骨水泥渗漏致右心室穿孔及肺动脉栓塞并主动脉瓣关闭不全患者同期手术的麻醉管理  

Anesthesia management in a one-stage surgery for bone cement leakage-induced right ventricular perforation and pulmonary artery embolism in a patient with aortic insufficiency

作　　者：李斌[1] 曹彬 张化[1] 黄辰[2] 徐敬[2] 王勇[1] LI Bin;CAO Bin;ZHANG Hua;HUANG Chen;XU Jing;WANG Yong(Department of Anesthesiology,Perioperative and Pain Medicine,the First Affiliated Hospital of Zhengzhou University,Zhengzhou,Henan 450052,China;Department of Cardiovascular Surgery,the First Af filiated 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手术期及疼痛医学部,河南郑州450052 [2]郑州大学第一附属医院心血管外科医学部,河南郑州450052

出　　处：《中华实用诊断与治疗杂志》2025年第1期61-66,共6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重点项目(SBGJ202302049)。

摘　　要：目的 总结1例骨水泥渗漏致右心室穿孔及肺动脉栓塞合并主动脉瓣关闭不全患者同期行右心室及右肺动脉异物取出+主动脉瓣置换术的麻醉管理方法。方法 2024年4月24日郑州大学第一附属医院就诊1例患者,女,58岁,诊断为右心室、肺动脉骨水泥栓塞,右心室破裂、心包积液,主动脉瓣反流并中度关闭不全。拟于全身麻醉浅低温体外循环下行右心室及右肺动脉异物取出+主动脉瓣置换术。麻醉诱导依次缓慢静脉注射咪达唑仑2 mg、依托咪酯20 mg、舒芬太尼50μg、罗库溴铵80 mg。麻醉维持持续静脉泵注环泊酚0.2~0.5 mg/(kg·h)、舒芬太尼0.02~0.04μg/(kg·min)、罗库溴铵2μg/(kg·min),间断吸入体积分数0.5%~1.5%七氟烷。根据脑电双频指数调整麻醉深度,维持脑电双频指数在40~60。术前经口置入超声探头行经食管超声心动图,术中实时监测心脏结构、收缩功能、血流动力学状态。体外循环中维持灌注压50~70 mmHg,复温后静脉泵注多巴胺3~5μg/(kg·min)、去甲肾上腺素0.05μg/(kg·min),维持心排血量5~7 L/min、收缩压90~120 mmHg、舒张压65~70 mmHg、心率80~90次/min、中心静脉压4~6 cm H_(2)O,血钾4.0~5.0 mmol/L。体外循环结束使用鱼精蛋白中和肝素(1.51)。肺通气采用容量控制模式,肺保护通气策略。术后镇痛采用胸横肌平面神经阻滞+腹直肌鞘阻滞联合静脉自控镇痛。结果 术中血流动力学平稳,氧合良好。手术时间5.1 h,体外循环时间125 min,升主动脉阻断时间92 min,术中出血量600 mL。术后2.5 h患者清醒,6 h后拔除气管导管。清醒拔管时视觉模拟评分2分,术后24 h时视觉模拟评分5分,生命体征平稳。术后3 d超声心动图示人工瓣膜功能良好,未见瓣周漏,心包腔内少量液性暗区。术后10 d患者症状好转出院。随访至2024年7月,患者康复。结论 右心室穿孔及肺动脉栓塞合并主动脉瓣关闭不全病情复杂,术前完善麻醉评估Objective To summarize the anesthesia management in a surgery of foreign bodies removal from right ventricle and right pulmonary artery followed by aortic valve replacement in an aortic insufficiency patient with right ventricular perforation and pulmonary artery embolism caused by bone cement leakage.Methods A 58-year-old female patient was admitted in the First Affiliated Hospital of Zhengzhou University on April 24,2024.She was diagnosed with bone cement embolism in the right ventricle and pulmonary artery,right ventricular rupture,pericardial effusion,and aortic regurgitation with moderate insufficiency,and was scheduled to foreign bodies removal from right ventricle and pulmonary artery followed by aortic valve replacement under general anesthesia and mild hypothermic cardiopulmonary bypass.Anesthesia induction was performed by slowly intravenously injecting midazolam 2 mg,etomidate 20 mg,sufentanil 50μg,and rocuronium 80 mg in turns.Maintenance anesthesia was performed by intravenously pumping0.2-0.5mg/(kg·h)cyclopropofol,0.02-0.04μg/(kg· min)sufentanil,and 2μg/(kg· min)rocuronium,and intermittently inhaling 0.5%-1.5% sevoflurane.The depth of anesthesia was adjusted according to the bispectral index value,which was maintained between 40to 60.The transesophageal echocardiography probe was placed orally before surgery,and the cardiac structure,systolic function and hemodynamic indicators were monitored in real time during surgery.The perfusion pressure was maintained between 50and 70mmHg during cardiopulmonary bypass.After rewarming,3-5μg/(kg· min)dopamine and 0.05μg/(kg· min)norepinephrine were pumped intravenously,maintaining the cardiac output of 5-7L/min,systolic blood pressure of 90-120mmHg,diastolic blood pressure of 65-70mmHg,heart rate of 80-90beats/min,central venous pressure of 4-6cm H2O,and potassium level of 4.0-5.0mmol/L.The protamine was used to neutralize heparin(1.5∶1)after cardiopulmonary bypass.Lung ventilation was conducted using volume control mode and lung protection ventilati

关 键 词：心脏穿孔 肺动脉栓塞 主动脉瓣关闭不全 骨水泥渗漏 麻醉管理 

分 类 号：R54[医药卫生—心血管疾病]