開心術中に気管内大量出血を来した1治験例

A Case of Massive Endotracheal Hemorrhage during Cardiopulnionary Bypass

　開心術中に気管内出血が生じた場合，ヘパリンの使用による抗凝固作用の亢進により止血が非常に困難である．今回われわれは，気管チューブを介した止血操作では出血をコントロールしえなかったため，心肺装置をヘパリンコーティングされた経皮的心肺補助回路（PCPS）に交換し，体外循環中ヘパリンを中和することで救命しえた症例を経験したので報告する．症例は73歳，男性．冠状動脈バイパス術を施行中，人工心肺離脱時に気管チューブより大量出血が出現した，直ちに気管チューブをダブルルーメンチューブに交換した．出血源は左下葉と思われ，チューブ内からの止血操作を施行したが効果が得られなかったため，体外循環をヘパリンコーティングPCPSに交換した．ヘパリンを中和することで出血のコントロールができ，体外循環からの離脱を可能にした．本手段は調べうる限り初の試みであった．

Massive endotracheal hemorrhage has a particularly high mortality rate in heparinized cardiopulmonary bypass patients. Many cases due to injury of the pulmo-nary artery by Swan-Ganz catheter have been reported, and the mortality rate in these cases was over 50 per-cent.

A 73-year old man underwent coronary artery bypass grafting (CABG). During weaning from extracorporeal circulation, a large amount of blood was aspirated from the endotracheal tube. Immediately, we isolated the two lungs with a double-lumen endotracheal tube, and then ventilated and suctioned the divided airways separately. Fiberoptic bronchoscopy revealed bleeding from the left lobe. However, the hemorrhagic site in the left side was not located due to massive hemorrhage. Hemostasis through the tube could barely control the hemorrhage. We switched the bypass to a haparin coated per-cutaneous cardiopulmonary support system (PCPS), and gave protamine sulfate. Hemorrhage was controlled after about one hour, and PCPS was removed. Postope-rative course of this patient has been good.

We suggest that using a double-lumen endotracheal tube and a PCPS provides a satisfactory method for controlling massive endotracheal hemorrhage during cardiopulmonary bypass.