第十二章第2次

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第十二章——胸科麻醉（6-10）

祁冬冬

6.A22-year-oldpatientwithahistoryofmoderatepersistentasthmaonmedium-doseinhaledcorticosteroidsandlong-actinginhaledβ-agonistpresentsforanemergencyappendectomy.Onclinicalexamination,heisactivelywheezing,butmaintaininganoxygensaturationof99%onroomair.Thesurgeonrequestsyoutoextubatethepatientfullyawakebecausehefoundextensiveintestinaladhesionsandisafraidofretainedgastriccontentsinthestomach.Whichofthefollowingwillbeyourmostlikelyplanofaction?

一名22岁有中度持续性哮喘病史的患者，吸入中等剂量的糖皮质激素和长效的β受体激动剂，紧急行阑尾切除术。查体时，他有明显的喘鸣，但是吸入室内空气时，血氧饱和度保持在99%。外科医生要求你在病人完全清醒的状态下拔管，因为他发现广泛的肠粘连，并担心胃内容物误吸。下列哪项是最正确的做法？

A.Insertanorogastric（口胃的）tube,emptythestomachasmuchasyoucan,andproceedwithadeepextubationtoavoidbronchospasm（支气管痉挛）

B.Administerintravenouslidocainetodecreasethelikelihoodofairwaystimulationandwaittillthepatientisfullyawakebeforeextubation

C.Shutofftheinhalational（吸入的）agentanduseintravenouspropofoltoavoidtransitioningthrougharockystage-2wakeup

D.Transitiontoalaryngealmaskairway(LMA)undersevoflurane（七氟醚）anesthesiaandletthepatientwakeupwithanLMA

答案及解析：B.Apatientwhohasadequatereturnofneuromuscularfunctionandhasaregularspontaneousbreathingpatternwithadequatetidalvolumescanbeconsideredacandidatefordeepextubation.Afterclearingoutthesecretionsfromtheoropharynxandtheendotrachealtube,extubationisperformedunderadeepplaneofanesthesiaandventilationcontinuedbyamask/LMA.Carefulpatientselectionisveryimportant,anditshouldnotbeconsideredinthoseatincreasedriskforaspirationofgastriccontentandifthenecessaryairwaymanagementskillsarenotimmediatelyavailable.Whenextubationisdelayedforreasonsofpatientsafety,(presenceofgastriccontentsinacasewithacuteappendicitis),intravenousadministrationoflidocaine(1.5–2mg/kgbolus)maydecreasethelikelihoodofairwayirritationandbronchospasm.Thus,extubationcanbeperformedafterthepatientisawakeandfollowing

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