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对称性胸腹连体儿分离手术的围术期管理
Perioperative management of symmetry operation of separation of thoracopagus conjoined twins
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DOI:
作者:
邱永升
Qiu Yong-sheng
作者单位:
郑州市儿童医院
Zhengzhou children‘s hospital
关键词:
双生,连体;分离术;麻醉
conjoined twins;separation ;anesthesia
摘要:
目的 探讨对称性胸腹连体儿分离手术的围术期管理的方法。方法 连体婴儿A和B均为女性,呈对称性面对面胸腹连体被动体位,两患儿胸腹体桥连接周径约310mm,两患儿肝实质相连,有两套肝门和胆道系统,胸骨下端及膈肌部分相连,体重共5300g,在做了充分的术前准备并制定了详细治疗方案后实施了连体儿分离手术。先对A婴行麻醉诱导,吸入2%七氟醚,待患儿意识消失静脉给予顺式阿曲库铵0.2mg,瑞芬太尼3μg,右侧卧位经视频喉镜顺利插入ID3.5mm的气管导管,同样方法对B婴进行诱导插管,采用定压模式控制呼吸,调整适当的气道压力(Paw)、通气频率(f)和吸呼比。吸入1%~3%七氟醚,静脉予瑞芬太尼10~20μg•kg-1•h-1、顺式阿曲库铵0.1~0.2mg• kg-1•h-1维持麻醉,泵入钠钾钙镁葡萄糖液进行补液。彩色超声引导下于两患儿颈内静脉分别放入中心静脉导管,行股动脉穿刺连续监测动脉压(ABP),查血气分析、电解质、血糖、血红蛋白指导治疗,用弹簧秤测得手术台上止血纱布重量估算出血量共约40ml,两患儿术中生命体征稳定。术中用超声刀沿两个肝脏边界腹膜腔分界处切开相连部分,手术历时240min。术毕两患儿安返SICU,带呼吸机SIMV+PS模式辅助呼吸,B婴和A婴分别在术后50h、72h撤离呼吸机,拔出气管导管。结果 两患儿均存活,围术期呼吸循环功能基本稳定,无麻醉相关并发症。结论 详细的治疗方案,周密的管理和先进的可视化设备,可以提高连体双胎救治的成功率。
Objective Explore the methods of perioperative management of symmetric thoracic-abdominal conjoined twins separated operation. Method of conjoined twins A and B were female, were symmetry face of thoracic and abdominal integrated passive position, two of children with ventral thoracic bridge connecting circumference of about 310mm, two children with liver parenchyma is connected, there are two sets of liver and biliary system, connected to bottom of the sternum and diaphragmatic part, weight is 5300g, made in full preoperative preparation and developed a detailed treatment after the implementation of the Siamese twins separated operation. First the A baby inhaled 2% sevoflurane anesthesia induction, loss of consciousness, the children were given intravenously cisatracurium 0.2mg, remifentanil 3 μ g, right lateral tracheal catheter was inserted into the ID3.5mm video laryngoscope smoothly, the same method of induction and intubation in B infants, the constant pressure mode control breath, adjust the appropriate (airway pressure Paw), respiratory rate (f) and respiratory ratio. Inhalation of 1%~3% sevoflurane and 10~20 μ g • kg-1 • h-1 remifentanil intravenous , cisatracurium 0.1~0.2mg • kg-1 • h-1 maintenance of anesthesia, pumps sodium potassium calcium magnesium glucose fluid replacement. Ultrasound-guided internal jugular vein in two children were placed in the central venous catheter, femoral artery puncture and continuous monitoring of arterial pressure (ABP), blood gas analysis, electrolyte, check blood glucose, hemoglobin to guide treatment, operation table hemostatic gauze weight estimate the amount of bleeding were about 40ml use spring balance measurement, vital signs of two patients in the stable. Using ultrasonic knife surgery along two liver boundary demarcation incision peritoneal cavity connected parts, operation duration 240min. At the end of two children returned to SICU, with ventilator SIMV+PS assisted respiration, B and A baby in postoperative 50h, 72h ventilator weaning, pulling out the tracheal catheter. Results two children survived the perioperative respiratory, circulatory function basically stable, without anesthesia complications. Conclusion the treatment of detailed, careful management and advanced visualization device, can improve the successful rate of treatment of Siamese twin.
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