Lin Tzu-Yu, Chiu Kuan-Ming, Lu Cheng-Wei, Jean Wei-Horng, Wang Ming-Jiuh, Chu Shu-Hsun
Departments of Anesthesiology, Far Eastern Memorial Hospital, Taipei, Taiwan, ROC.
Acta Anaesthesiol Taiwan. 2007 Mar;45(1):3-8.
Immediate extubation after cardiac operations in the operating room (OR) is rarely practised in Taiwan. The increased use of the minimally invasive and off-pump coronary artery bypass surgery (CABG) and the financial pressure from health insurance have raised the interest of its application after cardiac operations. The purpose of the study was to investigate the practice of immediate extubation in patients undergoing cardiac operations via minimal invasive thoracotomy against via midline sternotomy.
Seventy unselected consecutive patients undergoing cardiac operations via either minimally invasive thoracotomy or midline sternotomy were enrolled for investigation. Anesthetic management, including bispectral index and continuous train-of-four (TOF) monitoring, was modified to extubate the patients in the OR within 15 min after the closure of the skin wound. Extubation criteria based on clear consciousness, recovery of muscle power, and stable hemodynamics without purposeful strong inotropic support were stipulated. Patient-controlled analgesia was used to provide adequate postoperative pain control.
Extubation within 15 min after the end of surgery was successful in all patients who underwent thoracotomy while there were five patients who could not be extubated in the sternotomy group. The PaCO2 values 30 min after extubation and the ICU stay were significantly higher and longer in patients of the sternotomy group. The pain intensity after extubation or the doses of analgesics used did not differ between two groups of patients. There was only one patient in the sternotomy group who needed reintubation and there was no postoperative death in both groups of patients.
We consider that immediate extubation after cardiac procedures either through thoracotomy or sternotomy is a rather safe practice and if possible minimally invasive technique should be chosen because it causes smaller wound and offers safer immediate extubation and shorter ICU stay.
在台湾，心脏手术后在手术室立即拔管的做法很少见。微创和非体外循环冠状动脉旁路移植术（CABG）的使用增加以及医疗保险带来的经济压力，引发了人们对其在心脏手术后应用的兴趣。本研究的目的是调查通过微创开胸手术与正中胸骨切开术进行心脏手术的患者立即拔管的情况。
连续纳入70例未经过筛选的通过微创开胸手术或正中胸骨切开术进行心脏手术的患者进行调查。调整麻醉管理，包括脑电双频指数和连续四个成串刺激（TOF）监测，以便在皮肤伤口缝合后15分钟内在手术室对患者进行拔管。规定了基于意识清醒、肌力恢复以及无需有创性强心支持即可保持稳定血流动力学的拔管标准。使用患者自控镇痛来提供足够的术后疼痛控制。
所有接受开胸手术的患者均在手术后15分钟内成功拔管，而胸骨切开术组有5例患者未能拔管。胸骨切开术组患者拔管后30分钟的PaCO2值和重症监护病房（ICU）停留时间明显更高和更长。两组患者拔管后的疼痛强度或使用的镇痛药物剂量没有差异。胸骨切开术组只有1例患者需要再次插管，两组患者均无术后死亡。
我们认为，无论是通过开胸手术还是胸骨切开术进行心脏手术后立即拔管都是一种相当安全的做法，如果可能应选择微创技术，因为它造成的伤口较小，提供更安全的立即拔管和更短的ICU停留时间。
