文章摘要
特发性肺动脉高压患者行双肺移植的围麻醉期管理
Perioperative anaesthetic management of bilateral lung transplantation for idiopathic pulmonary arterial hypertension
  
DOI：
中文关键词: 肺动脉高压  双肺移植  麻醉  体外膜肺氧合
英文关键词: Pulmonary arterial hypertension  Bilateral lung transplantation  Anesthesia  Extracorporeal membrane oxygenation
基金项目:国家“十一五”重大科技支撑计划资助(2008BAI0B05)
作者单位E-mail
胡春晓 214023,无锡市,南京医科大学附属无锡人民医院麻醉科 huchunxiao91211@163.com 
许波 214023,无锡市,南京医科大学附属无锡人民医院麻醉科  
王志萍 214023,无锡市,南京医科大学附属无锡人民医院麻醉科  
杨勇刚 214023,无锡市,南京医科大学附属无锡人民医院麻醉科  
吴金波 214023,无锡市,南京医科大学附属无锡人民医院麻醉科  
陈静瑜 214023,无锡市,南京医科大学附属无锡人民医院移植科  
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中文摘要:
      
目的 探讨治疗特发性肺动脉高压(idiopathic pulmonary arterial hypertension,IPAH)患者行双肺移植术的围麻醉期管理的要点。
方法 回顾性分析20例接受双肺移植治疗的重症IPAH患者的临床资料,男2例,女18例,ASA Ⅲ或Ⅳ级。观察麻醉后双肺通气30 min、体外膜肺氧合(extracorporeal membrane oxygenation, ECMO)转流后15 min、单肺通气、肺动脉阻断30 min、肺动脉开放和手术结束各时点血流动力学变化以及手术前后心超检查心血管形态学的改变。
结果 与麻醉后双肺通气30 min比较,ECMO转流后15 min时PaO2、每搏输出量变异度(SVV)明显升高,肺动脉压(PAP)、肺动脉楔压(PAWP)和PaCO2明显降低(P<0.05)。与ECMO转流后15 min比较,单肺通气时PAP、PAWP明显升高,SVV明显降低(P<0.05);与肺动脉阻断30 min比较,肺动脉开放时SVV明显升高,PAP、PAWP明显降低(P<0.05)。4例术毕即刻撤除ECMO,余16例辅助带入ICU。3例术后第1天行开胸探查止血术;13例术后发生不同程度左心功能不全,其中4例出现急性左心衰竭后,2例给予右股静脉-右股动脉(V-A)ECMO转流,2例给予右股静脉-右颈内静脉(V-V)ECMO转流。术后仅3例分别于第5、第6和第13天行气管切开。所有患者均治愈出院,心血管形态学均得到改善。
结论 积极改善围术期心功能、麻醉诱导和术中血流动力学的平稳、ECMO的合理应用和术后的过渡辅助是IPAH患者手术成功的关键。
英文摘要:
      
Objective To explore the key points of anaesthetic management of bilateral lung transplantation treating severe idiopathic pulmonary arterial hypertension.
Methods Clinical data of 20 cases with severe IPAH treated by bilateral lung transplantation were analyzed retrospectively, 2 males and 18 females, ASA physical status Ⅲ or Ⅳ. The hemodynamic changes were observed at various points (30 min after double lung ventilation, 15 min after ECMO, during one-lung ventilation, 30 min after pulmonary artery block, at the opening of pulmonary artery and at the end of surgery) and pre- and post-operative changes of cardiovascular morphology were analyzed with heart ultrasound.
Results Compared with 30 min after double lung ventilation, PaO2 and SVV were significantly increased and PAP, PAWP and PaCO2 were decreased 15 min after extracorporeal membrance oxygenation (ECMO) (P<0.05). PAP and PAWP were significant higher and SVV was lower 30 min after pulmonary artery block than 15 min after ECMO (P<0.05). Opening of pulmonary artery had significantly increased SVV and reduced PAP and PAWP compared with pulmonary artery block (P<0.05). ECMO was removed in 4 cases at end of the surgery. The remaining 16 cases assisted by ECMO were transferred to ICU, 3 cases underwent thoracotomy for exploration and hemostasis 1 day after the operation while 13 cases suffered from different degrees of left heart dysfunction postoperatively, 4 of which had acute heart failure. Of the 4 cases, 2 were treated by right femoral vein-right femoral artery bypass (V-A ECMO bypass) and 2 underwent right femoral vein-right internal jugular vein bypass (V-V ECMO bypass). Moreover, 3 cases performed tracheotomy 5 days, 6 days and 13 days day after the operation, respectively. All the patients were cured and discharged. Their cardiovascular morphology was improved.
Conclusion The key successful factors of IPAH treated by bilateral lung transplantation are to improving perioperative heart function, keeping stable hemodynamics during induction of anesthesia and the operation and using ECMO properly and postoperative support.
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