CAJ | 학술논문

目的：总结胸、腹腔镜联合微创食管癌根治术的麻醉管理经验。方法2013年5～11月12例双腔支气管内插管静吸复合全麻下行胸、腹腔镜联合微创食管癌根治术。麻醉诱导采用丙泊酚、芬太尼和顺苯磺酸阿曲库铵静脉注射，插入左侧双腔支气管导管，纤维支气管镜检查定位。术中吸入七氟烷和静脉持续输注瑞芬太尼维持麻醉。胸腔镜操作中行左侧单肺通气（one-lung ventilation，OLV）。记录麻醉诱导前、麻醉诱导后、OLV前、OLV后30 min以及手术结束时等不同时点SBP、DBP、MAP、HR、PaO2、PaCO2和Ppeak值。结果12例均完成胸、腹腔镜联合微创食管癌根治术。手术时间（425．7±90．1）min，麻醉时间（497．3±84．6）min。术中共输液（3020±606）ml，其中晶体液（2020±527）ml，胶体液（1000±316）ml，2例各输入红细胞悬液400 ml；术中出血量（204±80）ml，尿量（700±231）ml。与麻醉诱导前相比，SBP在麻醉诱导后、OLV前和手术结束时有统计学差异（q＝7．607，P＜0．05；q＝4．890，P＜0．05；q＝3．713，P＜0．05），MAP在麻醉诱导后有统计学差异（q＝5．560，P＜0．05）；不同时点DBP、HR均无显著性差异（F＝2．31，P＝0．070；F＝0．45，P＝0．770）。与麻醉诱导后相比， OLV 30 min时PaCO2和Ppeak值明显升高（q＝5．657，P＜0．05；q＝8．132，P＜0．05），PaO2显著降低（q＝14．375，P＜0．05）。术中8例使用1种以上的血管活性药物。4例在OLV刚开始时出现SpO2下降，经右肺持续吹入低流量氧气2 L／min，左肺加用5 cm H2 O PEEP处理后SpO2升至97％以上。术后9例返回普通病房，3例转入ICU。术后均无复张性肺水肿、肺不张及其他麻醉并发症发生。结论胸、腹腔镜联合微创食管癌根治术对麻醉管理的要求较高，只有采取合理的麻醉管理措施，才能保证麻醉效果和手术安全。目的：總結胸、腹腔鏡聯閤微創食管癌根治術的痳醉管理經驗。方法2013年5～11月12例雙腔支氣管內插管靜吸複閤全痳下行胸、腹腔鏡聯閤微創食管癌根治術。痳醉誘導採用丙泊酚、芬太尼和順苯磺痠阿麯庫銨靜脈註射，插入左側雙腔支氣管導管，纖維支氣管鏡檢查定位。術中吸入七氟烷和靜脈持續輸註瑞芬太尼維持痳醉。胸腔鏡操作中行左側單肺通氣（one-lung ventilation，OLV）。記錄痳醉誘導前、痳醉誘導後、OLV前、OLV後30 min以及手術結束時等不同時點SBP、DBP、MAP、HR、PaO2、PaCO2和Ppeak值。結果12例均完成胸、腹腔鏡聯閤微創食管癌根治術。手術時間（425．7±90．1）min，痳醉時間（497．3±84．6）min。術中共輸液（3020±606）ml，其中晶體液（2020±527）ml，膠體液（1000±316）ml，2例各輸入紅細胞懸液400 ml；術中齣血量（204±80）ml，尿量（700±231）ml。與痳醉誘導前相比，SBP在痳醉誘導後、OLV前和手術結束時有統計學差異（q＝7．607，P＜0．05；q＝4．890，P＜0．05；q＝3．713，P＜0．05），MAP在痳醉誘導後有統計學差異（q＝5．560，P＜0．05）；不同時點DBP、HR均無顯著性差異（F＝2．31，P＝0．070；F＝0．45，P＝0．770）。與痳醉誘導後相比， OLV 30 min時PaCO2和Ppeak值明顯升高（q＝5．657，P＜0．05；q＝8．132，P＜0．05），PaO2顯著降低（q＝14．375，P＜0．05）。術中8例使用1種以上的血管活性藥物。4例在OLV剛開始時齣現SpO2下降，經右肺持續吹入低流量氧氣2 L／min，左肺加用5 cm H2 O PEEP處理後SpO2升至97％以上。術後9例返迴普通病房，3例轉入ICU。術後均無複張性肺水腫、肺不張及其他痳醉併髮癥髮生。結論胸、腹腔鏡聯閤微創食管癌根治術對痳醉管理的要求較高，隻有採取閤理的痳醉管理措施，纔能保證痳醉效果和手術安全。
목적：총결흉、복강경연합미창식관암근치술적마취관리경험。방법2013년5～11월12례쌍강지기관내삽관정흡복합전마하행흉、복강경연합미창식관암근치술。마취유도채용병박분、분태니화순분광산아곡고안정맥주사，삽입좌측쌍강지기관도관，섬유지기관경검사정위。술중흡입칠불완화정맥지속수주서분태니유지마취。흉강경조작중행좌측단폐통기（one-lung ventilation，OLV）。기록마취유도전、마취유도후、OLV전、OLV후30 min이급수술결속시등불동시점SBP、DBP、MAP、HR、PaO2、PaCO2화Ppeak치。결과12례균완성흉、복강경연합미창식관암근치술。수술시간（425．7±90．1）min，마취시간（497．3±84．6）min。술중공수액（3020±606）ml，기중정체액（2020±527）ml，효체액（1000±316）ml，2례각수입홍세포현액400 ml；술중출혈량（204±80）ml，뇨량（700±231）ml。여마취유도전상비，SBP재마취유도후、OLV전화수술결속시유통계학차이（q＝7．607，P＜0．05；q＝4．890，P＜0．05；q＝3．713，P＜0．05），MAP재마취유도후유통계학차이（q＝5．560，P＜0．05）；불동시점DBP、HR균무현저성차이（F＝2．31，P＝0．070；F＝0．45，P＝0．770）。여마취유도후상비， OLV 30 min시PaCO2화Ppeak치명현승고（q＝5．657，P＜0．05；q＝8．132，P＜0．05），PaO2현저강저（q＝14．375，P＜0．05）。술중8례사용1충이상적혈관활성약물。4례재OLV강개시시출현SpO2하강，경우폐지속취입저류량양기2 L／min，좌폐가용5 cm H2 O PEEP처리후SpO2승지97％이상。술후9례반회보통병방，3례전입ICU。술후균무복장성폐수종、폐불장급기타마취병발증발생。결론흉、복강경연합미창식관암근치술대마취관리적요구교고，지유채취합리적마취관리조시，재능보증마취효과화수술안전。
Objective To summarize the anesthetic management of combined thoracoscopic and laparoscopic minimally invasive esophagectomy . Methods Twelve patients underwent combined thoracoscopic and laparoscopic esophagectomy under intravenous and inhalational anesthesia .After induction of anesthesia with propofol , fentanyl , and cisatracurium , a double-lumen endobronchial tube was intubated and its position was checked by using fiberoptic bronchoscopy .Anesthesia was maintained with sevoflurane and remifentanil .One-lung ventilation ( OLV) was performed during the thoracoscopic operation .Values of systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), arterial partial pressure of oxygen (PaO2), arterial partial pressure of carbon dioxide (PaCO2), and peak airway pressure (Ppeak) were recorded at following time points: before anesthesia induction , after anesthesia induction , before OLV, 30 min after OLV, and end of surgery. Results The operation was successfully completed in all the patients .The total operation time was (425.7 ±90.1) min and the anesthesia time was (497.3 ±84.6) min.The volume of fluid given intraoperatively was (3020 ±606) ml, including crystal solution (2020 ±527) ml and colloid solution (1000 ±316) ml.Two patients received 400 ml red blood cells.The volume of blood loss and urinary output intraoperatively were (204 ±80) ml and (700 ±231) ml, respectively.The SBP values after anesthesia induction , before OLV, and at the end of surgery were significantly lower than that before anesthesia induction (q=7.607,P<0.05;q=4.890, P<0.05;q=3.713,P<0.05);the MAP after anesthesia induction was significantly lower than that before anesthesia induction (q=5.560,P<0.05).No significant difference was found between values of DBP and HR (F=2.31,P=0.070;F=0.45,P=0.770). The PaCO2 and Ppeak values at 30 min after OLV were significantly higher than those after anesthesia induction (q=5.657,P<0.05;q=8.132,P<0.05), and the PaO2 values at 30 min after OLV were significantly lower than those after anesthesia induction ( q=14.375,P<0.05).A total of 8 cases were given more than one kind of vasoactive drugs .The SpO2 dropped in 4 cases at the beginning of OLV , and recovered after blowing 2 L/min oxygen into the right lung and adding 5 cm H2 O PEEP to the left lung .Nine cases returned to the general ward after operation and 3 cases were transferred to ICU .No postoperative anesthesia-related complications occurred, such as reexpansion pulmonary edema and atelectasis . Conclusions The surgery of combined thoracoscopic and laparoscopic esophagectomy presents anesthetists with more challenges .Reasonable management skills are essential to ensure anesthetic quality and patient safety .