许晴琴,王晓,杜耘,曹宇,乔欣,贾小林
XU Qingqin,WANG Xiao,DU Yun,CAO Yu,QIAO Xin,JIA Xiaolin

• 1:四川大学华西医院麻醉科
• 2:重庆市人民医院麻醉科
• 3:重庆市人民医院骨科

摘要(Abstract)：

目的:经食道超声(TEE)监测全麻下非骨水泥型半髋关节置换对老年患者右心房内发生微栓及循环系统的影响。方法:选取50例全麻下行非骨水泥型半髋置换手术老年患者,于手术开始、股骨锉髓、股骨假体植入、关节复位、手术结束的各时段采用TEE观察右心房微栓影像分级情况,记录手术开始(T1)、股骨锉髓开始(T2)、股骨锉髓2 min时(T3)、股骨假体植入2 min时(T4)、关节复位2 min时(T5)、手术结束时(T6)的血氧饱和度(SPO_2)、呼气末二氧化碳分压(ETCO_2)、心率(HR)、有创动脉收缩压(IASBP)、有创动脉舒张压(IADBP),观察右心房发生1级和2级微栓时段的IASBP、IADBP变化。结果:50例患者全程未见3级微栓影像和反常性栓子,手术开始和结束时均未见微栓影像,在股骨锉髓、股骨假体植入、关节复位时点部分患者右心房出现1级和2级微栓影像,不同时点的微栓分级不全相同(P<0.001);T2与T1时点比较,患者HR、IASBP、IADBP均明显升高(P<0.01);T3、T4、T5时点与T1比较,患者IASBP、IADBP、ETCO_2均明显降低(P<0.01);患者各个时点SPO_2比较差异无统计学意义(P>0.05);股骨锉髓、股骨假体植入时段发生2级微栓影像患者的IASBP、IADBP分别较0级、1级患者降低(P<0.05)。结论:使用TEE可以观察到非骨水泥型半髋置换术中老年患者右心房在股骨锉髓、股骨假体植入和关节复位时段可能存在不同程度的微栓,并伴有血流动力学明显变化,尤其发生微栓影像2级时血压下降更为明显,需引起麻醉医生的重视。
Objective: To monitor the microembolism of the right atrium and its effect on circulatory system in elderly patients undergoing cementless hemiarthroplasty under general anesthesia by TEE. Methods: Fifty elderly patients undergoing cementless hemiarthroplasty under general anesthesia were observed by Transesophageal Echocardiography(TEE). The incidence and grading of microembolism in right atrium at the beginning of operation, femoral canal, implantation of sterm, relocation of hip joint and the end of surgery were recorded. At the beginning of operation(T1), the beginning of femoral canal(T2), two minutes after femoral canal(T3), two minutes after implantation of sterm(T4), two minutes after relocation of hip joint(T5) and the end of surgery(T6), pulse oxygen saturation(SPO_2), end-expiratory carbon dioxide partial pressure(ETCO_2),heart rate(HR), invasive arteria systolic blood pressure(IASBP)and invasive arteria diastolic blood pressure(IADBP)were recorded at each time point. The changes of invasive blood pressure during grade 1 and grade 2 of microembolic image were also recorded. Results: In the right atrium of 50 elderly patients, grade 1 and grade 2 of microembolism can be observed at the time of femoral canal and implantation of sterm, while only grade 1 of microembolic image can be observed at the time of relocation of hip joint. The incidences of microembolism were 34%, 54% and 50% at the three times respectively. The difference of the microembolic grades at each time point was statistically significant(P<0.001). HR, IASBP and IADBP in patients were significantly increased at T2 compared with those at T1(P<0.01).As in the respiratory and circulatory system,IASBP, IADBP and ETCO_2 were significantly decreased at T3,T4,T5 compared with those at T1(P<0.01). There was no significant difference in SPO_2 between T1-T6(P>0.05). IASBP and IADBP of microembolic grade 2 were significantly lower than those of grade 0 and grade 1 during the femoral canal and implantation of sterm, the difference was statistically significant(P<0.05). Conclusion: During the period of femoral canal, implantation of sterm and relocation of hip joint, TEE monitoring showed that different degrees of microembolism were found in right atrium of elderly patients undergoing cementless hemiarthroplasty, accompanied by significant changes in hemodynamics. Especially when the grade 2 of microembolic image occured, the decrease of blood pressure was more obvious, which still needs more attention by anesthesiologists.

关键词(KeyWords)： 半髋关节置换术;经食道超声;骨水泥植入综合征;微栓子监测;循环系统
hemiarthroplasty;transesophageal echocardiograph;cement implantation syndrome;microemboli monitoring;circulatory system

Abstract:

Keywords:

基金项目(Foundation): 重庆市卫生计生委医学科研计划项目(2016HBRC005)

作者(Author): 许晴琴,王晓,杜耘,曹宇,乔欣,贾小林
XU Qingqin,WANG Xiao,DU Yun,CAO Yu,QIAO Xin,JIA Xiaolin

DOI: 10.19367/j.cnki.1000-2707.2019.11.022

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