腹主动脉瘤腔内修复与开腹切除术的麻醉管理比较

目的比较腹主动脉瘤腔内修复与开腹切除术的麻醉管理特点。方法 2010年2月~2011年1月,70例ASAⅡ~Ⅳ级,肾下型腹主动脉瘤行腔内修复术52例（腔内修复组）,开腹切除术18例（开腹切除组）。开腹切除组采用气管内插管全身麻醉。腔内修复组采用的麻醉方法包括气管内插管全身麻酔、全凭静脉麻醉（喉罩通气）和监护麻醉。气管内插管全身麻醉采用快速顺序静脉诱导,气管插管后机械控制呼吸,静吸复合方式维持麻醉;全凭静脉麻醉（喉罩通气）采用丙泊酚靶控静脉输注,经喉罩行机械通气控制呼吸;监护麻醉保留自主呼吸,适当镇静镇痛。结果开腹切除组在气管内插管全身麻醉下完成手术,术中均需要使用血管活性药物控制血压。腔内修复组有57.7%（30/52）的患者采用气管内插管全身麻醉、34.6%（18/52）的患者采用全凭静脉麻醉（喉罩通气）和7.7%（4/52）的患者在监护麻醉下完成手术。与开腹切除组相比,腔内治疗组术中血压较平稳,麻醉时间（90±27）min vs.（210±44）min,t=13.668,P=0.000]、手术时间（45±22）min vs.（187±36）min,t=-19.811,P=0.000]、术中输注晶体液（750±178）ml vs.（1896±367）ml,t=17.486,P=0.000]、胶体液（349±147）ml vs.（1257±266）ml,t=18.034,P=0.000]、异体血（50±34）ml vs.（898±154）ml,t=-37.615,P=0.000]、术后返ICU患者比例（15.4%vs.66.7%,χ2=17.231,P=0.000）及术后住院时间（8.5±2.1）d vs.（15.2±4.3）d,t=8.700,P=0.000]均明显降低。结论腹主动脉瘤腔内修复术的麻醉手术时间、液体出入量及血管活性药物应用水平远低于腹主动脉瘤开腹切除术,且监护麻醉、全凭静脉麻醉适用于该术式。

Comparison of Anesthetic Managements for Abdominal Aortic Aneurysm Endovascular and Open Aortic Surgery

Objective To compare the anesthetic managements of endovascular and open aortic surgeries for abdominal aortic aneurysm. Methods Between February 2010 and January 2011,a total of 70 patients（ASA class Ⅱ~Ⅳ） were treated for infrarenal abdominal aortic aneurysm,among which 52 received endovascular aortic surgery and 18 received open aortic surgery.Under general anesthesia（endotracheal intubation）,total intravenous anesthesia（TIVA）（ventilated via laryngeal mask airway）,or monitored anesthesia care（MAC）,the operations were carried out.Rapid sequence induction was used for general anesthesia with intubation,after the intubation mechanical ventilation was employed,and then both intravenous and inhaled anesthesia were used for maintenance.For TIVA,we employed target-controlled intravenous infusion of propofol,and then used laryngeal mask for mechanical ventilation.During anesthesia monitoring,spontaneous ventilation was maintained,and sedation and analgesia were used when necessary. Results All the patients in the open surgery group received general anesthesia with intubation.Though vasoactive agents were applied during the operation,severe hemodynamic fluctuations could still be observed.In the endovascular surgery group,57.7% of the patients（30/52） received general anesthesia,34.6%（18/52） received TIVA（ventilated via laryngeal mask airway）,and 7.7%（4/52） received MAC.The blood pressure was relatively stable during the operation in this group compared to the open surgery group.The anesthesia time （90±27） min vs.（210±44） min,t=13.668,P=0.000],operation time （45±22） min vs.（187±36） min,t=-19.811,P=0.000],and postoperative hospital stay （8.5±2.1） d vs.（15.2±4.3） d,t=8.700,P=0.000] in the endovascular surgery group were significantly lower than those in the the open surgery group. Conclusion Compared to open surgery,endovascular aortic surgery not only requires less anesthesia and operation time,but also leads to less blood loss and transfusion.The total volume of vasoactive agents applied in the endovascular surgery is much lower.MAC and TIVA are feasible in endovascular aortic surgery.