异丙酚和异氟醚对婴幼儿体外循环心内直视手术患者心肌肌钙蛋白I

1、异丙酚和异氟醚对婴幼儿体外循环心内直视手术患者心肌肌钙蛋白I的影响吉林大学第一临床医学院麻醉科（长春市 130021） 周春燕吉林省长春市儿童医院麻醉科（长春市 130000） 王立波目的：现在认为异氟醚可通过类似缺血预处理的机制对缺血再灌注心肌产生保护作用，而异丙酚则是通过有效地清除自由基对缺血再灌注心肌产生保护作用。本研究通过动态观察婴幼儿体外循环心内直视手术心肌缺血/再灌注期间血清心肌肌钙蛋白I（cTnI）的变化，比较麻醉剂异丙酚、异氟醚在婴幼儿体外循环心内直视手术中对心肌的保护作用。方法：将27例先天性心脏病房间隔缺损和/或室间隔缺损拟行低温体外循环心内直视修补术的婴幼儿患者，随机分为

2、三组：对照组即芬太尼组（F组）8例，异丙酚组（P组）9例，异氟醚组（I组）10例。三组患儿术前用药相同即地西泮和吗啡各0.2mg/kg于术前30分钟肌肉注射。麻醉诱导：对照组静脉注射力月西0.1mg/kg，芬太尼5ug/kg，维库溴胺1.0mg/kg静脉注射；两观察组的芬太尼和维库溴胺用量同对照组，异丙酚组用异丙酚2mg/kg静脉注射，异氟醚组吸入0.5-1.0%异氟醚。气管插管后行机械通气，使呼气末二氧化碳浓度维持在30-35mmHg。麻醉维持：对照组静脉用咪唑安定0.08mg/kg/h，芬太尼20-30ug/kg/h，维库溴胺1.2-1.5mg/kg/h；两观察组的芬太尼和维库溴胺用量同对

3、照组，异丙酚组用微泵持续静注异丙酚4-6mg/kg/h（包括体外循环过程中）；异氟醚组吸入0.5-1.5%异氟醚（并保证在体外循环开始前0.5%-1.5%异氟醚吸入30分钟以上）。分别于麻醉后手术开始前（T0）、升主动脉开放后30分钟(T1)、术后6小时（T2）、术后24小时（T3）取中心静脉血测定血清cTnI浓度。结果：各组患儿血清cTnI值于主动脉开放后30分钟开始均有不同程度的升高（与术前比p<0.01）；cTnI值于主动脉开放30分钟至术后6小时升高达峰值，术后24小时已明显回降（与术后6小时比P<0.01），但仍然高于正常值（与术前值比P<0.01）；两观察组cTn

4、I值于T1、T2、T3时相均低于对照组（P<0.05），两观察组之间各时相cTnI值无显著性差异。结论： 1、异丙酚、异氟醚在婴幼儿体外循环心内直视手术中具有一定的但不完全的心肌保护作用；2、异丙酚、异氟醚在婴幼儿体外循环心肌直视手术中的心肌保护作用效果无显著差别。Patient with critical tracheal occlusion due to tumor: perioperative management Dr Taidi Zhong, MD Director, Department of Anaesthesia, Sir Run Run Shaw Hospital, H

5、angzhou,310016，ChinaDr 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 wh

6、at surgery should 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

7、 haemoptysis was 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 saturatio

8、n on room. Fibreoptic 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，From presentation to bronchoscopy to CT for one day and worri

9、ed about big bleeding,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 sit

10、uated about six cm above 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

11、about bleeding while anticoagulated. 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. Surgi

12、cal access was by median 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 ext

13、ubation next morning with 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 app

14、ropriate choice1. The 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

15、imaging techniques such 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 t

16、umor. The scans helped 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

17、 the number of patients 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 cura

18、tive laser therapy6. Use 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 strat

19、egy because of the concern 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

20、area for resection used 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 vie

21、w of the tumor showing 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, Dep

22、artment of Anaesthesia, 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 byp