病例讨论系列 - 第28讲

【围术期医学院】病例讨论系列 - 第28讲

Academy of Perioperative Medicine

Case Discussion Series

Topic：年轻女性心包开窗后死亡

Presenters：邹小华（贵州医大），刘虹（加州大学）

Moderators & Guests：童传耀（维克大学），周少凤（德州大学），薛张纲（复旦大学），孟令忠（耶鲁大学）

Date & Time：10月10日 星期六晚上 8:30–10:30（北京时间）

       一位26岁的女性，有甲状腺功能减退、哮喘、血管性血友病和缺铁性贫血病史，在发生翻车车祸后被转移到三级医疗中心。这名患者由血液科医生监测了几年，她的出血性疾病被归类为中度到重度的I型vWD，在过去的记录中，von Willebrand factor（vWF）水平非常低。车祸大约40小时后，病人被带到手术室进行心包切开术。手术结束。拔管后不久，在将病人从手术台转移到病床前，心电图显示II导联ST段抬高明显，V5导联ST段 抬高更为明显，同时伴有间歇性的心室内传导延迟。患者出现短暂低血压，静脉注射约 250毫升晶体后缓解。到达重症监护室时获得的12导联心电图显示，下导联ST段抬高明显，前外侧导联也有缺血迹象（见下图）。在床边进行的经胸超声心动图评估显示左心室 射血分数为35%，多壁运动异常，二尖瓣中度返流。左心室壁也似乎比基线时厚。患者 在准备紧急转运至心导管室时，血压下降、心动过缓，对阿托品和大剂量去甲肾上腺素和肾上腺素的药物复苏无反应。体外膜肺氧合（ECMO）通过股动脉和静脉建立，无脉冲电活动，接受再插管和胸部按压。

A 26-year-old woman with a medical history of hypothyroidism, asthma, vWD, and irondeficiency anemia was transferred to a tertiary medical center after involvement in a rollover motor vehicle collision. The patient had been monitored by a hematologist for several years, and her bleeding disorder was categorized as moderate to severe type I vWD with very low levels of von Willebrand factor (vWF) documented in the past. Approximately 40 hours after her motor vehicle collision, the patient was brought to the operating room for a pericardiotomy. Surgery finished. Soon after extubation and before moving the patient to the hospital bed, the electrocardiogram showed significant ST elevation in leads II and more subtly in V5, as well as an intermittent intraventricular conduction delay. The patient developed transient hypotension that resolved with IV administration of approximately 250 mL crystalloid. A 12-lead electrocardiogram obtained on arrival in the intensive care unit showed prominent ST elevations in the inferior leads and also signs of ischemia in the anterolateral leads (Figure 2). A transthoracic echocardiography evaluation performed at the bedside demonstrated a left ventricular ejection fraction of 35%, multiple wall motion abnormalities, and moderate mitral regurgitation. The left ventricular walls also seemed thicker than at baseline. The patient was being prepared for emergent transport to the cardiac catheterization laboratory when she became increasingly hypotensive and bradycardic and unresponsive to pharmacologic resuscitation with atropine and high-dose norepinephrine and epinephrine infusions. She developed pulseless electrical activity and underwent reintubation and chest compressions while venous-arterial extracorporeal membrane oxygenation (ECMO) was instituted through the femoral artery and vein.