Abstract:

Objective To summary the application value of pulmonary sequestration，anesthesia management and extracorporeal membrane oxygenation（ECMO）during lung transplantation anesthesia. Methods Clinical data of 330 cases of lung transplant recipients were collected，age 51.4±9.6 yearsold，ASA grade Ⅲ or Ⅳ . All patients were treated with preoperative oxygen clinotherapy，including 6 cases with tracheotomy and 12 cases with tracheal intubation and respiratory support. During the surgery, all patients were treated by intravenous injection of midazolam 0.05-0.1 mg/kg，fentanyl 4 μg/kg，etomidate 0.2-0.4 mg/kg and vecuronium 0.1 mg/kg. A double lumen bronchial tube，a single chamber double balloon catheter（Univent tube） or a bronchial obstruction wasselected according to the need of operation. Ventilation mode was used in pressure control，and the parameters were adjusted according to the blood gas index and vital signs，manual ventilation if necessary. ECMO was used in patients who could not tolerate single lung ventilation and cardiac dysfunction during surgery. Results 132 patients underwent single lung transplantation patients，121 of them were treated with non operative side double lumenbronchial tube ；3 patients were treated with tracheotomy before operation and 6 cases were treated with bronchial obstruction. 2 of them were treated with short stature and Univent tube. There were 198 patients underwent bilateral lung transplantation，187 cases of them applied the left double lumen endobronchial tube，among which 5 cases replaced the tube due to surgical operation punctured the cuff，7 cases applied the left bronchial anastomosis return tube ；6 patients underwent Univent tube ；5 cases used endobronchial blocker. 5 cases of bronchiectasis patients and 3 idiopathic pulmonary fibrosis（IPF）patients had sputum obstruction after induction of anesthesia，4 cases turnedbetter after treatment，1 case died due to continuous hypoxemia. ECMO was used in 148 cases，including 69 cases of pulmonary hypertension，17 cases of cardiac insufficiency，57 cases of hypoxia and 5 cases of hypercapnia. 133 cases immediately removed ECMO after surgery，15 patients continued to use ECMO due to the hemodynamic instability and poor postoperative oxygenation. Conclusion Rational application of pulmonary sequestration technology is the premise of the completion of lung transplantation anesthesia ；The effective management of respiratory and circulation in the patients during the perioperative period is the basis of ensuring the success of operation ；ECMO is an effective method for lung transplantation，which can improve the success rate of anesthesia in lung transplantation.

摘要：

目的 总结肺移植麻醉期间肺隔离技术、麻醉管理及体外膜肺氧合（ECMO）的应用价值。方法 收集无锡市人民医院 330 例肺移植受者的临床资料，年龄（51.4±9.6）岁，ASA 分级Ⅲ或Ⅳ级。所有受者术前均需卧床接受吸氧治疗，其中包括 6 例气管切开和 12 例气管插管呼吸支持患者。入室后常规给予静脉注射咪达唑仑 0.05 ～ 0.1 mg/kg、芬太尼 4 μg/kg、依托咪酯 0.2 ～ 0.4 mg/kg 及维库溴铵 0.1 mg/kg 后，行气管内插管。气管导管根据手术需要分别选择双腔支气管导管、单腔双囊气管（Univent 导管）导管或支气管阻塞器。通气方式均采用压力控制，根据受者血气指标及生命体征调节通气参数，必要时行手控通气。对于术中不能耐受单肺通气或心功能异常的患者给予 ECMO 辅助。结果 132 例单肺移植患者中，121 例应用非术侧双腔支气管导管；3 例术前气管切开患者和 6 例术前气管插管给予呼吸支持患者应用支气管阻塞器；2 例因身材矮小而应用Univent 导管。198 例双肺移植中，187 例应用左侧双腔支气管导管，其中 5 例术中因手术操作刺破套囊而更换导管，7 例在吻合左侧支气管时退管 ；6 例应用 Univent 导管 ；5 例应用支气管阻塞器。5 例支气管扩张患者和 3 例特发性肺纤维化（IPF）患者在麻醉诱导后出现痰液阻塞，经处理后 4 例好转，1 例因持续低氧血症而死亡 ；共 148 例术中应用 ECMO，包括肺动脉高压 69 例 ；心功能不全 17 例 ；低氧血症 57 例 ；高碳酸血症 5 例。133 例术毕即刻撤除 ECMO，15 例因血流动力不稳定、氧合差，术后继续使用 ECMO。结论 合理应用肺隔离技术是完成肺移植麻醉的前提 ；对围麻醉期受者的呼吸和循环进行有效地管理，是确保手术麻醉成功的基础 ；ECMO 是肺移植术中心肺辅助的有效手段，可提高肺移植手术的麻醉成功率。