摘要
目的:评价原发性腹膜后副神经节瘤切除术全身麻醉管理要点并分析预后影响因素。方法:回顾自2016年1月至2021年12月收治于北京大学国际医院在全身麻醉下实施腹膜后副神经节瘤切除术的患者围术期麻醉管理，并对围术期的血流动力学变化、出血及输血情况和预后情况进行分析。结果:共计41例患者纳入本研究，男性28例，女性13例，平均年龄（51.3±11.8）岁，术前按照美国麻醉医师协会分级（ASA）标准Ⅰ级7例，Ⅱ级25例，Ⅲ级9例。14例（34.2%）切除肿瘤时发生高血压危象，19例（46.3%）切除肿瘤后出现低血压；15例术前口服酚苄明预处理，平均（16.2±7.0）d，其中5例（33.3%）切除肿瘤时发生高血压危象，9例切除肿瘤后发生低血压；26例术前未口服酚苄明治疗，9例切除肿瘤时发生高血压危象，10例切除肿瘤后发生低血压。41例中有27例术前进行了儿茶胺类激素水平检测，去甲肾上腺素增高17例中12例术前应用酚苄明；肾上腺素增高4例；多巴胺增高7例。中位出血量1039.5 ml（50~4500 ml），其中7例（16.3%）患者出血量≥2000 ml，术中血制品输注包括：红细胞20例，血浆19例，白蛋白13例，纤维蛋白原7例，凝血酶原复合物7例。手术平均时长（3.4±1.5）h，麻醉时长平均（4.6±1.5）h，37例患者术毕拔管回病房，4例患者带管返回ICU，无围术期死亡和院内死亡病例，均顺利出院。患者术后住院时长（16.5±8.8）d，与肿瘤切除后收缩压呈负相关，与术中突发高血压危象无相关性（P＞0.05）。结论:原发性腹膜后副神经节瘤患者术中存在出血和血流动力学剧烈波动的双重风险，恰当的术前评估和准备以及围术期麻醉有效管理对确保患者平稳度过围术期至关重要。
Abstract
Objective:To summarize the key points of anesthesia management and identify the prognostic factors in patients undergoing retroperitoneal paraganglioma resection.Methods:A retrospective analysis was performed on patients undergoing retroperitoneal paraganglioma resection with general anesthesia from January 2016 to December 2021 at Peking University International Hosptial. Data on anesthesia management, haemodynamic changes, blood loss, and blood transfusion were collected, and potential prognostic factors were identified.Results:A total of 41 patients who received retroperitoneal paraganglioma resection were included in this study, including 28 males and 13 females with a mean age of (51.3±11.8) years. Following the American Society of Anesthesiologists (ASA) criteria, 7 patients were classified as having ASA I, 25 as having ASA Ⅱ, and 9 as having ASA Ⅲ. During surgery, 14 patients (34.2%) developed a hypertensive crisis, and 9 (46.3%) developed hypotension after tumor removal. There were 15 cases receiving phenoxybenzamine as preoperative treatment started (16.2±7.0) days on average before surgery, of whom 5 (33.3%) developed a hypertensive crisis during retroperitoneal paraganglioma resection and 9 developed hypotension after tumor removal.Of the remaining 26 cases with no phenoxybenzamine pre-treatment, 9 developed a hypertensive crisis and 10 developed hypotension after tumor removal. Among the 41 cases included, plasma catecholamine concentrations were measured in 27 patients before surgery. Of these individuals, 17 showed an increase in noradrenaline (12 of the 17 patients received phenoxybenzamine as preoperative treatment), 4 showed an increase in adrenaline, and 7 showed an increase in dopamine. The median (range) volume of haemorrhage was 1039.5 (50~4500) ml among all the subjects, of whom 7 (16.3% of total) had intraoperative hemorrhage greater than 2000 ml. Regarding perioperative blood product use, 20 cases received packed RBC transfusions, 19 received plasma transfusion intraoperatively, 13 were treated with 20% albumin infusions, 7 were treated with fibrinogen supplementation, and 7 received prothrombin complex concentrate intraoperatively. Mean duration of operation was (3.4±1.5) h, and mean duration of anaesthesia was (4.6±1.5) h. Thirty-seven patients were extubated in the operating room at the end of the surgery, and four were transferred to the intensive care unit. There were no perioperative deaths and no in-hospital deaths in this series. All patients were discharged uneventfully. The average length of stay in the hospital after operation was (16.5±8.8) days, which was negatively correlated with the systolic blood pressure after tumor removal, but had no significant correlation with emergent hypertensive crisis episodes during surgery (P＞0.05).Conclusion:Retroperitoneal paraganglioma resection is associated with a high risk of major bleeding and dramatic hemodynamic fluctuation. Proper preoperative evaluation and preparation in combination with appropriate anesthetic management are of vital importance to patient safety in the preoperative stage.
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