小儿先天性心脏病合并肺动脉高压的麻醉管理

目的探讨小儿先天性心脏病合并肺动脉高压的麻醉处理。方法先天性心脏病合并肺动脉高压的小儿63例,年龄3月～3岁,ASAⅢ～Ⅳ级。大剂量芬太尼静脉复合七氟烷吸入全身麻醉,浅低温体外循环下行房室间隔缺损修补术和(或)动脉导管未闭结扎术。体外循环中至手术结束维持PEEP 2～5 mmHg,以减少肺水。维持PCO2在30～35 mmHg,CVP在7～15 mmHg。开放主动脉前10 min开始静脉泵入多巴胺5～10μg/(kg.min)、硝普钠0.5～2.0μg/(kg.min)和米力农0.5～1.0μg/(kg.min)。其中,在术前肺动脉压>45mmHg的患儿中,多巴胺的给药途径为经左房导管泵入。结果所有患儿术中血流动力学均稳定,开放升主动脉后,58例心脏自动复跳,4例心内1～2 J除颤1次,1例除颤2次后复跳。所有患儿均顺利停体外循环辅助。术前彩超提示有8例右向左或双向分流的患儿在术后2 d脱离呼吸机拔除气管导管,其余患儿均在术后1 d拔除气管导管。所有患儿均痊愈出院,无严重并发症。结论先天性心脏病合并肺动脉高压的患儿,首先应保证合理的容量负荷,体外循环转机前保持一定的体循环压力以减少右向左分流,体外循环后通过血管活性药物的合理使用,降低肺动脉压并维持体循环阻力,以使血流动力学平稳。

Anesthesia management of children with congenital heart disease and pulmonary hypertension

Objective To discuss the anaesthesia methods of children combined with congenital heart disease and pulmonary hypertension.Methods 63 children with congenital heart disease and pulmonary hypertension received operation and anaesthesia,which aged from three months to three years and ASA classified as Ⅲ-Ⅳ degree.The children accepted open heart operation of atrial and ventricuiar sepatl defect and/or patent ductus arteriosus under general anaesthesia of combined intravenous and inhalation and mild hypothermic cardiopulmonary bypass.CVP was maintained between 7-15mmHg.In order to minimize the extravasculur lung water and improve ventilation,PEEP was set at 2-5mmHg from the beginning of the cardiopulmonary artificial bypass to the end of the operation.High minute ventilation was used to maintain the PCO2 between 30-35mmHg.Dopamine 5-10μg/(kg·min),Nitroprusside sodium 0.5-2.0μg/(kg·min) and Milrinone 0.5-1.0μg/(kg·min) were administered intravenously by micropump when rewarming started(ten minutes before declamping of the arteriae aorta).In the children whose pulmonary arterial pressure >45mmHg,dopamine was given via atria sinistrum.Results Hemodynamics was stable in all of the children during operation.After aortic declamping,58 children resuscitated spontaneously,but 4 cases received defibrillation 1-2J once and one child received twice before resuscitation.All of the children separated from the extracorporeal circulation.55 children had tracheal extubation at first postoperative day,meanwhile 8 cases with bidirectional shunt showed by preoperative echocardiogram had extubation at the second postoperative day.All of the patients were discharged without severe complications.Conclusion In the operation of the children with congenital heart disease and pulmonary hypertension,adequate volume load should be reached.From the beginning of the cardiovascular bypass to the end of the operation,vasoactive drugs should be used to decrease the pulmonary arteri al resistance and maintain the general circulation resistance.