前上纵隔恶性肿瘤姑息切除并冠状动脉旁路移植1例

前上纵隔恶性肿瘤姑息切除并冠状动脉旁路移植1例 前上纵隔恶性肿瘤姑息切除并冠状动脉旁 路移植1例 堕.笪病~——20—07—8—第26第三期 JoumalofCardiovascular&PulmonaryDiseases,Aust2007,V01.26,N0.3 合适的麻醉深度.本组病例术中BIS值均在4060 范围,但?,?组患者术中BIS值低于I组(P< 0.05).由于3组患者术中丙泊酚用量差异无显着 性(P>0.05),但?,?组患者术中舒芬太尼用量多 于I组(P<0.01),推测术中在多种镇静催眠药物 (本组为咪达唑仑与丙?自酚)存在的条件下,舒芬太 尼的剂量对术中BIS值具有明显的影响,与以前认 为阿片类药物对BIS值无显着影响的观点j不一 致.可能的解释是,阿片类药物对BIS值无显着影 响的观点,是在健康自愿者或患者气管插管前得出 的结论,所用阿片类药物剂量较小,不足以影响脑皮 质的电活动,而本组病例为了对抗手术刺激的影响, 所用舒芬太尼剂量较大,足以对脑电图产生明显的 影响,产生较强镇静效应,从而显着影响BIS值. 舒芬太尼对术中BIS值的影响有待进一步证实. 随着剂量增大,舒芬太尼对心功能的抑制作用 越来越强J.本组发现?组患者CI在提升胸骨前 低于I组(P<0.05),也支持选用0.6ng/mL效应室 浓度优于0.8ng/mL浓度的观点. 采用0.4ng/mL,0.6ng/mL或0.8ng/mL固定效 应室浓度的舒芬太尼靶控静脉麻醉,对OPCAB患者 术中均可以维持满意的血流动力学,而0.6ng/mL为 最合适的靶控浓度. 参考文献 [1]JainU,BodySC,BellowsW,eta1.Multieenterstudyof target—controlledinfusionofpropofol—sufentanilorsufentanil— midazolamforcoronaryarterybypassgraftsurgery. [2] [3] [4] [5] [6] [7] [8] [9] 155 Anesthesiology,1996,85:522—535. 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(2007一O1—15收稿) 前上纵隔恶性肿瘤姑息切除并冠状动脉旁路移植1例 王云顾继伟万荣华刘旭东李军朋 患者,男,69岁,主因"左前胸痛伴左肩放射痛频繁发作 1年"收住院.查体:桶状胸,心尖部可闻及收缩期杂音.胸 部x线示:左侧膈肌麻痹.胸部CT示:前上纵隔占位,有中 心液化坏死和环形钙化.肺功能测试:重度通气功能减损. 心电图:11I,AVF导联不典型Q波.超声心动图示:升主动脉 增宽,主动脉瓣(无冠瓣)退行性改变,EF值0.63.冠状动脉 作者单位:750004宁夏银川宁夏医学院附属医院胸心外科(王云 万荣华刘旭东)宁夏医学院2004级研究生(顾继伟李军朋) 病例报告? 造影示:右冠状动脉病变,狭窄80%;左冠状动脉前降支近 端,主干及4条分支均狭窄约85%,回旋支中段及远段2处 80%狭窄,造影诊断:冠心病,三支病变.术前诊断:1.冠心 病;不稳定型心绞痛;2.前上纵隔肿瘤.于2006年l2月l4 日行纵隔肿瘤切除并冠状动脉旁路移植术(CABG).复合麻 醉后,胸骨正中切口开胸,胸骨上段由于纵隔肿瘤侵犯,开胸 困难,探查分离肿瘤见纵隔左前上方有一肿瘤,不规则10am ×8cm×8am,肿瘤硬,呈浸润性生长,严重侵犯胸骨上段, (下转第184页) l84心肺血管病杂志2007年8月第26卷第3期 JournalofCardiovascular&PulmonaryDiseases,August2007,Vo1.26,No.3 [7] [8] [9] [10] [12] [13] [14] ArantCB,WesselTR,OlsonMB,eta1.Hemoglobinlevel isanindependentpredictorforadversecardiovascular outcomesinwomenundergoingevaluationforchestpain: resultsfromthenationalheart,lung,andbloodinstitute women'sischemiasyndromeevaluationstudy.JAmColl Cardio1.2004.43:2oo9—2014. 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(2006—09—22收稿) (上接第155页) 左前上胸壁内乳动脉,无名静脉,心包,膈神经,左肺上叶,右 侧胸膜.切开心包见淡血性积液150mL.主动脉和肺动脉 壁有肿瘤侵犯.肿瘤质地呈烂鱼肉样,中央有钙化灶,直径 2cm,姑息切除大部分肿瘤,同时切除增厚的主动脉和肺动 脉外膜.冰冻切片:低分化腺癌.取左,右下肢大隐静脉(直 径0.4,0.5.cm,质好)备用.建立体外循环,转机降温,阻断 升主动脉,主动脉根部间断灌注氧合血心麻液,扪诊左前降 支中段,第一对角支中段,右冠状动脉远段,回旋支中段,硬 化斑明显,行大隐静脉一后降支(直径1.5mm),大隐静脉一 回旋支远段(直径2mm),大隐静脉一第一对角支中段(直径 2mm),大隐静脉一左前降支中段(直径2inln),吻合满意. 开放主动脉,心脏自动复跳,主动脉上侧壁钳,完成4个大隐 静脉桥近端吻合,并行循环后顺利停机.体外循环期间,肿 瘤切除创面用纱布严密覆盖.冰冻标本石蜡切片报告:1. 纵隔恶性肿瘤;2.主动脉壁增生并玻璃样变性的纤维结缔 组织中可见恶性肿瘤组织浸润.术后胸部切El上段裂开,经 换药后愈合,痊愈出院. 讨论胸腺肿瘤和CABG手术同时实施的病例,国内未 见报道.本病例先摘除肿瘤再行CABG手术,是因为肿瘤巨 大.不摘除肿瘤,不切除主动脉壁上的肿瘤病灶,CABG手术 无法进行.转机期间,肿瘤切面用纱布严密覆盖,防止肿瘤 随体外循环扩散转移,中和肝素后,未见恶性胸腺瘤姑息切 除创面广泛渗血.纵隔肿瘤切除合并CABG虽然少见,但仍 然是安全的. (2007—04—16收稿)