異丙酚和異氟醚對嬰幼兒體外循環(huán)心內直視手術患者心肌肌鈣蛋白I

1、異丙酚和異氟醚對嬰幼兒體外循環(huán)心內直視手術患者心肌肌鈣蛋白I的影響吉林大學第一臨床醫(yī)學院麻醉科（長春市 130021） 周春燕吉林省長春市兒童醫(yī)院麻醉科（長春市 130000） 王立波目的：現(xiàn)在認為異氟醚可通過類似缺血預處理的機制對缺血再灌注心肌產(chǎn)生保護作用，而異丙酚則是通過有效地清除自由基對缺血再灌注心肌產(chǎn)生保護作用。本研究通過動態(tài)觀察嬰幼兒體外循環(huán)心內直視手術心肌缺血/再灌注期間血清心肌肌鈣蛋白I（cTnI）的變化，比較麻醉劑異丙酚、異氟醚在嬰幼兒體外循環(huán)心內直視手術中對心肌的保護作用。方法：將27例先天性心臟病房間隔缺損和/或室間隔缺損擬行低溫體外循環(huán)心內直視修補術的嬰幼兒患者，隨機分為

2、三組：對照組即芬太尼組（F組）8例，異丙酚組（P組）9例，異氟醚組（I組）10例。三組患兒術前用藥相同即地西泮和嗎啡各0.2mg/kg于術前30分鐘肌肉注射。麻醉誘導：對照組靜脈注射力月西0.1mg/kg，芬太尼5ug/kg，維庫溴胺1.0mg/kg靜脈注射；兩觀察組的芬太尼和維庫溴胺用量同對照組，異丙酚組用異丙酚2mg/kg靜脈注射，異氟醚組吸入0.5-1.0%異氟醚。氣管插管后行機械通氣，使呼氣末二氧化碳濃度維持在30-35mmHg。麻醉維持：對照組靜脈用咪唑安定0.08mg/kg/h，芬太尼20-30ug/kg/h，維庫溴胺1.2-1.5mg/kg/h；兩觀察組的芬太尼和維庫溴胺用量同對

3、照組，異丙酚組用微泵持續(xù)靜注異丙酚4-6mg/kg/h（包括體外循環(huán)過程中）；異氟醚組吸入0.5-1.5%異氟醚（并保證在體外循環(huán)開始前0.5%-1.5%異氟醚吸入30分鐘以上）。分別于麻醉后手術開始前（T0）、升主動脈開放后30分鐘(T1)、術后6小時（T2）、術后24小時（T3）取中心靜脈血測定血清cTnI濃度。結果：各組患兒血清cTnI值于主動脈開放后30分鐘開始均有不同程度的升高（與術前比p0.01）；cTnI值于主動脈開放30分鐘至術后6小時升高達峰值，術后24小時已明顯回降（與術后6小時比P0.01），但仍然高于正常值（與術前值比P0.01）；兩觀察組cTnI值于T1、T2、T3時

4、相均低于對照組（P0.05），兩觀察組之間各時相cTnI值無顯著性差異。結論： 1、異丙酚、異氟醚在嬰幼兒體外循環(huán)心內直視手術中具有一定的但不完全的心肌保護作用；2、異丙酚、異氟醚在嬰幼兒體外循環(huán)心肌直視手術中的心肌保護作用效果無顯著差別。Patient with critical tracheal occlusion due to tumor: perioperative management Dr Taidi Zhong, MD Director, Department of Anaesthesia, Sir Run Run Shaw Hospital, Hangzhou,310016，C

5、hinaDr Yongqing Wang, MD Department of Cardio Thoracoc Surgery, Sir Run Run Shaw Hospital, Hangzhou, 310016，ChinaIntroductionPatients with obstructing pathology requiring tracheal resection present numerous, often difficult, decisions in the pre- and perioperative period including what surgery shoul

6、d be undertaken, whether laser therapy is appropriate, or if pre-induction cardiopulmonary bypass should be used1. No matter what surgical approach is used, the perioperative care presents many challenges for the anesthetist2. We present one such case.Case ReportA 41 yr old male with haemoptysis was

7、 referred to the Respiratory Medicine Unit at Sir Run Run Shaw Hospital, Hangzhou, China. The patient had been a heavy smoker for 20 years but was otherwise in good health. Only Haemoptysis twice within two monthes. On examination，The patient was maintaining adequate oxygen saturation on room. Fibre

8、optic bronchoscopy showed an intraluminal tracheal mass that was occupying about 80% of the lumen (Figure 1). Because of the highly vascular appearance of the mass the respiratory physicians decided against taking a biopsy，F(xiàn)rom presentation to bronchoscopy to CT for one day and worried about big ble

9、eding,emergence operation done after CT report that afternoon within same day. A CT scan using a volume rendering technique 3 (Figure 2) of neck and chest revealed a homogenous intraluminal mass, about 1.8cm 1.3 cm, attached to the left wall of the trachea. The peduncle was situated about six cm abo

10、ve the carina. The thoracic surgeons decided to treat the lesion with tracheal resection. They decided against laser therapy, or physical debulking, due to concern about bleeding. Cardiopulmonary bypass was considered but was reserved as an emergency measure because of concern about bleeding while a

11、nticoagulated. General anesthesia was induced with Popofolol 2.5mg/kg,Rocuronium 0.8mg/kg,Fentanyl 5g/kg.After 2 minutes oxygenation,and adequate anaesthetic depth and guided by fibreoptic scope,the tip of the endotracheal tube was inserted to about two cm above the mass. Surgical access was by medi

12、an sternotomy with the trachea exposed down to the carina. There was no extra-tracheal extension of the mass. The trachea was opened and, as expected, the soft mass had a pedicle to left lateral wall of the thoracic trachea. sedation and ventilation for one night in ICU and extubation next morning w

13、ith no any problemsrecovered and discharged one week late.the pathology of the lesion was schwannomaDiscussionThis case highlights the need for careful preoperative planning for tracheal resection and that several divergent options are available but with limited evidence on appropriate choice1. The

14、most common cause for tracheal obstruction requiring resection is stenosis from a benign stricture, often following intubation1. Tumors are less common reasons for tracheal resection with malignant tumors being more common than benign1.This case demonstrates the value of newer imaging techniques suc

15、h as volume rendering techniques (VRT) of CT images (Figure 2)3. Other approaches can give 3-dimensional views that may further assist in airway assessment 4. The volume-rendered view from the CT scan gave valuable information about the site, size, shape and attachment of the tumor. The scans helped

16、 confirm the airway plan to intubate the trachea, under bronchosocpic view, and for the surgeons to place a second, lower endotracheal tube.Two preoperative decisions concerned using laser therapy and cardiopulmonary bypass. In some centres, intracheal laser therapy has reduced the number of patient

17、s requiring tracheal resection5 6, or reduced tumor bulk which is thought to allow safer resection due to greater airway patency7. In this case, the vascularity of the tumor and the perceived risk of life threatening haemorrhage led to a decision to avoid adjuvant laser or curative laser therapy6. U

18、se of cardiopulmonary bypass may also improve patient safety in some cases, by reducing the need for continous ventilation and improving surgical access 1 8 9. Again, in this case, it was decided to have cardiopulmonary bypass on standby rather than to use it as a primary strategy because of the con

19、cern about bleeding associated with heparin anticoagulation 8 10.Many different anaesthetic techniques have been used for tracheal resection ranging from spontaneous ventilation to jet ventilation1 2 11. The approach of using two endotracheal tubes, one above and one below the area for resection use

20、d is one of the more frequently described approaches 1 2. Without cardiopulmonary bypass airway management was more critical. Management of the two endotracheal tubes requires particularly good communication between the anaesthesia and surgical teams.Figure 1. Bronchoscopic view of the tumor showing

21、 its bulk and vascular nature.Figure 2. CT derived volume rendered (VRT) image of the posterior view showing the midtracheal positon of the pedunculated tumor.Emergency cardiopulmonary bypass for prolonged cardiac arrest during hepatic resection Dr Taidi Zhong, MD Director, Department of Anaesthesia

22、, Sir Run Run Shaw Hospital, Hangzhou, 310016，ChinaDr Chunyan Yan, MDFellow, Department of Anaesthesia, Sir Run Run Shaw Hospital, Hangzhou, 310016，ChinaA/Prof David A. Story; MD, FANZCA Joint Director of Research, Department of Anaesthesia; and Associate Professor, The University of Melbourne, Department of Surgery; Austin Health, Heidelberg, Victoria, AustraliaInstitution: Sir Run Run Shaw Hospital, Hangzhou, ChinaAbstractThere are sporadic reports of emergency percutaneous cardiopulmonary bypas