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    Coopdech支氣管封堵導管在小兒微創心臟手術中的應用
    關鍵字:心臟,手術,應用,IJ,KL,GH,EF,AB,CD,MN, 發布時間:2011-08-19

    第20卷第4期 2010年7月 江蘇大學學報(醫學版) JournalofJiangsuUniversity(MedicineEdition) V01.20No.4 July2010 Coopdech支氣管封堵導管在小兒微創心臟手術中的應用 陳勇,吳周全 (南京醫科大學附屬常州第二人民醫院麻醉科,江蘇常州213003) [關鍵詞】Coopdech導管;單肺通氣;微創心臟手術;小兒 [中圖分類號]R654.2【文獻標志碼]B[文章編號】1671—7783(2010)04—0357—02 微創手術治療心臟疾病傷痕小,美容效果好。 近年來,胸壁打孔非體外循環房間隔缺損封堵術已 廣泛運用于小兒先天性心臟病的治療。由于手術需 在胸腔鏡的配合下進行,因此能否施行單肺通氣是 手術順利進行的重要因素,但由于目前還沒有較好 的小兒雙腔管,許多醫院只能采用單腔管行雙肺通 氣,大大地增加了手術操作的難度,延長了手術時 間。Coopdech導管遠端設計成彎角,可順利地將導 管插入目標支氣管,并且插管和定位方便,損傷小, 分隔雙肺完全。本試驗通過與單腔管進行比較,探 討Coopdech導管在小兒微創一tk,臟手術中應用的可 行性。 1對象與方法 1.1病例 12例先天性房間隔缺損病例為2009年1月至 2009年12月我院胸外科住院患者。ASAI一Ⅱ級, 年齡6一12歲,術前均無明顯心肺功能受損。將病 例隨機分為兩組:A組(17,=6)為普通氣管導管組,B 組(n=6)為Coopdech封堵支氣管導管組。 1.2麻醉方法 患者采用氯胺酮基礎麻醉后進人手術室行常規 監測,行左橈動脈和頸內靜脈穿刺置管。靜注咪達 唑侖100~150斗g/kg,丙泊酚1.5—2mg/kg,芬太 尼5一10斗g/kg,順式阿曲庫銨0.1一O.2mg/kg行 麻醉誘導。A組經口插入普通單腔管(F=年@/4 +4.0),B組先經口插入普通氣管導管(F=年齡/4 +4.0),然后將Coopdech支氣管封堵導管用液狀石 蠟充分潤滑后插入氣管導管中,將導管彎曲度朝向 需要隔離側,深入導管直至遇到阻力位置,采用纖維 支氣管鏡檢查將導管調整到正確位置,Coopdech支 氣管封堵導管的套囊位于需要阻塞的支氣管內隆突 之下。 1.3術中監測 機械通氣后開始肺萎陷和手術野評價(評價標準 參照Campos等【11的方法)。優:術側肺完全萎陷,手 術野顯露滿意(所有的肺萎陷和手術野均由外科醫師 描述);良:術側肺基本萎陷,肺內仍殘存有部分氣體, 但肺無通氣,手術野顯露比較滿意;差:術側肺未萎陷 或部分萎陷,影響手術操作。兩組患者均采用壓力控 制模式,術中通過調節控制壓力和呼吸頻率,使呼氣 末二氧化碳分壓(PetC02)保持在35—45mmHg之 間,記錄穩定后的控制壓力(Paw);于術前(To)、插管 后30min(T。)、拔管后30min(T2)行血氣分析;術畢 均記錄手術持續時間(T。。,)、拔管時間(T。。)。 1.4統計學分析 計量資料用均數-t-標準差(孑a-s)表示,組間比 較采用t檢驗,P<0.05為差異有統計學意義。 2結果 根據外科醫生描述,B組患者肺萎陷評價結果: 優4例,良2例,僅1例患者經纖支鏡調整后肺萎陷 仍不佳;A組肺萎陷評價結果:優0例,良1例,差 5例。 B組手術持續時間比A組明顯縮短(t=4.93,P <0.05),術中B組的控制壓力較A組高(t=8.03, 尸<0.05),但術中最大壓力不超過20ernH:O。兩 組患者T0、T。和T:血氣分析結果及拔管時間差異無 統計學意義,見表1、表2。 表1兩組患者手術持續時間、拔管時間、氣道壓力比較 8:P<O.05,與A組比較 萬方數據 換頁 358 江蘇大學學報(醫學版)第20卷 3討論 胸腔的容積相對固定,在行胸腔鏡輔助手術時 如果能很好地阻斷肺膨脹就更有利于保證外科醫生 在胸腔的手術操作范圍,更好地顯露手術野。為滿 足以上要求,臨床上通常采用單肺通氣的方法。雖 然雙腔支氣管插管是目前施行單肺通氣的最常用的 麻醉方法舊J,但是在/bJL中運用卻有著許多的局限 性。首先很難找到一個與年齡相匹配的雙腔支氣 管,資料表明目前最小的d,JL雙腔管是26號的,適 合于8歲的小兒;其次雙腔管外徑較粗,插管時易致 呼吸道損傷,兩肺分隔定位較難,而導管內徑太細, 氣道阻力高,因此在臨床應用中常受到一定限制。 Coopdech支氣管封堵導管是一種由日本研制 的新型簡易支氣管堵塞器。導管長65cm,外直徑3 mm,導管遠端有開孔,以便肺內氣體排出及分泌物 的吸引,其套囊為低壓高容,近端有一多功能接頭, 分別可接通氣密閉環路,纖支鏡檢查通路,氣管導管 連接口【3J。它利用氣囊阻塞手術側支氣管的方法 來實施單肺通氣,其插管的難易程度等同于一般單 腔插管,這就使得在導管口徑的選擇上有較大的余 地,因此對患者的正常生理功能的影響較小,對上呼 吸道有變異或雙腔管插管困難者也特別適用HJ。 況且支氣管氣囊阻塞法操作簡便,無需考慮對側支 氣管開口對位情況。 因本研究中有年齡不足8歲患兒,故對照組均 采用普通氣管導管行通氣。根據外科醫生的描述, B組患者的肺萎陷良好,手術操作順利,從放置胸腔 鏡至釋放房缺閉合器的時間明顯縮短;雖然在壓力 控制模式行機械通氣過程中,B組患者控制壓力較 A組高,但最大控制壓力不超過20cmH:0,且術中、 術后的血氣分析表明B組患者通氣功能與A組沒 有明顯差別,更重要的是B組患者較高的控制壓力 并不影響患者的拔管時間以及拔管后的通氣情況。 Campos等引的研究也曾證明支氣管封堵導管對肺 損傷較小。 綜上所述,Coopdech支氣管封堵導管更有利于 手術視野的顯露,且對患者生理干擾小,適合用于小 兒微創心臟手術。 [參考文獻] [1]CamposJH,KemstineKH.Acomparisonofaleft?sided Broncho-Cathwiththetorquecontrolblockeruniventand thewireguidedblocker[J].AnesthAnalg,2003,96(1): 283—289. [2]CamposJH.Currenttechniquesforperiopemtivelungi— solationinadults[J].Anesthesiology,2002,97(5): 1295—1301. [3]Minabei畫E,JohnsonC,TemianA.One?lunganesthesia update[J].SeminCardiothoraeVascAnesth,2005,9 (3):213—226. [4]UzukiM,KanayaN,MizuguchiA,eta1.One—lungventi— 18Iionusinganewbronchialblockerinapatientwith tracheostomystoma[J].AnesthAnalg,2003,96(5): 1538一1539. [5] CarnpesJH,ReasonerDK,MoyersJR.Comparisonofa modifieddouble-lumenendotrachealtubewith asingle- lumentubewithenclosedbronchialblocker[J].Anesth Analg,1996,83(6):1268—1272. [收稿日期】2010—03—02[本文編輯]。何承志 萬方數據 換頁

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