困难气管插管全麻复苏喉痉挛置入喉罩维持呼吸1例

2019-01-11 黄友芳 李俊英 基层医学论坛

患者:男,65岁,身高165 cm,体重85kg,ASAⅡ级。主诉:上腹疼痛不适,恶心、呕吐;腹部B超诊断:胆囊结石。拟在气管插管全麻下行腹腔镜胆囊切除术。术前访视患者;查体:意识清醒,心率(HR):89次/min、血压(BP):135/82mmHg、呼吸(RR):20次/min、血氧饱和度(SpO2):98%、体温(T):36.5℃、气道评估:张口度3.2 cm。

1.病例介绍
 
患者:男,65岁,身高165 cm,体重85kg,ASAⅡ级。主诉:上腹疼痛不适,恶心、呕吐;腹部B超诊断:胆囊结石。拟在气管插管全麻下行腹腔镜胆囊切除术。术前访视患者;查体:意识清醒,心率(HR):89次/min、血压(BP):135/82mmHg、呼吸(RR):20次/min、血氧饱和度(SpO2):98%、体温(T):36.5℃、气道评估:张口度3.2 cm。
 
Mallampati:Ⅲ级舌咽关系:仅见软腭,而腭弓和悬雍垂全被舌根遮住,骸甲间距:6.0 cm,颈部活动度可,呈困难气管插管体征。向患者及家属交代困难气管插管风险,患者家属表示理解,签署麻醉知情同意书。接患者入手术室,开放静脉通道监测生命体征平稳,全麻诱导静脉给咪达唑仑2mg,芬太尼0.1mg、丙泊酚100mg、氯化琥珀胆100mg,麻醉深度及肌松满意,使用可视喉镜行经口气管插管。
 
可视喉镜片将舌体推向左侧进入舌根部挑起会厌未见声门,助手按压环状软骨仍未见声门,沿着会厌下正中盲探插入气管导管受阻,患者指端脉搏血氧饱和度降至94%,即予面罩加压给氧人工呼吸,患者指端脉搏血氧饱和度升至98%,自主呼吸恢复。静脉继续注入丙泊酚150mg,保留患者自主呼吸行气管插管,可视喉镜挑起会厌随呼吸运动见少部分声门,自声门插入气管导管,患者呛咳激烈,立即静脉推注丙泊酚170mg,机控呼吸听诊双肺呼吸音清晰均匀,静脉给予长效肌松药维库溴铵8mg,预防患者多次气管插管后致喉头水肿,静脉注射地塞米松10mg,静脉全麻维持泵注,术中生命体征平稳。
 
手术历时3h,手术结束前10min停止静脉全麻药维持泵注,停药后20min患者自主呼吸恢复,唤患者可睁眼,可完成指令性动作,潮气量及意识恢复满意,遂吸干口腔分泌物,拔除气管导管,患者自主呼吸5min,指端脉搏血氧饱和度降至88%,听诊患者双肺呼吸音弱闻及喉喘鸣音,诊断患者出现喉痉挛。加压面罩给氧,指端脉搏血氧饱和度升至97%,患者诉呼吸不畅,在浅麻醉下使用纤维支气管镜引导经鼻气管插管,患者呛咳反射剧烈,插管失败,纤维支气管镜下未见喉部异常体征,置入喉罩人工辅助维持呼吸,指端脉搏血氧饱和度回升至98%。
 
送患者至ICU病房,保留喉罩自主呼吸,必要时人工或机控辅助通气;继续严密观察患者病情,患者呼吸困难程度减轻,听诊患者双肺呼吸音清晰喉喘鸣音消失,拔除喉罩,观察患者生命体征平稳;术后第2天访视患者未诉不适,指端脉搏血氧饱和度>95%。
 
2.讨论
 
①气管困难术前预测,麻醉前访视重点内容之一是检查患者气道的通畅情况,客观评估气管插管的难易程度,预测其困难所在。②经评估为气管插管困难气道,无插管成功把握,应常规选用浅麻醉保留自主呼吸气管插管或清醒气管插管,禁忌静脉给予快速长效肌松诱导气管插管。备纤维支气管镜,气管插管失败改用置入喉罩维持患者呼吸道通畅呼吸,喉罩为声门上通气管道,采用声门上通气管道既能保证气道的畅通,又能快捷迅速置入,且伤害刺激强度小;而采用声门上通气道的危险因素是内压增高导致内容物反流引发误吸。③气管插管困难者拔管时,必须十分慎重,拔管后可再度出现呼吸困难,而需再次插管,因此拔管前自主呼吸须完全恢复,吸出口咽鼻腔分泌物,做好人工控制呼吸准备,拔管后密切观察患者呼吸,回病房后必须随访2d~3d。
 
本例患者体型肥胖,体重指数>30kg/m2,Mallampati:Ⅲ级舌咽关系,评估为困难气管插管可能。患者入手术室,全麻诱导麻醉深度及肌松效果满意行气管插管失败,患者自主呼吸恢复再次气管插管成功,术毕拔除气管导管后患者出现喉痉挛,呼吸困难,面罩加压给氧患者指端脉搏血氧饱和度能维持在正常范围,停止加压面罩给氧指端脉搏血氧饱和度即降至正常范围以下。
 
行纤维支气管镜引导气管插管失败,置入喉罩减少刺激辅助维持呼吸,指端脉搏血氧饱和度回升至98%。患者回ICU保留喉罩自主通气,必要时人工或机控辅助通气,呼吸困难程度减轻,听诊双肺呼吸音清晰喉喘鸣音消失,拔除喉罩术后第2天回访患者未诉呼吸困难,血氧饱和度可。因此困难气管插管全麻复苏喉痉挛,可置入喉罩维持呼吸道畅通减少伤害性刺激,效果良好。
 
原始出处:

黄友芳,李俊英.困难气管插管全麻复苏喉痉挛置入喉罩维持呼吸1例[J].基层医学论坛,2018,(13):1844.

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    2019-01-13 lizhou0204
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    2019-01-13 apoenzyme
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