同种原位心脏移植手术的麻醉管理  

Anesthesia management for orthotropic heart transplantation

作　　者：王成彬[1] 赵嘉美 丁琳 贾一新[2] 孟婓 马骏[1] Wang Chengbin;Zhao Jiamei;Ding Lin;Jia Yixin;Meng Fei;Ma Jun(Department of Anesthesiology,Beijing Anzhen Hospital,Capital Medical University,Beijing 100029,China;Heart Valve and Heart Transplant Center,Beijing Anzhen Hospital,Capital Medical University,Beijing 100029,China;Department of Anesthesiology,Peking University International Hospital,Beijing 102206,China)

机构地区：[1]首都医科大学附属北京安贞医院麻醉中心,100029 [2]首都医科大学附属北京安贞医院心脏瓣膜与心脏移植中心,100029 [3]北京大学国际医院麻醉科,102206

出　　处：《中华麻醉学杂志》2018年第9期1107-1110,共4页Chinese Journal of Anesthesiology

摘　　要：回顾总结2015年4月至2016年11月本院36例同种原位心脏移植手术,分析和讨论同种原位移植手术的麻醉管理经验和相关问题.终末期心脏疾病患者的麻醉管理方案以减少血流动力学波动,避免恶性心律失常为目标.本组病例选择静脉注射地西泮5~10 mg、依托咪酯0.2~0.3 mg∕kg或氯胺酮1 mg∕kg、舒芬太尼1.0~1.5μg∕kg或芬太尼10~15μg∕kg、罗库溴铵0.6 mg∕kg进行麻醉诱导;持续输注右美托咪定0.3~0.5μg·kg-1·h-1、顺式阿曲库铵10 mg∕h和舒芬太尼0.5~1.0μg·kg-1·h-1维持麻醉.使用漂浮导管监测受体肺动脉压和供心功能.体外循环后静脉输注多巴胺、肾上腺素和异丙肾上腺素维持循环稳定;静脉输注硝酸甘油和前列环素降低肺动脉压.免疫抑制治疗采用甲基强的松+吗替麦考酚酯+环孢霉素∕FK506方案.本组病例出院32例,死亡4例.其中1例死于肺动脉高压(肺动脉收缩压>67 mmHg),右心功能衰竭;1例脱离体外循环困难,使用EC-MO辅助,最终死亡;2例患者死于难治性低心排,多器官衰竭.心脏移植术麻醉管理需要熟知心力衰竭病理生理机制,有创监测、平稳的麻醉诱导和维持、稳定的围术期血流动力学、良好的供心保护是保证心脏移植手术麻醉管理的关键.Anesthesia was done for 36 patients undergoing orthotropic heart transplantation in Beijing Anzhen Hospital from April 2015 to November 2016.Anesthesia management for orthotropic heart transplantation and related problems were analyzed and investigated.Anesthesia management protocol for patients with end-stage heart disease was aimed at reducing fluctuation of hemodynamics and avoiding malignant arrhythmia.Anesthesia was induced by intravenously injecting diazepam 5-10 mg,etomidate 0.2-0.3 mg/kg or ketamine 1mg/kg,snfentanil 1.0-1.5μg/kg or fentanyl 10-15μg/kg and rocuronium 0.6 mg/kg.Anesthesia was maintained by continuously infusing dexmedetomidine 0.3-0.5 μg·kg^-1·h^-1,cisatracurium 10mg/h and sufentanil 0.5-1.0μg·kg^-1·h-1.Pulmonary arterial pressure and donor heart function were monitored using the flow-directed pulmonary artery catheter.Dopamine,epinephrine and isoprenaline were intravenously infused after cardiopulmonary bypass to maintain circulation stable.Nitroglycerin and prostacyclin were intravenously infused to decrease pulmonary arterial pressure.Immunosuppressive therapy was performed with methylprednisone,mycophenolate mofetil and cyclosporine/FK506.Thirty-two patients were discharged from hospital,and 4 cases died.Among.the 4 patients died,1 patient died of pulmonary hypertension (pulmonary arterial systolic pressure>67mmHg)and right heart failure and,1 patient showed difficulty in weaning from cardiopulmonary bypass and 2 patients died of refractory low cardiac output and multi-organ failure.Anesthetic management for heart transplantation required an appreciation of the pathophysiological mechanism of heart failure.Invasive monitoring,steady anesthesia induction and maintenance,stable hemodynamics in the perioperative period and good donor heart protection were the keys to ensuring anesthesia management for orthotropic heart transplantation.

关 键 词：心脏移植 麻醉 回顾性研究 

分 类 号：R614[医药卫生—麻醉学]