胸廓重度畸形行骨折内固定麻醉处理1例

2018-10-20 鲍秀霞 王祥和 丰浩荣 医学理论与实践

患者,男性,36岁,因“右肱骨外科颈、肱骨头骨折”入院。入院时:脉搏128次/min,呼吸31次/min,身长150 cm,体重47kg,口唇发绀,头颈向右侧倾斜,双侧肩部不等高,右肩较左肩向前突出约2 cm,右胸饱满呈半圆桶形,左胸较扁凹,双肩胛冈呈现左高、斜向上而右低、斜向下。两肺野呼吸音弱,心率128次/min,律齐。两肩胛间区脊柱呈“S”形。骨盆倾斜,左骼后上棘几乎到该侧腋窝内下侧。

患者,男性,36岁,因“右肱骨外科颈、肱骨头骨折”入院。入院时:脉搏128次/min,呼吸31次/min,身长150 cm,体重47kg,口唇发绀,头颈向右侧倾斜,双侧肩部不等高,右肩较左肩向前突出约2 cm,右胸饱满呈半圆桶形,左胸较扁凹,双肩胛冈呈现左高、斜向上而右低、斜向下。两肺野呼吸音弱,心率128次/min,律齐。两肩胛间区脊柱呈“S”形。骨盆倾斜,左骼后上棘几乎到该侧腋窝内下侧。
 
入院时:胸片:胸廓重度畸形,左肺约为正常20%。CT提示:胸椎呈横行排列,左胸腔小,Haller指数测定为4.9。血气分析:PaO2:52.6mmHg(1mmHg=0.133kPa),PaCO2:48.1mmHg。肺功能:FEV1:1090ml,FVC:1140ml,DLco:7.8mL·mmHg-1·min-1,重度通气功能障碍和中度弥散功能障碍。经吸氧、抗炎,雾化吸入及呼吸功能锻炼等治疗9d后,呼吸功能改善,复查血气示:PaO2:79.7mmHg,PaCO2:35.7mmHg。故行手术治疗。
 
首先选用超声引导下臂丛神经阻滞及C形臂X线机导引下颈段高位硬膜外穿刺置管,因畸形严重操作失败,故选择全凭静脉麻醉。除常规监测后,还行有创桡动脉压及颈内中心静脉压监测,同时连接BIS行麻醉深度监测,连接加速度仪采用4个成串刺激(TOF)法行肌松监测。
 
麻醉诱导:依次静脉缓慢推注戊乙奎醚1mg,咪达唑仑0.15μg/kg,舒芬太尼2pg/kg,依托咪酯0.4mg/kg,顺式阿曲库按0.15mg/kg,肌松完全后静注艾司洛尔20mg,以纤维支气管镜行气管插管,麻醉机行压力控制通气,呼吸频率16次/min,麻醉维持为靶控输注瑞芬太尼及丙泊酚,间断给予顺式阿曲库铵。术中维持?PETCO2 36~42 mmHg,BIS50~55,IBP140~115/85~60mmHg,心率100~120次/min,CVP在8~10 cmH2O。切口缝合前行0.375%罗哌卡因局部浸润,待患者清醒、呼吸功能恢复后(TOFR达95%)拔除气管导管,术后静脉给予帕瑞昔布钠辅助镇痛,并送ICU观察治疗24h。术后第2天均随访,未见任何麻醉并发症。
 
原始出处:

鲍秀霞, 王祥和, 丰浩荣. 胸廓重度畸形行骨折内固定麻醉处理1例[J]. 医学理论与实践, 2017, 30(11):1596-1596.

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