慢性血栓性肺动脉高压病人血栓内膜剥脱术的麻醉管理

本院1997年-2008年行肺动脉血栓内膜剥脱术的慢性血栓性肺动脉高压病人52例,男性41例,女性11例,年龄33～67岁,术前心功能Killip分级Ⅱ～Ⅳ级.麻醉诱导:静脉注射依托咪酯、芬太尼或舒芬太尼、罗库溴铵或维库溴铵,必要时静脉注射小剂量咪达唑仑,根据病人心功能状况和麻醉诱导中血液动力学变化调整给药剂量.气管插管后行机械通气,并放置Swan-Ganz导管.术中监测经食管超声心动图、鼻咽温和膀胱温.麻醉维持:以大剂量芬太尼或舒芬太尼为主,必要时吸入低浓度异氟烷或七氟烷.深低温低流量灌注或停循环条件下,行双侧肺动脉血栓内膜剥脱术.体外循环期间维持红细胞压积18%～25%.缓慢复温,保持鼻咽温与膀胱温之差小于5℃.停体外循环时维持血红蛋白浓度>100 g/L.体外循环后,给予相应的循环和呼吸支持,并行抗肺动脉高压处理.术毕循环和肺气体交换功能稳定后送外科ICU.肺血管血栓内膜剥离后肺出血6例(12%);术后持续性肺动脉高压35例(67%);术后出现神经系统并发症7例(14%);术后感染4例(8%);术后住院死亡8例(15%).

Anesthesia management of pulmonary endarterectomy in patients with chronic thromboembolism

Fifty-two patients with chronic thrombeembolism (41 male, 11 female) aged 33-67 yr underwent pulmonary endarterectomy between 1997-2008. Anesthesia was induced with etomidate, fentanyl/ sufentanil and rocuronium/vecuronium and maintained with large doses of narcotics supplemented with low concentrations of isoflurane/sevoflurane if necessary. Swan-Ganz catheter was placed after induction of anesthesia. Trausesophageal echocardiography was monitored. Bilateral pulmonary thromboembolism was performed using profound hypothermia with circulatory arrest. After operation, 35 patients still had sustained pulmonary hypertension (67%). Nervous system complications occurred in 7 patients ( 14% ). Six patients developed lung bleeding (12%) during and after operation and 4 patients infection (8%). The mortality was 15%.