非体外循环下机器人冠状动脉旁路移植手术的麻醉管理

目的 总结非体外循环机器人冠状动脉旁路移植手术中的麻醉技术.方法 2007年1月至2011年3月共完成机器人心脏跳动下冠状动脉旁路移植手术163例,其中62例全机器人冠状动脉旁路移植手术,101例机器人辅助肋间小切口冠状动脉旁路移植手术.麻醉均采用全麻,左侧双腔气管插管.结果 术中单肺通气和CO2气胸引起动脉氧分压(PaO2)和静脉氧饱和度显著降低,163例患者中有17例出现低氧,SpO2降至0.92.使用5～15 cmH2O的持续气道正压后,PaO2从(59±12)mm Hg升至(115±23)mm Hg(P<0.05).CO2气胸开始阶段平均动脉压和心脏指数明显降低,同时伴有平均肺动脉压增高、心率加快,经快速补液和使用血管活性药得以纠正.术后(7.5±3.1)h拔管,ICU停留平均21h.1例因肺部感染在ICU治疗3天;1例行二次手术止血.全部患者术后住院4～7天.结论 非体外循环机器人冠状动脉旁路移植手术中的单肺通气和CO2气胸对患者循环和呼吸功能的影响是麻醉管理的关键.心脏外科医师和麻醉医师要熟练掌握单肺通气和CO2气胸的相关技术知识,恰当处理术中缺氧和血流动力学波动.

Abstract：

Objective Anesthesia for endoscopic robotic coronary artery bypass grafting surgery on beating heart to deal with the hemodynamic compromise, hypoxia and hypercarbia relevant to one lung ventilation ( OLV ) and intrathoracic inflation of CO2 with positive pressure (CO2 pneumothorax) is crucial. Methods Between February 2007 and January 2011, 163 patients underwent robotically assisted coronary artery bypass surgery on beating heart using the da Vinci S Surgical System. Of them, 62 patients underwent totally endoscopic coronary artery bypass grafting ( TECAB). Other 101 patients underwent robotically assisted endoscopic atraumatic coronary artery bypass ( ENDOACAB) in which the left internal mammary artery was harvested robotically and direct anastomosis via a small left anterior thoractomy incision. Results PaO2 and SvO2 after initiate of OLV and CO2 pneumothorax showed a significant decrease. Meanwhile, the SpO2 decreased to 0.92 in 17 of the 163 patients.In these patients, application of CPAP setting 5-15 cmH2O to the collapsed lung resulted in an increase in PaO2 from (59 ±12) mmHg to (115 ±23) mmHg (P < 0.05). At the beginning of CO2 pneumothorax the most dramatic fall in MAP and CI was showed with an increase in MPAP and HR. The hemodynamie compromise was counteracted by transfusion and inotropes/ vasopressors. Postoperatively, the average extubation time was (7. 5 ±3. 1) hours, and median ICU length of stay was 21 hours. One patient remained in the ICU for 3 days for treatment of a postoperative pneumonia. One patient who had underwent ENDOACAB were reexplored for bleeding in the left anterior thoracotomy incision. All patients were discharged home 4 to 7 days after surgery. Conclusion Anesthetic management for the procedures requires detailed knowledge of OLV and CO2 pneumothorax in addition to expertise required in conventional cardiac surgery.

Anesthesia for endoscopic robotic coronary artery bypass grafting on beating heart

Objective Anesthesia for endoscopic robotic coronary artery bypass grafting surgery on beating heart to deal with the hemodynamic compromise, hypoxia and hypercarbia relevant to one lung ventilation ( OLV ) and intrathoracic inflation of CO2 with positive pressure (CO2 pneumothorax) is crucial. Methods Between February 2007 and January 2011, 163 patients underwent robotically assisted coronary artery bypass surgery on beating heart using the da Vinci S Surgical System. Of them, 62 patients underwent totally endoscopic coronary artery bypass grafting ( TECAB). Other 101 patients underwent robotically assisted endoscopic atraumatic coronary artery bypass ( ENDOACAB) in which the left internal mammary artery was harvested robotically and direct anastomosis via a small left anterior thoractomy incision. Results PaO2 and SvO2 after initiate of OLV and CO2 pneumothorax showed a significant decrease. Meanwhile, the SpO2 decreased to 0.92 in 17 of the 163 patients.In these patients, application of CPAP setting 5-15 cmH2O to the collapsed lung resulted in an increase in PaO2 from (59 ±12) mmHg to (115 ±23) mmHg (P < 0.05). At the beginning of CO2 pneumothorax the most dramatic fall in MAP and CI was showed with an increase in MPAP and HR. The hemodynamie compromise was counteracted by transfusion and inotropes/ vasopressors. Postoperatively, the average extubation time was (7. 5 ±3. 1) hours, and median ICU length of stay was 21 hours. One patient remained in the ICU for 3 days for treatment of a postoperative pneumonia. One patient who had underwent ENDOACAB were reexplored for bleeding in the left anterior thoracotomy incision. All patients were discharged home 4 to 7 days after surgery. Conclusion Anesthetic management for the procedures requires detailed knowledge of OLV and CO2 pneumothorax in addition to expertise required in conventional cardiac surgery.