滞;Ⅰ度房室传导阻滞伴左束支阻滞;完全性右束支传导阻滞伴左前分支阻滞等。术前心腔心电图引导放置临时心脏起搏器,穿刺途径分别为左锁骨下静脉18例,右颈内静脉54例。结果所有病例全部起搏成功,均无相关并发症发生。结论术前患者心腔心电图引导放置临时心脏起搏器是一种安全、简便的方法。     

手术诱发心脏病发作死亡六例教训

对于合并心脏病而需要手术的病人行手术治疗无疑增加了手术的危险性。自1986年~2004年笔者曾遇6例经手术诱发心脏病发作死亡的病例,现报告如下。临床资料本组男性4例,女性2例;年龄35~79岁,平均59.3岁,60岁以上者4例。慢性胆囊炎急性发作者2例;肝血管瘤、胃底癌、直肠癌和双侧甲状腺瘤者各1例;2年前因“心肌梗塞”治愈、高血压心脏病史20年和既往有“心慌、心悸”病史者各1例,心电图示:完全性右束支传导阻滞、窦性心动过速频发房性早搏和窦性心律T波改变者1例,另3例为窦性心律。采用连续硬膜外阻滞麻醉3例,全身麻醉2例,颈丛阻滞麻醉1例。行…     

封堵器介入治疗膜部室间隔缺损患者的护理

实施介入治疗的42例PMVSD患者,介入治疗技术成功率100%,术后2例发生不完全性右束支传导阻滞,2例非阵发性房室交界区性心动过速,1例第三度房室阻滞.经积极治疗,并给予术前心理护理加常规准备,术后加强穿刺部位出血、栓塞、心律失常、发热、机械性溶血、封堵器脱落等并发症的观察及护理,结果均痊愈.提示充分的术前护理,积极的术后监护,是保证患者手术成功,防止并发症的关键.     

临时心脏起搏器在心律失常病人术中的应用

我科将临时心脏起搏器 (英国产ＥＶ 4 5 4 3型 )应用于麻醉手术中 ,为一些过去认为不宜手术或高危病人安全地进行了手术治疗 ,收到了良好的效果。现报告如下。资料与方法一般资料　 18例中 ,男 15例 ,女 3例 ,ＡＳＡⅡ～Ⅲ级 ,年龄 35～ 85岁。心电图示二度Ⅱ型房室传导传导阻滞 7例 ,频发室性早搏 6例 ,右束支加左前分支传导阻滞 3例 ,病窦综合征 2例 (ＨＲ <4 8次 /分 )。其中前列腺增生汽化切除术 5例 ,腹腔镜胆囊切除术 2例 ,胃癌行胃大部切除术 4例 ,双下肢截肢术 1例 ,脾功能亢进行脾切除术 3例 ,子宫次全切除 1例 ,脑挫裂伤开颅探查…     

甲磺酸罗哌卡因用于硬膜外麻醉的有效性与安全性的临床研究

目的 以盐酸罗哌卡因注射液为对照,研究甲磺酸罗哌卡因注射液在下腹部和下肢手术患者中实施硬膜外麻醉的安全性和有效性.方法 采用前瞻性、多中心、随机、双盲、阳性药物平行对照试验方法 ,随机入组122例患者,均分为甲磺酸罗哌卡因注射液组(研究组)和盐酸罗哌卡因注射液组(对照组).观察两组患者术前感觉阻滞上界达T8或T10时间、感觉阻滞和运动阻滞范围,术后感觉阻滞和运动阻滞消失时间、麻醉医师、手术医师满意度.结果 麻醉失败3例,术中改变麻醉方案1例.实际完成病例数:研究组58例,对照组60例.麻醉有效性:两组药物达到T8麻醉平面的时间为15 min(中位数);达到T10的时间研究组为15 min,对照组为10 min,两组间差异无统计学意义.两组患者的麻醉阻滞平面最高达到T2,最低在T12,多数在T5～T10在用药后30 min,两组多数患者(83.63%～88.33%)的运动阻滞处于改良Bromage评分2级或3级.停药后感觉阻滞平面消失的时间研究组平均(中位数)为210 min,对照组平均为180 min,两组间差异无统计学意义.全部患者感觉阻滞消失的时间在300 min.安全性:研究药物使用前后对谷丙转氨酶(ALT)、谷氨酸氨基转移酶(AST)、尿素氮(BUN)、肌酐(Cr)的观察显示,对照组有1例发生ALT改变(增高至152 u/L)、3例发生头晕、恶心、耳鸣、双腿麻木、不适、烦躁等不良反应,未经特别处理自行恢复.结论 甲磺酸罗哌卡因注射液与盐酸罗哌卡因注射液有相似的麻醉有效性和安全性.     

联合阻滞麻醉在高龄高危患者PFNA手术中的临床观察

目的 评价神经刺激仪定位腰丛一坐骨神经联合阻滞麻醉在高龄高危患者应用AO股骨近端髓内钉-抗螺旋刀片(PFNA)手术中的麻醉效果.方法 对30例合并多种严重内科疾病行PFNA手术的高龄患者,采用神经刺激仪定位下行腰丛-坐骨神经联合阻滞麻醉,术中辅助镇静,常规管理呼吸和循环,并记录血流动力学变化和不良反应的发生率.结果 30例PFNA手术患者麻醉效果满意,术中血流动力学较平稳,无神经阻滞不全,无局麻药中毒、恶心、呕吐,尿潴留及术后低血压等并发症发生.结论 对高龄高危PFNA手术患者采用神经刺激仪定位下腰丛-坐骨神经联合阻滞麻醉是比较理想的麻醉方法.     

精索阻滞麻醉用于阴囊内手术

以往做阴囊内手术时,常采用脊髓麻醉而很少采用精索阻滞麻醉。本文作者三年中对数百例阴囊内手术患者运用此法,并与脊髓麻醉进行了比较认为这种麻醉方法的优点在于快速、高效、价廉、安全,可以作为阴囊内手术的首选麻醉法。作者对343例需作各种阴囊内手术病例采用了精索阻滞麻醉。     

心脏手术患者术中安置临时起搏器的护理

Ⅲ度房室传导阻滞，窦性停搏等心律失常是体外循环心脏手术患者常见而又严重的并发症，与术中低温、麻醉、传导束水肿及手术损伤等因素有关，安置起搏器是最有效且可靠的防治手段。我科１９９７～１９９８年对１０例心脏手术患者于术中安置临时起搏器，护理如下。１临床资...     

Perioperative transcutaneous pacemaker in patients with chronic bifascicular block or left bundle branch block and additional first-degree atrioventricular block

BACKGROUND: Complete heart block is dreaded perioperatively in patients with chronic bifascicular or left bundle branch block (LBBB) and additional first-degree A-V block. Our aim was to investigate the necessity as well as the efficacy and safety of transcutaneous pacing in the perioperative setting. METHODS: Thirty-nine consecutive patients with asymptomatic chronic bifascicular block or LBBB and prolongation of the P-R interval scheduled to undergo surgery under anesthesia were prospectively enrolled in the study. Preoperatively, a transcutaneous pacemaker (PACE 500 D, Osypka Co.) was applied; its efficacy was checked with intra-arterial blood pressure measurement; the pain level was recorded. Additionally, 24-h Holter monitoring (CM2, CM5) was applied. Occurrences of a block progression or a bradycardia of <40 beats/min with hemodynamic impairment were the defined end points. RESULTS: Thirty-seven of the 39 patients (95%) could be successfully stimulated with a median current strength of 70 mA; whereby 33 of the 39 patients felt moderate to severe pain. There was no perioperative block progression. Three cases of brady-cardia of <40 beats/min with a critical drop in blood pressure occurred; but these patients were successfully treated with drug therapy without pacemaker stimulation. CONCLUSION: The perioperative application and testing of the pacemaker was safe and could be performed in nearly all patients successfully. However, we do not consider a routine prophylactic transcutaneous placement in patients with chronic bifascicular or LBBB and additional first-degree A-V block justified. Nevertheless, appropriate drugs and temporary pacemaker equipment should be easily accessible.     

Pacemaker therapy in Kearns-Sayre syndrome

Kearns-Sayre syndrome is regarded as a type of mitochondrial encephalomyopathy accompanied with mitochondrial DNA abnormality of the muscle. Diagnosis of this disease is based upon the progressive external ophthalmoplegia, atypical retinal pigmentation and cardiac conduction block. We report two clinical cases of this disorder treated with permanent pacemaker implantation at a 20 year old man (patient 1) and a 27 years old woman (patient 2). Patient 1 with bifascicular block at 19 years old progressed into complete heart block at 20 years old. Patient 2 with complete heart block was occurred "torsade de pointes." Several problems of this disease in permanent pacing should be considered the patients' small size, pacing mode selection and coexistence of congenital heart disease. Routine electrocardiography is recommended for these patients and bifascicular block in this disease constitutes a definite indication for prophylactic pacemaker implantation.     

Hyperkalaemic complete heart block. A report of 2 unique cases and a review of the literature

Two White male patients with temporary complete heart block (CHB) secondary to hyperkalaemia are presented. One, a 40-year-old man, developed CHB with ensuing shock within the first 24 hours of repeat aortic valve replacement for a paraprosthetic leak caused by previous endocarditis. This patient experienced iatrogenic hyperkalaemia. The second was an 81-year-old man who had chronic renal failure and presented with Stokes-Adams attacks. This patient was initially thought to have degenerative CHB and nearly underwent inadvertent permanent pacemaker insertion. Both patients were initially treated with emergency temporary cardiac pacing with subsequent successful management. Temporary CHB secondary to hyperkalaemia, from whatever cause, has very rarely been documented in the literature. A review of this potentially lethal complication is undertaken and the significance of unifascicular and bifascicular conduction block as a consequence of hyperkalaemia is discussed.     

Late recovery of atrioventricular conduction after pacemaker implantation for complete heart block associated with surgery for congenital heart disease

OBJECTIVES: Pacemaker implantation is a standard recommendation for patients with persistent complete heart block following surgery for congenital heart disease. This study was performed to determine the incidence and clinical significance of late recovery of atrioventricular conduction following pacemaker implantation. METHODS: Between 1990 and 2001, 5662 open cardiac procedures for congenital heart defects were performed at our institution. The postoperative course of all patients with complete heart block in whom a permanent pacemaker was implanted was followed on a monthly basis, by either clinical or transtelephonic follow-up. RESULTS: A total of 72 patients with persistent postoperative complete heart block underwent pacemaker implantation. After insertion of the pacemaker, recovery of atrioventricular conduction was recognized in 7 of 72 patients (9.6%) at a median of 41 days (18-113 days) after the initial cardiac operation. These included 3 patients with ventricular septal defect, 2 with ventricular inversion or single ventricle, and 1 each with left ventricular outflow tract obstruction and atrioventricular septal defect. During a mean follow-up of 4.4 +/- 2.6 years, there was no late recurrence of heart block. Three patients had residual right bundle branch block and 1 had first-degree atrioventricular block. CONCLUSIONS: Atrioventricular conduction may return in a small but significant percentage of patients following pacemaker implantation for complete heart block associated with congenital heart surgery. When recovery of atrioventricular conduction occurs within the first months after surgery it appears reliable, which suggests that lifelong cardiac pacing may not be necessary in these individuals.     

Pre-operative prophylactic transvenous cardiac pacing for bifascicular heart block

Some authorities consider that the combination of right bundle-branch block with left axis deviation (bifascicular block) is not an indication for prophylactic insertion of a pacing generator in patients undergoing non-cardiac surgery. Five patients who developed peri-operative progression of bifascicular block to complete heart block are described. Bifascicular block, together with any other cardiovascular condition, advanced age or surgery in regions that promote vagal stimulation, merit consideration for prophylactic pacing. A cardiological opinion is an essential aspect of the pre-operative preparation of patients with this abnormality.     

Perioperative risk of complete heart block in patients with bifascicular block and prolonged PR interval.

Because there is a paucity of information on the perioperative risk of developing complete heart block among patients with bifascicular block (either right bundle branch block and left anterior hemiblock or left bundle branch block) and a long PR interval on the surface electrocardiogram, we undertook an analysis of 76 such patients. Twenty-three patients had right bundle branch block and left axis deviation with a long PR interval and 53 had left bundle branch block with along PR interval. Thirty patients had 37 general anaesthetics, 23 had 32 spinal anaesthetics, and 50 had 64 local anaesthetics or endoscopic procedures. No patient developed complete heart block. Four patients developed sinus bradycardia during general anaesthetics, responsive to atropine or isoproterenol. Similarly, none of the 23 such patients in the literature reviewed had developed complete heart block. Because placement to temporary pacemakers is not without risk, we conclude that prophylactic pacing is not necessary in asymptomatic patients with bifascicular block even in the presence of a long PR interval. Since we did not study patients with recent syncope or myocardial infarction, caution should be exercised in applying these results to such patients.     

Treatment of cardiac arrhythmias in patients with acute myocardial infarction

Cardiac arrhythmias and conduction disturbances are commonly observed in patients with acute myocardial infarction. The available data suggest the administration of prophylactic lidocaine, either through a large intramuscular dose (300 mg), which is particularly suited for out-patient situations, or through intravenous loading doses followed by a constant lidocaine infusion. Patients with ventricular arrhythmia should be treated with direct-current countershock if hemodynamic deterioration is present. Drug therapy for patients with ventricular arrhythmias who are resistant to lidocaine include procainamide, bretylium, or intravenous amiodarone (experimental drug).Treatment of atrioventricular block in acute infarction depends on the site of atrioventricular block, the infarct location, and the hemodynamic status. Generally, atrioventricular block associated with inferior infarction and normal hemodynamic states generally does not require insertion of a pacemaker. In contrast, patients with anterior myocardial infarction and Mobitz II or third degree atrioventricular block should be treated with emergent temporary insertion of a pacemaker. In addition, prophylactic pacing is clearly indicated for those with acute myocardial infarction complicated by the bifascicular block pattern or first degree atrioventricular block and new onset bundle branch block.     

Disorders of cardiac rhythm and conduction after radical correction of tetralogy of Fallot]

The work is based on the results of examination of 78 patients conducted before, in the immediate, and in the late-term periods after the operation (6.5 +/- 5.0 years on the average). Holter's monitoring and bicycle ergometry conducted before the operation revealed rhythm disorders in 55% of patients: complete block of the right limb of the bundle of His in 30, I-III degree atrioventricular block in 9%, supraventricular arrhythmias in 2.5%, ventricular arrhythmias in 5%, and combined arrhythmias in 7.5% of patients. Complete block of the right limb of the bundle of His was discovered in all patients in the late-term postoperative periods, and other types of rhythm disorders were found in 62% of patients: I degree atrioventricular block in 2.5%, bifascicular block in 2.5%, ++tri-fascicular block in 1%, ventricular arrhythmias in 26%, and combined arrhythmias in 30% of patients. The results of the examination showed that: (1) the presence of stable block of the right limb of the bundle of His, bifascicular block, as well as ventricular arrhythmia of I-II gradation after Laun-Wolf does not lead to decrease of myocardial working capacity and contractile function. In contrast, III-IV gradient ventricular arrhythmia is attended by significant diminution of myocardial contractility; (2) the incidence of ventricular arrhythmias grows with increase of the patients' age at the time of the operation and intensification of the degree of initial arterial hypoxemia and the anatomical severity of the anomaly; (3) correction of the anomaly contributes to the disappearance of the preoperative arrhythmias.(ABSTRACT TRUNCATED AT 250 WORDS)     

Complete atrioventricular block during anesthesia

PURPOSE: To describe a case of asymptomatic first degree atrioventricular block with a bifascicular block that progressed to complete atrioventricular block during anesthesia. This potentially fatal block was successfully treated with transesophageal ventricular pacing. CLINICAL FEATURES: A 67-yr-old man was scheduled for microvascular decompression of the right trigeminal nerve under general anesthesia. His preoperative ECG showed first degree atrioventricular block with complete right bundle branch block and left anterior hemiblock, but he had experienced no cardiovascular symptoms. Anesthesia was induced with sevoflurane 5%, and maintained with isoflurane 1.5-2% in oxygen. Fifteen minutes later in the left lateral decubitus position, the systolic arterial blood pressure suddenly decreased from 80 mmHg to 0 mmHg. Then, the ECG abruptly changed from sinus rhythm to complete atrioventricular block. The heart was unresponsive to drug therapy such as atropine 1.3 mg and isoproterenol 0.5 mg, or transcutaneous pacing but transesophageal pacing was successful. CONCLUSION: Asymptomatic first degree atrioventricular block with bifascicular block advanced to complete atrioventricular block during anesthesia. The block was successfully managed with transesophageal pacing.     

Cardiac pacing in premature infants and neonates: steroid eluting leads and automatic output adaptation.

BACKGROUND: Appropriate generator and lead selection as well as techniques of implantation are most important aspects of cardiac pacing in the extremely young patient. Here we report the clinical results using a new technique with automatic output adaptation based on evoked response in combination with steroid-eluting epicardial leads in small children. METHODS: One neonate and 2 premature infants underwent permanent pacemaker implantation because of congenital high-degree atrioventricular block or postoperative complete heart block, respectively. Steroid-eluting epicardial leads and a multiprogrammable pacemaker with automatic output adaptation were used. RESULTS: Intermuscular abdominal generator placement and epicardial suture-fixation of the bipolar lead through a subcostal approach was without complications. Serial follow-up examinations revealed safe and consistent pacemaker function up to 12 months after operation. CONCLUSIONS: The technique represents an excellent alternative for permanent cardiac pacing in extremely small patients. We believe that it provides an increase in functional lifetime of the devices and delays the need for battery replacement with its associated complications in this young patient population.