背景:没有全身麻醉的胸外科手术可以追溯到第一次世界大战,由于大量枪伤患者需要紧急胸外科手术,因此使用胸段硬膜外阻滞来完成手术。通过减少术中阿片类药物剂量,术中和术后阿片类药物相关的不良事件,如呼吸抑制,恶心和呕吐,谵妄,痛觉过敏,和其他副作用可以减少患者的利益。
方法:一名72岁的男性患者入院,有5天由跌倒引起的全身多灶性疼痛的病史。当时伤口没有得到治疗,疼痛逐渐增加,伴有咳嗽,排痰困难。
方法:左肺挫伤;创伤性肺炎;左侧多发肋骨骨折;左侧液性气胸;甲状腺性质不明,可能是恶性的。Ⅰ级气管狭窄;脑梗死后遗症。因为甲状腺肿和严重的气管压迫,患者未插管,并接受了全麻联合硬膜外麻醉以保持自主呼吸。
结果:在电视辅助胸腔镜探查结束时,患者立即意识清醒,6分钟后直接返回病房。患者能够在手术后自由活动,并在手术后6小时内正常进食。术后视觉模拟量表评分2分,随访期间无麻醉并发症。
结论:无阿片类药物的全麻策略,允许老年气管狭窄患者接受电视胸腔镜手术的自主呼吸联合硬膜外麻醉,不仅可以避免气管插管和机械通气造成的事故和伤害,还能显著减少术后呼吸道并发症,优化术后镇痛,并有助于实现手术后的康复。
BACKGROUND: Thoracic surgery without general anesthesia can be traced back to the First World War, and thoracic epidural block was used to complete the operation due to a large number of patients with gunshot wounds who needed emergency thoracic surgery. By reducing the intraoperative opioid dose, intraoperative and postoperative opioid-related adverse events such as respiratory depression, nausea and vomiting, delirium, hyperalgesia, and other side effects can be reduced to the benefit of patients.
METHODS: A 72-year-old male patient was admitted to the hospital with a 5-day history of multifocal pain throughout the body caused by a fall. The injury was not treated at that time, and the pain gradually increased, accompanied by cough with difficulty expelling sputum.
METHODS: Left lung contusion; traumatic pneumonia; multiple left rib fractures; left fluid pneumothorax; thyroid tumor of unknown nature, possibly malignant. Grade I tracheal stenosis; Sequelae of cerebral infarction. Because of goiter and severe tracheal compression, the patient was not intubated and received deopiated general anesthesia combined with epidural anesthesia to preserve spontaneous breathing.
RESULTS: At the end of the video-assisted thoracoscopic exploration, the patient was immediately conscious and returned directly to the ward 6 min later. The patient was able to move freely after surgery and eat normally within 6 h of surgery. The postoperative visual analog scale score was 2 points, and there were no anesthetic complications during the follow-up.
CONCLUSIONS: The opioid-free anesthesia strategy of tubeless general anesthesia, allowing spontaneous breathing combined with epidural anesthesia in elderly patients with tracheal stenosis undergoing video-assisted thoracoscopic surgery can not only avoid accidents and injuries caused by tracheal intubation and mechanical ventilation, but can also significantly reduce postoperative respiratory complications, optimize postoperative analgesia, and help achieve enhanced recovery after surgery.