双肺移植同期冠状动脉旁路移植术1例麻醉管理  

Anesthesia management in bilateral lung transplantation plus coronary artery bypass grafting in one case

作　　者：曹彬 王勇[1] 金峰[1] 范怡明 任莉方 赵高峰[2] 丁志丹[2] 王跃斌[2] 乔晨晖[3] 黄明君[4] 艾艳秋[1] CAO Bin;WANG Yong;JIN Feng;FAN Yi-ming;REN Li-fang;ZHAO Gao-feng;DING Zhi-dan;WANG Yue-bin;QIAO Chen-hui;HUANG Ming-jun;AI Yan-qiu(Department of Anesthesiology and Perioperative Medicine,the First Affiliated Hospital of Zhengzhou University,Zhengzhou,Henan 450052,China;Department of Thoracic Surgery and Lung Transplantation Surgery,the First Affiliated Hospital of Zhengzhou University,Zhengzhou,Henan 450052,China;Department of Cardiac Surgery,the First Affiliated Hospital of Zhengzhou University,Zhengzhou,Henan 450052,China;In Vitro Support Center,the First Affiliated Hospital of Zhengzhou University,Zhengzhou,Henan 450052,China)

机构地区：[1]郑州大学第一附属医院麻醉与围术期医学部,河南郑州450052 [2]郑州大学第一附属医院胸外科/肺移植外科,河南郑州450052 [3]郑州大学第一附属医院心脏外科,河南郑州450052 [4]郑州大学第一附属医院体外支持中心,河南郑州450052

出　　处：《中华实用诊断与治疗杂志》2023年第1期59-63,共5页Journal of Chinese Practical Diagnosis and Therapy

基　　金：河南省医学科技攻关计划省部共建项目(SB201901001)。

摘　　要：目的探讨1例行双肺移植同期冠状动脉旁路移植术患者的麻醉管理方法。方法1例特发性肺纤维化合并冠心病患者,男,55岁,于体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)辅助下采用全静脉麻醉行双肺移植同期冠状动脉旁路移植术。术中采用小潮气量保护性肺通气策略联合ECMO维持心肌氧供,应用经食管超声和Swan-Ganz导管监测心脏收缩功能、血流动力学参数和容量状态,指导血管活性药物使用。记录麻醉诱导后10min(T_(0))、置入Swan-Ganz导管后5min(T_(1))、ECMO运转10min(T_(2))、单肺通气30min(T_(3))、吻合左前降支(T_(4))、搭桥完成后10min(T_(5))、左肺动脉阻断后10min(T_(6))、左肺动脉开放后10min(T_(7))、右肺动脉阻断后10min(T_(8))、右肺动脉开放后10min(T_(9))、双肺通气10min(T_(10))、出手术室(T_(11))时心率、动脉血压、中心静脉压、血氧饱和度和肺动脉压。记录患者麻醉诱导前、T_(3)、T_(4)、T_(7)、T_(9)时pa(O_(2))和pa(CO_(2)),肺移植前后双侧肺静脉流速。结果术中动脉血压、中心静脉压在T_(8)时均降低,其他各时间点均维持正常范围;随着ECMO运行及肺移植手术的进行,T_(2)~T_(11)时肺动脉压逐渐下降维持稳定但均高于正常值,双肺移植后(T_(9)~T_(11))肺动脉压降至术中最低(28/19mm Hg);患者术中氧合状态良好,血氧饱和度、pa(O_(2))均维持在正常范围;ECMO运行后,T_(3)、T_(4)、T_(7)、T_(9)时pa(CO_(2))逐渐降至正常范围;肺移植前左、右肺静脉流速分别为60、56cm/s,双肺移植后分别升高至92、100cm/s。术后16h撤除ECMO,术后第1天出现低心排血量综合征,术后第2天出现中度原发性移植肺失功,经对症治疗后心功能、肺功能逐渐改善。术后第6天为便于气道管理行气管切开。术后第13天患者心功能恢复良好,血流动力学平稳,可下床活动,间断撤离呼吸机。目前继续康复治疗中。结论双肺移植同期冠状动脉旁路�Objective To investigate the anesthesia management of combined lung transplantation and coronary artery bypass grafting in one case.Methods A 55-year-old male patient with idiopathic pulmonary fibrosis and coronary heart disease underwent bilateral lung transplantation and coronary artery bypass grafting assisted by extracorporeal membrane oxygenation(ECMO)under total intravenous anesthesia.Low-tidal volume protective pulmonary ventilation strategy was applied in combination of ECMO in operation.During operation,transesophageal echocardiography and Swan-Ganz catheter were used to monitor cardiac systolic function,hemodynamic parameters and capacity status,and to guide the application of vasoactive drugs.The heart rate,arterial blood pressure,central venous pressure,blood oxygen saturation and pulmonary artery pressure in 10min after anesthesia induction(T0),5min after Swan-Ganz catheter insertion(T1),10min after ECMO operation (T2),30 min after one lung ventilation (T3),before anastomosis of the left anterior descending branch(T4),10min after bypass grafting(T5),10min after left pulmonary artery clamping(T6),10min after left pulmonary artery unclamping (T7),10 min after right pulmonary artery clamping (T8),10 min after right pulmonary artery unclamping(T9),10min after bilateral lung ventilation(T10),and leaving the operating room (T11)were recorded.The pa(O2)and pa(CO2)before anesthesia induction,and at the time points of T3,T4,T7and T9,and the flow velocity of bilateral pulmonary vein before and after lung transplantation were recorded.Results The arterial blood pressure and central venous pressure decreased at T8,and remained stable at other time points.With the operation of ECMO and progress of lung transplantation,the pulmonary artery pressure at T2to T11decreased gradually and remained stable,but was still higher than the normal level;the pulmonary artery pressure after bilateral lung transplantation(T9-T11)decreased to the lowest level(28/19 mm Hg)during operation.During operation,the patient had a good oxy

关 键 词：双肺移植 冠状动脉旁路移植术 全身麻醉 血流动力学 通气策略 

分 类 号：R614[医药卫生—麻醉学]