术前窦性心动过缓的患者,通常需要事先进行充分评估和准备才能进行麻醉,以避免术中出现心跳骤停等需要抢救的情况。病例汇报:该患者术前阿托品试验阳性,术前心率50次/分,入室42~45次/分,术中多次出现中重度心动过缓,最低心率31次/分,但血流动力学仍较稳定。讨论:对于此类中度至重度心动过缓但血流动力学较稳定的患者的处理,可以采取暂不处理或仅维持在术前水平即可。 Preoperative patients with sinus bradycardia usually need to be fully evaluated and prepared before anesthesia to avoid intraoperative cardiac arrest and other conditions requiring rescue. Case report: The patient had positive preoperative atropine test, with preoperative heart rate of 50 beats per minute and 42 - 45 beats per minute in the room. Moderate and severe bradycardia occurred several times during the operation, with the lowest heart rate of 31 beats per minute, but hemodynamics was still stable. Discussion: In patients with moderate to severe bradycardia but with stable hemodynamics, treatment may be left untreated or maintained at the preoperative level.
术前窦性心动过缓的患者,通常需要事先进行充分评估和准备才能进行麻醉,以避免术中出现心跳骤停等需要抢救的情况。病例汇报:该患者术前阿托品试验阳性,术前心率50次/分,入室42~45次/分,术中多次出现中重度心动过缓,最低心率31次/分,但血流动力学仍较稳定。讨论:对于此类中度至重度心动过缓但血流动力学较稳定的患者的处理,可以采取暂不处理或仅维持在术前水平即可。
窦性心动过缓,全身麻醉
Qianqian Sun, Xinrong Zhao
Affiliated Hospital of Yan’an University, Yan’an Shaanxi
Received: Aug. 12th, 2020; accepted: Aug. 26th, 2020; published: Sep. 2nd, 2020
Preoperative patients with sinus bradycardia usually need to be fully evaluated and prepared before anesthesia to avoid intraoperative cardiac arrest and other conditions requiring rescue. Case report: The patient had positive preoperative atropine test, with preoperative heart rate of 50 beats per minute and 42 - 45 beats per minute in the room. Moderate and severe bradycardia occurred several times during the operation, with the lowest heart rate of 31 beats per minute, but hemodynamics was still stable. Discussion: In patients with moderate to severe bradycardia but with stable hemodynamics, treatment may be left untreated or maintained at the preoperative level.
Keywords:Sinus Bradycardia, General Anesthesia
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临床中引起心动过缓的最常见的原因是病理性窦性心动过缓、窦性停搏、窦房阻滞、房室传导阻滞。还可见于病态窦房结综合征、急性心肌梗死、甲状腺机能低下、颅内压增高或使用了有减慢心率作用的药物等。而在术中面对窦性心动过缓的患者更加需要麻醉医生过硬的知识储备及灵活的应变能力。
患者女,65岁,155 cm,56 kg,农民。因患直肠癌非急症入院。现病史及既往病史无特殊。术前心电图报告:窦性心动过缓(心率55次/分),左室高电压,显著ST-T改变。24 h动态心电图显示:最慢心率34次/分,最快97次/分,平均50次/分,偶发室早、房早,心律不齐,下壁、侧壁ST-T下斜型下移。心脏彩超未见明显异常,实验室检查未见明显异常。诊断为:1.直肠癌 2.心律失常 窦性心动过缓。拟行腹腔镜辅助直肠癌(2~6 cm)根治术。请麻醉科会诊:患者血压140/63 mmHg,心率58次/分,一般情况,ASA II级,NYHA心功能分级I级,建议请心内科会诊,排除病窦综合征,判断是否需要放置临时起搏器。心内科会诊意见:行阿托品试验:最快心率<90次/分,即阿托品试验阳性。后行异丙肾上腺素试验,患者心率有明显升高,最快心率>100次/分,建议可不放置临时起搏器,但需做好术中升心率的准备。
入室后常规建立左上肢静脉通路。行心电监护,提示心率42~45次/分,监测无创血压、脉搏血氧饱和度、BIS,行左侧桡动脉穿刺置管术并行有创动脉血压监测。术前备好阿托品,多巴胺,异丙肾上腺素(1 ug/ml)等抢救药物。面罩给氧3分钟后,进行麻醉诱导:依次缓慢静推咪达唑仑3 mg,舒芬太尼30 ug,苯磺酸顺式阿曲库铵10 mg后心率立刻掉至32次/分,血压从146/90 mmHg掉至102/67 mmHg,给予多巴胺2 mg,阿托品0.5 mg,心率升至61次/分后进而降低至40次/分,血压升至180/105 mmHg,给予5mg依托咪酯后观察数分钟,循环稳定后充分暴露声门行气管插管术,连接呼吸机并固定气管导管,行机械通气。听诊双肺呼吸音正常,随后调整呼吸机参数维持呼气末二氧化碳分压35~45 mmHg。麻醉维持:以七氟醚维持麻醉,瑞芬太尼0.1 ug/kg/min进行镇痛,间断静推顺式阿曲库铵,维持BIS值在40~60之间。麻醉诱导完成后,行颈静脉穿刺置管术,巡回护士置入导尿管。在手术进行中,患者心率长时间维持在31~37次/分之间,但血压基本稳定在120/60 mmHg左右,心电图等并未出现缺血等改变。在起初麻醉由不平稳发展为平稳的过程中,患者心率降至35次/分时曾给予1 ug异丙肾上腺素从颈内静脉置管处推注,患者心率升至83次/分左右,收缩压升至175 mmHg左右,后心率逐渐下降至40次/分,血压逐渐恢复至给药之前的水平。此后心率维持在35次/分左右,大约四十分钟之后心率再一次降至31次/分,出于防止心率进一步下降甚至心跳骤停的考虑,再一次给予1 ug异丙肾上腺素从颈内静脉置管处推注,给药之后的反应和上次给药后的情况大致相同。之后术中心率基本在32~53次/分之间,轻微调整麻醉药物使得BIS值控制在40~60,血压一直较为平稳,因此再未对心率给予处理。手术顺利,历时4 h,手术结束前15 min关七氟醚,10 min停瑞芬太尼,术终患者迅速清醒,清醒后心率在53次/分左右,转至PACU观察,拔管平稳,无特殊不适,安返病房。术后6 h访视,患者意识清醒,无明显不适,心率稳定在47~52次/分,血压98/66 mmHg。
窦性心动过缓即窦性心律慢于60次/分,其症状可表现为阵发性心悸、胸闷,头晕等,严重时甚至可造成心源性猝死,产生窦性心动过缓的病因是多方面的,可分为生理性和病理性,其中老年人多为器质性病变引起。按其程度可分为:轻度(50次/分~59次/分)、中度(36次/分~49次/分)、重度(<35次/分) [
那么临床中如果遇到类似中重度窦性心动过缓但血流动力学稳定的患者,在术中可不必强求正常的心率,仅维持在患者术前状态即可,但需要注意的是一定要做好术中抢救的准备,如备好阿托品和异丙肾上腺素等抢救药品、除颤仪之外,还需做好术中安装临时起搏器的准备。
孙倩倩,赵欣荣. 术中处理重度窦性心动过缓一例A Case of Severe Sinus Bradycardia Was Treated during Operation[J]. 医学诊断, 2020, 10(03): 108-110. https://doi.org/10.12677/MD.2020.103017