摘要
目的总结DeBakey I型主动脉夹层围术期处理要点。方法纳入2004年2月-2008年1月解放军总医院完成De-BakeyI型主动脉夹层急诊手术的19例患者,其中男16例,女3例,年龄43.6±9.4岁。全部替换升主动脉,同期替换主动脉根部(Bentall)5例、主动脉瓣2例、右半弓11例、全弓6例(其中降主动脉内带膜支架4例、传统象鼻手术1例),同期行二尖瓣成形术1例。涉及主动脉弓部的手术均在深低温停循环下完成。16例经右腋动脉插管。围术期处理策略:入院后立即应用大剂量β受体阻断剂和硝普钠等将收缩压控制在90mmHg左右,2h内完成主动脉CT扫描三维重建、超声心动图、心电图、X线胸片和实验室检查等急诊术前准备。术中根据夹层和内膜破口的部位采取简便可行的手术方案,以挽救生命为第一目标。常规使用超滤以减轻水负荷和炎症反应。术毕将收缩压严格控制在90mmHg左右。术后强化镇静和呼吸机治疗,强调使用呼吸机呼气末正压(PEEP),待低氧血症纠正和肺水肿消退后方可脱离呼吸机。结果19例患者体外循环时间215.9±73.6min,主动脉阻断时间138.2±55.7min,脑部停循环时间29.3±11.5min。呼吸机辅助通气时间156.1±112.8(11～460)h。死亡3例(15.8%);发生须行血液透析的一过性肾功能不全1例,慢性心包填塞行穿刺引流2例;发生低氧血症(氧合指数PaO2/FiO2≤300)10例,其中5例术前已存在低氧血症。结论DeBakey I型主动脉夹层手术风险大,完善的围术期处理是降低死亡率的重要保障。
Objective To summarize the strategy of perioperative management for DeBakey I acute aortic dissection. Methods Nineteen cases of DeBakey I acute aortic dissection （16 males and 3 females,aged 43.6±9.4 years old） were surgically treated from Feb. 2004 to Jan. 2008. Ascending aorta was replaced in all patients. According to the pathological anatomy,concomitant procedure was performed including 5 cases of aortic root replacement （Bentall operation）,2 cases of aortic valve replacement,11 cases of right semi-arch replacement,6 cases of total arch replacement and 1 case of mitral valvuloplasty. The procedure involved arch replacement was performed under circulatory arrest and deep hypothermia. Sixteen cases underwent right axillary artery catheterization. High dosage of β-receptor blocking agents and nitroprusside were immediately administered under monitoring to control the systolic blood pressure to 90mmHg when the patients were admitted to ICU. Computed tomography angiography （CTA） for precise diagnosis of aortic dissection,echocardiography,ECG,chest X-ray and laboratory examination were completed before emergency surgery within 2h after admission. Simplified and effective procedure was meticulously performed according to the aortic pathological anatomy for the most important aim of saving life,and ultra-hemofiltration was routinely used to remove excessive water and inflammatory factors during cardiopulmonary bypass. The systolic blood pressure was strictly controlled to 90mmHg when the operation finished and the patient was transferred back to ICU. Mechanical ventilation and PEEP were cautiously weaned off until hypoxemia and pulmonary edema were resolved. Results The mean duration of cardiopulmonary bypass was 215.9±73.6min,aortic clamping time was 138.2±55.7min and circulatory arrest time was 29.3±11.5min. Mean time of mechanical ventilation was 156.1±112.8h. Three cases of in-hospital death occurred （15.8%）. One case of acute renal failure necessitating hemodialysis,2 cases of chronic peri
出处
《解放军医学杂志》
CAS
CSCD
北大核心
2009年第11期1374-1375,1384,共3页
Medical Journal of Chinese People's Liberation Army
关键词
主动脉瘤
胸
动脉瘤
夹层
心血管外科手术
aortic aneurysm
thoracic
aneurysm
dissecting
cardiovascular surgical procedures
