非体外循环冠状动脉搭桥手术的麻醉管理

目的　总结非体外循环冠状动脉搭桥手术的麻醉管理体会。方法　麻醉前用药为吗啡0 15mg/kg ,东莨菪碱0 3mg。病人入室后面罩吸氧,行心电图Ⅱ/V5导联、MAP、CVP及血气、体温、SpO2 监测。以咪唑安定、芬太尼、维库溴胺作麻醉诱导,用药原则为间断、缓慢给药。术中用异氟醚、芬太尼、异丙酚、间断予维库溴胺维持。手术开始后给予硝酸甘油0 5～2 μg/kg/min。术中以艾司洛尔辅助控制心率,据血流动力学变化予苯肾上腺素或去甲肾上腺素、多巴胺和硝酸甘油/硝普钠维持MAP稳定。及时补充血容量和电解质。结果　5 2例病人在非体外循环下顺利完成手术,手术过程心率维持在70次/分左右,MAP维持在6 0mmHg左右。术后拔除气管导管时间为2 0±1 1h。5例患者因术中出现顽固性心律失常而紧急在体外循环下完成手术。结论　非体外循环冠状动脉搭桥手术麻醉原则是维持心肌氧供平衡。麻醉管理关键在于控制心率、适当减低心肌收缩幅度,维持冠状动脉灌注压、保持血流动力血相对平稳。

ANESTHETIC MANAGEMENT OF OFF-PUMP CORONARY ARTERY BYPASS GRAFTING

Objective To summarize anesthetic management of off-pump coronary artery bypass grafting (CABG). Methods Preanesthetic morphine 0.15mg/kg and scopolamine 0.3mg were given intramuscularly. ECG of lead Ⅱand Ⅴ5, MAP, CVP, SpO 2, body temperature and blood gas were monitored after patients were sent into the operation room. Anesthesia was slowly and intermittently induced with midazolam, fentanyl and vecuronium and maintained with isoflurane, fentanyl, propofol and vecuronium. Nitraglycerine was infused when the operation was started. Heart rate was controlled with esmolol. Phenynephrine, noradrenarine, dopamine and nitraglycerine or sodium nitrapruside were administered acording to hemodynamic change. Crystal and colloid solutions and electrolytes were given timely. Results 52 off-pump operations were smoothly completed. Heart rate was maintained at about 70 per minute and MAP at about 60 mmHg. Postoperative tracheal extubation was conducted in 2.0±1.1hours following the end of surgery. 5 patients were transferred to on-pump operations due to obstinate intraoperative arrhythmias. Conclusion The principle of anesthetic management of off-pump CABG is to maintain the balance between myocardial oxygen consumption and supply. The key is to control heart rate, moderately reduce myocardial contractility, maintain coronary perfusion and keep a smooth hemodynamics.