Story D, Mariampillai E, Nikfarjam M, Howard M, Nunn A, Onders R
Department of Anaesthesia, Austin Health, Melbourne, Victoria, Australia.
Anaesth Intensive Care. 2010 Jul;38(4):740-3. doi: 10.1177/0310057X1003800418.
Some patients with high cervical spinal cord injury are largely or completely dependent on mechanical ventilator support. Diaphragmatic phrenic nerve pacing is a new technique that offers some patients greater independence from mechanical ventilation. In selected patients, electrodes are placed on the abdominal side of the diaphragm via laparoscopy. An external pacing box provides the pacing stimulus. We report our experience with four patients with spinal cord injury in a pilot project, presenting for laparoscopic insertion of diaphragmatic phrenic nerve pacing leads inserted. The surgery took about two hours and diaphragmatic mapping precluded muscle relaxants. We used desflurane with remifentanil for maintenance. Apart from transferring the patients to and from their usual ventilators, other anaesthesia issues were difficult venous and arterial access for lines and long-term tracheostomies with no cuff or cuffs filled with water While hypotension was a frequent problem, one patient also developed intraoperative hypertension secondary to autonomic dysreflexia. Preoperative testing predicted pacing outcome with three of the four patients having successful pacing with tidal volumes of up to 10 ml/kg at the end of surgery. This initial Australian experience may lead to greater use of the technique.
一些高位颈脊髓损伤患者在很大程度上或完全依赖机械通气支持。膈神经起搏是一种新技术，可为一些患者提供更大程度的脱离机械通气的独立性。在选定的患者中，通过腹腔镜将电极放置在膈肌的腹侧。一个外部起搏盒提供起搏刺激。我们报告了在一个试点项目中对4例脊髓损伤患者进行腹腔镜插入膈神经起搏导线的经验。手术耗时约两小时，膈肌标测时不能使用肌肉松弛剂。我们使用地氟醚和瑞芬太尼维持麻醉。除了将患者转运至和转出其常用呼吸机外，其他麻醉问题包括建立静脉和动脉通路困难、长期气管切开且无套囊或套囊充水。虽然低血压是一个常见问题，但有1例患者还因自主神经反射异常出现术中高血压。术前检查可预测起搏结果，4例患者中有3例手术结束时起搏成功，潮气量可达10 ml/kg。澳大利亚的这一初步经验可能会促使该技术得到更广泛的应用。
