围麻醉期突发高二氧化碳血症的典型病例分享

2020-08-12 麻醉MedicalGroup 麻醉MedicalGroup

围麻醉期出现高二氧化碳血症于全麻的患者会出现苏醒延迟,甚至影响脑细胞的功能恢复。为了让广大同仁有更直观地了解,本期,我们找出一列典型病例分享给大家:

围麻醉期出现高二氧化碳血症于全麻的患者会出现苏醒延迟,甚至影响脑细胞的功能恢复。为了让广大同仁有更直观地了解,本期,我们找出一列典型病例分享给大家:

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患者,男性,62岁,体重80kg。

因升结肠癌根治术后切口、吻合口撕裂,行急诊剖腹探查术。

术前患者一般情况好,查心电图正常,血压140/90mmHg。

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选择全身麻醉气管内插管,芬太尼、异氟烷维持麻醉,维库溴铵维持肌肉松弛。

手术历时1小时40分钟,术毕时改侧卧位予L9-10间隙行硬膜外穿刺,安装止痛泵。侧卧位期间患者清醒,有自主呼吸,并有咳嗽、屏气、血压高、心率快等。

硬膜外置管完毕改仰卧位,立即拔除气管导管。拔管后舌后坠,血压上升至210/130mmHg,心率210次/分,出现频发房性期前收缩,ST段下移0.15mV,氧饱和度下降。患者意识清楚,呼吸频率30次/分,考虑为切口疼痛致血管反应。给予硬膜外注射2%利多卡因20ml未见好转,又给予硝酸甘油静脉滴注,毛花苷C0.4mg静脉滴注,血压、心率无明显下降,SpO2 继续下降,用面罩吸氧,SpO2 上升至98%,去面罩后又下降。

急查血气:pH 7.125,PaO2117mmHg,PaCO2 87mmHg,BE-3.1mmol/L,确诊为高碳酸血症,给予面罩辅助呼吸。

82841597030614897

30分钟后血压、心率下降至术前水平,心电图转为窦性,ST段正常,停止吸氧,SpO2维持在93%以上,复查血气未见异常。

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那么,针对围麻醉期突发高二氧化碳血症,我们有哪些思考?

对于腔镜手术,患者常常发生皮下气肿,再加上术中麻醉机通气不良或者参数设置欠佳时,极容易导致患者发生高二氧化碳血症。对于有原发性肺部疾病的患者,由于肺通气和肺换气功能障碍,也容易突发高二氧化碳血症。因此全麻期间,麻醉医生必须对患者的病理生理有一个较全面的了解,也要注意麻醉机是否能正常工作及其工作期间的参数设置,同时也要注意气管导管通气不畅等(痰栓堵塞,弯曲折叠)。

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如果PaCO2较高,且持续一定 的时间,经治疗PaCO2快速下降时可能发生二氧化碳排出综合征,表现为血压下降,心动过缓,心律失常,甚至心跳停止,其原因有:

①PaCO2升高时的应激反应突然消失;

②骨骼肌的血管扩张,加之过度通气时胸内压增高,使回心血量减少;

③CO2突然排出可使冠状血管和脑血管收缩,以致心脏和脑供血不足。

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因此,对于持续一段时间的高二氧化碳血症处理方法是对PaCO2升高的患者人工通气量要适当控制,逐步增加,此外注意补充血容量,必要时使用血管活性药物。

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    2021-04-03 挑灯看贱

    那个镇痛泵间隙错了

    0

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    2021-04-03 挑灯看贱

    感谢分享

    0

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