【摘要】 目的 探讨1例行双肺移植同期冠状动脉旁路移植术患者的麻醉管理方法。方法 1例特发性肺纤维化合并冠心病患者，男，55岁，于体外膜肺氧合（extracorporeal membrane oxygenation, ECMO）辅助下采用全静脉麻醉行双肺移植同期冠状动脉旁路移植术。术中采用小潮气量保护性肺通气策略联合ECMO维持心肌氧供，应用经食管超声和Swan-Ganz导管监测心脏收缩功能、血流动力学参数和容量状态，指导血管活性药物使用。记录麻醉诱导后10 min（T₀）、置入Swan-Ganz导管后5 min（T₁）、ECMO运转10 min（T₂）、单肺通气30 min（T₃）、吻合左前降支（T₄）、搭桥完成后10 min（T₅）、左肺动脉阻断后10 min（T₆）、左肺动脉开放后10 min（T₇）、右肺动脉阻断后10 min（T₈）、右肺动脉开放后10 min（T₉）、双肺通气10 min(T₁₀)、出手术室(T₁₁)时心率、动脉血压、中心静脉压、血氧饱和度和肺动脉压。记录患者麻醉诱导前、T₃、T₄、T₇、T₉时pa（O₂）和pa（CO₂）,肺移植前后双侧肺静脉流速。结果 术中动脉血压、中心静脉压在T₈时均降低，其他各时间点均维持正常范围；随着ECMO运行及肺移植手术的进行，T₂～T₁₁时肺动脉压逐渐下降维持稳定但均高于正常值，双肺移植后(T₉～T₁₁)肺动脉压降至术中最低（28/19 mm Hg）;患者术中氧合状态良好，血氧饱和度、pa（O₂）均维持在正常范围；ECMO运行后，T₃、T₄、T₇、T₉时pa（CO₂）逐渐降至正常范围；肺移植前左、右肺静脉流速分别为60、56 cm/s,双肺移植后分别升高至92、100 cm/s。术后16 h撤除ECMO,术后第1天出现低心排血量综合征，术后第2天出现中度原发性移植肺失功，经对症治疗后心功能、肺功能逐渐改善。术后第6天为便于气道管理行气管切开。术后第13天患者心功能恢复良好，血流动力学平稳，可下床活动，间断撤离呼吸机。目前继续康复治疗中。结论 双肺移植同期冠状动脉旁路移植术中麻醉管理采用小潮气量保护性肺通气策略联合应用ECMO可改善患者术中氧合状态、纠正高碳酸血症、降低肺动脉压力、维持心肌氧供需平衡；术中应用经食管超声和Swan-Ganz导管指导血管活性药物使用和限制性液体治疗，可维持术中血流动力学平稳，减轻术后心功能衰竭。更多还原

【Abstract】 Objective To investigate the anesthesia management of combined lung transplantation and coronary artery bypass grafting in one case.Methods A 55-year-old male patient with idiopathic pulmonary fibrosis and coronary heart disease underwent bilateral lung transplantation and coronary artery bypass grafting assisted by extracorporeal membrane oxygenation（ECMO）under total intravenous anesthesia.Low-tidal volume protective pulmonary ventilation strategy was applied in combination of ECMO in operation.During operation,transesophageal echocardiography and Swan-Ganz catheter were used to monitor cardiac systolic function,hemodynamic parameters and capacity status,and to guide the application of vasoactive drugs.The heart rate,arterial blood pressure,central venous pressure,blood oxygen saturation and pulmonary artery pressure in 10min after anesthesia induction（T₀）,5min after Swan-Ganz catheter insertion（T₁）,10min after ECMO operation （T₂）,30 min after one lung ventilation （T₃）,before anastomosis of the left anterior descending branch（T₄）,10min after bypass grafting（T₅）,10min after left pulmonary artery clamping（T₆）,10min after left pulmonary artery unclamping （T₇）,10 min after right pulmonary artery clamping （T₈）,10 min after right pulmonary artery unclamping（T₉）,10min after bilateral lung ventilation(T₁₀),and leaving the operating room (T₁₁)were recorded.The pa（O₂）and pa（CO₂）before anesthesia induction,and at the time points of T₃,T₄,T₇and T₉,and the flow velocity of bilateral pulmonary vein before and after lung transplantation were recorded.Results The arterial blood pressure and central venous pressure decreased at T₈,and remained stable at other time points.With the operation of ECMO and progress of lung transplantation,the pulmonary artery pressure at T₂to T₁₁ decreased gradually and remained stable,but was still higher than the normal level;the pulmonary artery pressure after bilateral lung transplantation(T₉-T₁₁)decreased to the lowest level（28/19 mm Hg）during operation.During operation,the patient had a good oxygenation status,and normal blood oxygen saturation and pa（O₂）.After ECMO operation,pa（CO₂）at T₃,T₄,T₇and T₉decreased gradually to the normal range.The left and right pulmonary vein velocities were 60 and 56cm/s before lung transplantation,and increased to 92 and 100 cm/s after bilateral lung transplantation,respectively.The ECMO was removed 16h after operation.Low cardiac output syndrome developed on the 1st day after operation,and moderate primary graft dysfunction developed on the 2nd day after operation,the heart function and lung function were gradually improved after symptomatic treatment.Tracheotomy was performed on the 6th day after operation for airway management.On the 13th postoperative day,the the cardiac function was well recovered and the hemodynamic parameters were stable,and the patient took off-bed exercise and intermittenously weaned from the ventilator.The patient is still undergoing rehabilitation treatment.Conclusions Low-tidal volume protective pulmonary ventilation strategy combined with ECMO can improve oxygenation status,correct hypercapnia,lower pulmonary artery pressure and maintain the balance of myocardial oxygen supply and demand.Intraoperative use of transesophageal ultrasound and Swan-Ganz catheter can guide the application of vasoactive drugs and the restricted fluid therapy to maintain hemodynamic stability,and reduce postoperative heart failure.更多还原