1例右肾巨大肿瘤合并下腔静脉血栓手术的麻醉体会

2018-12-17 付海钰 西南军医

患者,男,54岁,体重60kg,因反复右上腹胀5月,加重1周入院。PET/CT示右肾中上份巨大混杂密度占位,约14.1×13.7×17.6 cm,考虑为恶性肿瘤。造影示下腔静脉下段及左髂静脉近端局部狭窄伴栓子形成。

1.病例介绍
 
患者,男,54岁,体重60kg,因反复右上腹胀5月,加重1周入院。PET/CT示右肾中上份巨大混杂密度占位,约14.1×13.7×17.6 cm,考虑为恶性肿瘤。造影示下腔静脉下段及左髂静脉近端局部狭窄伴栓子形成。
 
D-二聚体7.35mg/L,纤维蛋白酶原5.64g/L。ASA分级2级。拟在全麻下行右肾探查根治性切除术。上午8:40入室,开放静脉,心率85次/分,血压133/90mmHg,SPO2 100%。常规诱导后气管插管,术中监测心率、有创血压、SPO2、CVP、PETCO2、BIS、体温,尿量。手术先切断下腔静脉下段,从远端及髂血管取出大量血栓,循环稳定,尿量正常。
 
随后处理肿瘤血管,分离难度大,止血困难,出血多,患者循环出现较大波动,心率140次/分,血压58/42mmHg,SPO2100%,CVP 6 cmH2O,加快输液输血,多巴胺去甲肾上腺素泵注维持平均动脉压至60mmHg左右,手术切除肿瘤及部分下腔静脉,用人工血管置换,于近心端直视下放置腔静脉滤器后端端缝合。
 
15:20开放下腔静脉,循环改善,心率100次/分,血压100/60mmHg,CVP 8 cmH2O,停止泵注血管活性药,但尿量一直偏少,给予速尿20mg观察半小时后尿量无变化,告知手术医师,并追加速尿40mg,仍无改善。术者遂探查左肾,发现其颜色暗红,体积增大,左肾静脉于肿瘤切除时被缝扎,遂用一人工血管与左肾静脉断端行端端吻合,再与下腔静脉人工血管端侧吻合。20:10搭桥血管开放,左肾颜色红润,体积缩小,尿量持续增加,循环稳定,血气基本正常。
 
手术历时12小时20分,共输注红细胞悬液17.5U,新鲜冰冻血浆1950mL,冷沉淀10U,乳酸林格液5700mL,羟乙基淀粉4500mL,出血6000mL,尿2100mL。术毕未拔管送重症ICU,术后患者恢复良好。
 
2.讨论
 
麻醉体会如下:
 
(1)围麻醉手术期少尿的最常见原因为有效循环血量不足,该例患者处理肿瘤血管时出血量大,血压偏低,故前期少尿主要考虑血容量不足;后期容量已补足,血管活性药物已停止泵注,血流动力学恢复稳定,但给予速尿后尿量仍无改善。此例麻醉医生重视尿量观察,记录详实,发现尿量异常后及时处理并与外科医生反馈结果,参与手术决策,降低了对患者的损伤。
 
(2)充分的术前准备,针对此例病人,对术中大出血要有预见性,术前备血要尽可能的充足。
 
(3)全面的术中监护,以及适时的血气、凝血功能及电解质检查;根据出血量的多少、血压、CVP、尿量的变化调整输血输液的量以及利尿剂的量,使患者血压、CVP维持在正常范围内,保持血流动力学稳定。
 
(4)体温监测是快速康复理念的重点,可降低切口感染率,围术期心血管事件及出血发生率,加快患者的麻醉恢复。麻醉可通过室温的调节,充气式体表加温及输血加温等综合措施保温。

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    2019-05-04 fusion
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    2019-08-19 xue8602
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