肺動脈導管置入之病人在脫離體外循環時所造成肺動脈穿孔出血個案報告

Management of Catheter-induced Pulmonary Artery Perforation during Weaning from Cardiopulmonary Bypass-- A Case Report

一位六十五歲女性患者因嚴重僧帽瓣逆流，需接受僧帽瓣置換術。術前心臟超音波顯示除嚴重僧帽瓣逆流外並無左心室收縮不良情形。在麻醉誘導後，給予isoflurane & rocunonium來維持麻醉；同時有週邊動脈導管及肺動脈導管作為監視。在手術接近尾聲，外科脫離體外循環，肺動脈波形消失。在將肺動脈導管外拔五公分後，肺動脈波形突然恢復。不幸的是動脈收縮壓從一百毫米汞柱掉至二十毫米汞柱，且呼吸道壓力上升至六十毫米汞柱；同時在氣管內管有出血情況。此時高度懷疑肺動脈破裂，同時要求體外循環再次運作。氣管鏡發現右下肺葉有出血情形。而後行右下肺葉切除及支氣管沖洗術。在完成以上程序後病人在穩定情況下送至恢復室。病人術後情況穩定且在三天後拔除氣管內管。這病人之所以能夠成功獲救且順利出院，是由於正確診斷及處置，包括早期懷疑肺動脈破裂；體外循環能即時運作不致造成肺循環終止情況使呼吸氣體交換得以維持；及時經由氣管鏡發現右下肺葉出血及適時行右下肺葉切除術且經肺灌流得宜。

We report a case of pulmonary artery perforation induced by Swan-Ganz catheter. Brisk massive airway hemorrhage occurred after withdrawl of the Swan-Ganz catheter post cardiopulmonary bypass. Early recognition, immediate re-establishment of cardiopulmonary bypass, lobectomy of the sanguineous lobe subsequent to rupture of the involved pulmonary artery, and thorough bronchial toilet were the major determinants contributing to successfully rescuing the patient's life. She was discharged uneventfully in spite of high mortality rate of the catheterinduced pulmonary artery perforation.