Some important problems about anesthetic management for surgical excision of pulmonary sequestrations 

FANG Cai, XIE Zhiqiong, CHEN Kunzhou et al. Department of Anesthesiology, Anhui Provincial Hospital, Hefei 230001, Anhui Province

[Abstract]  Objectve To analysis some major problems perioperatively about anesthesia management for surgical excesion of pulmonary sequestrations Methods 10 patients with pulmonary sequestrations(M/F=7/3, Age 20～34yr., ASAⅠ～Ⅱ) received an operation of pulmonary sequestrations removed under intra-tracheal anesthesia, in which 4 cases were intubated with single-lumen bronchial tubes(Mallinckrodt) and 6 cases with double-lumen tubes(DLT)(right-sided Robertshaw). One-lung ventilation(OLV) was taken intermittently for all patients during anesthesia. Results 6 cases with intralobar sequestration(ILS) and 4 cases with extralobar sequestration(ELS) were verified during operation. The patients with ILS and ELS accepted left-low lobectomy and a excision of sequestered pulmonary mass, respectively. The time of surgical procedure continued 2.5～9 hours. The volume of blood loss was about 300～1700 ml in operation. 9 patients had passed a smooth anesthesia and successful operation, and was discharged 7～10 days after surgery. One patient appeared suddenly a serious airway obstruction when bronchial of sequestered pulmonary lobe being cut off, which cause should be a great quantity of blood from surgical field and led to a long-time (6min.) critical hypoxemia(SpO2<40％), and died 4days after operation because of MOS. Conclusion Some factors, such as a good preparation preoperatively, accurate application of DLT, techniques of OLV and acting in close coordination between anesthetists and surgeons, are very important for a successful surgical excision of pulmonary sequestrations.

[Key Words]   Pulmonary sequestration；Operation；General anesthesia；

Double-lumen tube；One-lung ventilation

肺隔离症（pulmonary sequestration，PST）是一种较少见的肺组织先天发育异常疾病，其最主要的病理生理特点是病变部位由体动脉供血并与正常肺组织分离^[1,2]。临床上由于病人缺乏典型体征和症状，以及特异性辅助检查手段，容易误诊、漏诊，手术麻醉风险增加。本文回顾我院近期所完成的10例PST手术资料，着重分析手术病人围麻醉期管理应注意的问题，总结经验教训。

                 临床资料

1、病史资料    10例PST手术病人年龄2～34岁，其中男性7例、女性3例。入院主诉反复咳嗽并咯血4例、咳嗽并胸闷或胸痛6例。所有病人术前均经过20天～6个月止血和/或抗炎、抗痨等系统的内科治疗，咯血停止，咳嗽和胸闷、胸痛症状消失，排除肺部炎症或肺结核病变。拟择期行隔离肺切除术。

2、术前影像学检查    所有病人胸部影像学检查主要表现X光片：左下肺叶病灶呈片状高密度阴影，境界清楚，边缘毛刺状，为一实质性肿块；CT（增强）：肺部块状阴影内有单个或多个囊性病变；MRI：左下肺多个大小不等团状阴影，与血管有关联，其中有3例显示肺部肿块与主动脉间存在条索状阴影。依据影像学检查，诊断包括左下肺“PST”、“支扩”、“血管性病变”、“囊肿”和“炎性假瘤”等。

3、手术治疗    术中见病灶或隔离肺与周围正常肺组织、壁层胸膜或膈肌粘连紧密，除左下肺动、静脉外，还有多条来自降主动脉、腹主动脉和/或肋间动脉分支血管供血，异常动脉外径2～12mm，隔离肺静脉回流主要入肺静脉（7例）、下腔静脉（2例）和半奇静脉（1例）。其中叶内型6例，行左下肺切除，叶外型4例，行单纯隔离肺切除。术中出血300～1700ml，手术时间2.5～9小时。术后病理诊断：PST。9例病人术后7～10天康复出院，1例术后4天死亡。

4、麻醉管理    所有病人术前全身状况良好（ASA Ⅰ～Ⅱ），双肺呼吸音清晰，各重要器官功能正常。麻醉前常规用药，开放上肢静脉通路并行锁骨下静脉穿刺置管，连续监测血压、ECG、SpO₂、CVP。采取气管内静-吸复合麻醉，麻醉诱导用药：咪唑安定、依托咪酯、芬太尼和琥珀胆碱。气管插管4例选择单腔支气管导管（Mallinckrodt），术中需单肺通气时将单腔支气管导管送入右支气管，6例选择双腔支气管导管（DLT）（Robertshaw），利用听诊法定位，确认双肺隔离完全。导管固定后接麻醉机行机械通气（IPPV），术中RR：12～16次/min、VT：8～12ml/kg、FiO₂=1.0、Paw<25～30cmH₂O、SpO₂>98％。麻醉维持间断静注芬太尼、哌库溴铵和吸入安氟醚。离断患肺支气管前清理气管导管，支气管断端包埋满意后恢复双肺通气。术毕清醒拔管8例，2例病人将DLT更换为单腔气管导管后送入ICU继续呼吸支持。

讨    论

PST为肺先天性发育异常，即一部分肺组织与正常肺分离，单独发育并接受体循环血液供应，多见于青少年，根据解剖结构特点可分为叶内型（intralobar sequestration, ILS）和叶外型（extralobar sequestration, ELS）二种。ELS虽较ILS少，但病人往往还合并其他先天性异常，如先心病、膈疝和消化道畸形等。本组病例ILS 6例，ELS 4例。PST组织血供常来自异常血管，其中75％病例常来主动脉分支，其余源自锁骨下、肋间、膈肌、胸廓内动脉和/或腹主动脉，静脉回流主要经由肺静脉。异常血管是造成病灶内出血、血胸或咯血等并发症的根本原因^[1]。本文10例病人隔离肺血供异常血管分支主要来自降主动脉和腹主动脉，少量系肋间动脉分支，静脉回流主要入肺静脉和下腔静脉，1例入半奇静脉。术前有咯血病史者4例。