日本小児循環器学会雑誌 Pediatric Cardiology and Cardiac Surgery

Online ISSN: 2187-2988 Print ISSN: 0911-1794
特定非営利活動法人日本小児循環器学会 Japanese Society of Pediatric Cardiology and Cardiac Surgery
〒162-0801東京都新宿区山吹町358-5アカデミーセンター Japanese Society of Pediatric Cardiology and Cardiac Surgery Academy Center, 358-5 Yamabuki-cho, Shinju-ku, Tokyo 162-0801, Japan
Pediatric Cardiology and Cardiac Surgery 35(2): 82-90 (2019)
doi:10.9794/jspccs.35.82

ReviewReview

小児心臓手術の麻酔管理Perioperative Management of Children Undergoing Surgery for Congenital Heart Disease

岡山大学病院小児麻酔科Department of Pediatric Anesthesiology, Okayama University Hospital ◇ Okayama, Japan

発行日:2019年5月1日Published: May 1, 2019
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本稿では小児心臓手術の麻酔管理について概説した.前投薬としてはミダゾラムが頻用されているが,その投与量には病態に応じた十分な配慮が必要である.循環を良好に維持するにはできる限り循環抑制のない麻酔薬であるオピオイドを中心とした麻酔管理を行うとともに心仕事を増加させないように管理する.そのためには,先天性心疾患の特徴である短絡血流がある場合は,肺・体血管抵抗を操作し体・肺循環のバランスをとることが重要であるが,体血管抵抗の調整がより効果的である.小児の肺胞は特に麻酔時に虚脱を起こしやすく軽度の呼気終末陽圧の附加,肺胞リクルートメントがその治療・予防に有効である.成人で肺保護に有効であるとされる低一回換気量の小児の肺への効果は定かでない.近赤外線脳酸素モニターは脳酸素需給バランスの破綻の早期発見に有用であるのみならず,循環管理の指標としても重要である.経食道心エコーも手術の評価や循環動態の把握に非常に有用であるが,非侵襲的であることに留意する.

In this paper, the perioperative management of children undergoing surgery for congenital heart disease is reviewed. Although midazolam is the most popular premedication sedative, the dosage must be tailored to each child’s condition. Opioids are the most suitable anesthetic drugs for the management of pediatric heart surgery, as they have very little cardiodepressant effect. Opioids should be used to stabilize the hemodynamic condition of patients during surgery; however, controlling pulmonary blood flow is essential not to exacerbate heart failure. It is necessary to keep Qp/Qs as close as possible to a one to one ratio by manipulating systemic and pulmonary vascular resistance, with the former having a greater effect on the ratio. Although the alveoli of younger children are susceptible to collapse, especially under general anesthesia, using low level positive end-expiratory pressure along with performing recruitment maneuvers is effective in avoiding and treating atelectasis. It remains uncertain whether low tidal volume ventilation, which is considered to be lung protective in adults, is also beneficial in younger children. Monitoring regional cerebral oxygen saturation is useful to detect cerebral ischemia as soon as possible and also as a measure of hemodynamic status. Although transesophageal echocardiography (TEE) provides useful information for evaluating the surgical procedure and also as a means of hemodynamic monitoring, it should be noted that TEE is clearly not a non-invasive procedure, and a low threshold not to use it in the presence of a clinical concern is warranted.

Key words: pediatric cardiac surgery; preoperative management; anesthesia

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This page was last modified on 2019-05-17T15:16:52.000+09:00


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