经胸降主动脉微创冠状动脉旁路移植术的麻醉处理  

Anesthetic Management for Off-Pump Coronary Artery Bypass Grafting with "Y" Blood Vessel Graft Anastomosis from Descending Thoracic Aorta

作　　者：杜立[1] 夏中元[1] 孟庆涛[1] 

机构地区：[1]武汉大学人民医院麻醉科,武汉430060

出　　处：《中国医药导刊》2011年第4期606-607,共2页Chinese Journal of Medicinal Guide

摘　　要：目的:探讨经胸降主动脉微创冠状动脉旁路移植术的麻醉处理实施和管理要点。方法:42例冠心病患者,拟经左胸小切口、经胸降主动脉"Y"型血管桥向心肌供血,实施非体外循环冠状动脉旁路移植术。实施静吸复合全身麻醉+双腔气管插管术。麻醉管理要点:①在冠状动脉造影的基础上,重点应实施静态肺功能评估和实质功能(动脉血气)测定;②采用静脉复合慢诱导、合理的麻醉深度及使用减轻气管插管反应的药物;③麻醉维持以七氟烷为主,使用小剂量硝酸甘油,实时监测P_(ET)CO_2和动脉血气,尽量缩短单肺通气时间;④合理镇痛:诱导前给予曲马多(1mg/kg～1.5mg/kg)+凯芬(1mg/kg)先发镇痛;术中使用舒芬太尼+曲马多(2mg/kg),术毕PICA。结果:麻醉诱导平稳、满意度高;麻醉维持期间2例因CO_2蓄积而采用间断单肺通气,余40例过程平稳顺利完成手术;16例病人术毕完全清醒、生命体征稳定、镇痛完善,顺利拔管。平均手术时间(104±13.8)min。带管入ICU患者术后平均机械辅助呼吸(5.2±2.5)h,平均ICU滞留(36.4±5.8)h,全组患者无死亡,均治愈出院。结论:经胸降主动脉冠状动脉旁路移植术于升主动脉存在钙化、扩张或粥样硬化斑块者的一个新途径。其麻醉要点为:采用复合用药、慢诱导达到合理麻醉深度以满足实施双腔气管插管的需要;尽量缩短单肺通气时间,避免缺氧和CO_2蓄积,加强动脉血气监测;平衡镇痛。Objective：To investigate the clinical results of minimally invasive coronary artery bypass grafting with ＂Y＂ blood vessel graft anastomosis from descending thoracic aorta to coronary artery.Methods：There were 66 patients with coronary heart disease,including 49 males and 17 females.Their age ranged from 46 to 52 years with a mean age of （63.8±9.0）years.Multi-vessel disease was found in all patients by coronary angiography,double ones in 15,three ones in 38,four ones in 13.Left ventricular ejection fraction was from 35%±62% with a mean of （53±8）%.Their angina pectoris was classified by the Canada cardiovascular society （CCS）,class Ⅱ in 15,class Ⅲ in 36,class Ⅳ in 15.We used several minimally invasive techniques including ＂Y＂ blood vessel（saphenous vein） graft anastomosis from descending thoracic aorta to coronary artery, minimally invasive incision on the left thorax and dissection of internal mammary artery by thoracoscope,off-pump coronary artery bypass grafting,etc.The meaning of ＂Y＂ blood vessel graft anastomosis is that one main vessel graft supplied blood to myocardium from descending thoracic aorta whose anastomotic stoma is 5cm on diaphragm by end to side anastomoses,another vessel supplied blood to myocardium from the main vessel graft by end to side anastomoses.The grafts were measured by Medi-Stim Butterfly Flowmetre for transient flow quality.Results：All patients were survived.The mean duration of intuhafion was （5.6±3.2） hours.The average ICU stay were （37.3±7.6） hours.The average chest drainage were （190±75）ml.The average blood transfusion were （150±50）mi.The Qm was （27±7）ml/min,PI was（3.5± 1.4）,Insuf was （7±5）%.All survived patients were followed up （12 to 48 months） by UCG and ECG, which showed they had no symptoms of anginactoris,their activity amount and cardiac function were improved.Conclusion：The ＂Y＂ blood vessel graft anastomosis from descending thoracic aorta to coronary artery with minimally invasive inc

关 键 词：冠状动脉 旁路术 非体外循环 降主动脉 麻醉处理 

分 类 号：R614[医药卫生—麻醉学]