左肺全切除术后心脏疝一例

2020-03-03 谭晓红 许成凤 张旭东 临床麻醉学杂志

患者,男,56岁,170 cm,68kg,ASAⅡ级,.以“咳痰、痰中带血20d”入院。术前CT提示,左上肺门处软组织肿块约2.8 cm×1.4 cm,纤支镜活检病理结果为非小细胞肺癌。拟全麻下行开胸左肺全切除术。患者现病史及既往史无特殊,无吸烟、饮酒嗜好,肺功能良好,ECG提示窦性心律、Ⅰ度房室传导阻滞、ST段上斜性抬高,心脏彩超示EF76%,术前化验检查无明显异常。

患者,男,56岁,170 cm,68kg,ASAⅡ级,.以“咳痰、痰中带血20d”入院。术前CT提示,左上肺门处软组织肿块约2.8 cm×1.4 cm,纤支镜活检病理结果为非小细胞肺癌。拟全麻下行开胸左肺全切除术。患者现病史及既往史无特殊,无吸烟、饮酒嗜好,肺功能良好,ECG提示窦性心律、Ⅰ度房室传导阻滞、ST段上斜性抬高,心脏彩超示EF76%,术前化验检查无明显异常。
 
入室监测生命体征,有创血压122/78mmHg,HR70次/分,SpO297%。常规给氧去氮5min,依次给予舒芬太尼30μg、丙泊酚120mg、罗库溴铵50mg静脉麻醉诱导,2min后行右双腔气管插管顺利,纤支镜辅助下定位准确,听诊双肺隔离效果好。术中静脉泵注丙泊酚和瑞芬太尼,吸入七氟醚,间断推注罗库溴铵和舒芬太尼维持麻醉,维持PETCO2在35~45mmHg。术中单肺通气效果佳,生命体征平稳。手术顺利,术中行心包开窗,游离带蒂心包片,包埋左侧支气管断端,止血满意后接胸腔闭式引流管并夹闭。手术持续90min,输入800ml晶体液、500ml胶体液,出血100ml,尿量300ml。
 
当术毕患者由右侧卧位转为平卧位时,监护仪显示ECG及BP波形突然呈直线,伴随PETCO2及SpO2快速下降。判断患者心跳骤停,立即开始常规心肺复苏,但患者对胸外心脏按压、肾上腺素、电除颤等对症治疗均无反应,迅速排除大出血、低钾血症、急性心肌梗死等围术期常见的导致心跳骤停的原因后,结合患者胸外心脏按压不能产生动脉波形及PETCO2波形的突出表现,考虑患者发生了循环梗阻可能,由于患者是在体位变动时突然发生心跳骤停,所以患者左肺全切除术后发生心脏扭转导致循环梗阻可能性较大。
 
于是常规心肺复苏3min后将患者置于右侧卧位,行开胸探查术。患者处于右侧卧位后,自行出现了无脉的心电活动,外科医师开胸后发现心脏从心包缺损处疝出并嵌顿,立即剪开心包,行心脏复位。患者心跳随即恢复,HR55次/分,有创血压196/106mmHg,1min后患者HR70次/分、有创血压193/112mmHg、SpO2100%、PETCO251mmHg。待生命体征进一步平稳后将患者送回ICU继续治疗,在ICU住院20d,常规脑复苏未成功,家属放弃治疗。
 
讨论
 
心脏疝(cardiac herniation)是心脏组织经心包缺损处疝出心包外发生心脏嵌顿或扭转导致血液动力学紊乱的紧急情况,世界第1例心脏疝由Bettaman和Tannenbaum于1948年报道,至今全球约有100例左右,每年新增5~8例病例报道。因外伤、先天性心包缺损、心脏手术、心包内全肺切除术等存在心包缺损的患者,当咳嗽、体位变动、膨肺、胸腔负压吸引等导致双侧胸腔压力失衡时可能发生心脏疝。
 
本例患者术中行游离带蒂心包片包埋左支气管残端,心包缺损未缝合或修补,术毕因体位改变引起心脏疝。心脏疝的临床表现与心包缺损位置有关。右侧发生心脏疝时腔静脉扭转,引起下腔和上腔静脉回流受阻,静脉压明显升高,心脏充盈量明显减少,体循环低血压,心率加快;左侧发生心脏疝时左心室受压,出现左心室的充盈和排空障碍,以及心肌本身的灌注障碍,导致心肌缺血和继发性心律失常,进而引起低血压、室颤和心肌梗死。但也有循环稳定的心脏疝患者,仅出现了完全倒置的T波。
 
心脏疝罕见,但后果严重,如不及时诊断及治疗,死亡率可高达50%~100%,且在病因未解除前复苏困难。当怀疑心脏疝时,可快速获取的床旁X线检查、床旁心脏彩超、经食管超声心动图等辅助检查能帮助明确诊断,如果患者病情允许,可进一步行胸部CT或心脏MRI检查。本例患者发生心脏疝,并导致心跳骤停,病情紧急,当胸外心脏按压结果提示循环梗阻时,立即开胸探查,使循环尽快恢复,得以挽救患者生命。所以本病例报道旨在提示当情况紧急,不能等待辅助检查时,诊断思路及外科手术探查很重要。开胸探查一方面可能发现病因,另一方面胸内心脏按压可能更有效,并且可以直接心脏内注药。
 
对于诊断明确的心脏疝须及时处理。对于无嵌顿或病情不是十分紧急者,可立即恢复患者为健侧卧位,在手术侧胸腔注入1~2L气体或生理盐水,增加术侧胸膜腔内压力和体积,减轻纵膈摆动使心脏复位。若保守治疗无效,须及时开胸行心脏复位。由于心脏疝没有特异性的临床表现,及时明确诊断较困难,而未诊断的心脏疝患者可能很快发展为呼吸循环衰竭,死亡率高达100%,所以临床重在预防。有文献建议无论心包缺损多大,都应给予间断缝合或补片修补,以有效预防心脏疝的发生。
 
原始出处:

谭晓红,许成凤,张旭东,王怀明,张可贤.左肺全切除术后心脏疝一例[J].临床麻醉学杂志,2019,35(02):204-205.

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