1 case of anaesthetic management of prostate particle implantation in patients with terminal hypertrophy and dilated cardiomyopathy

1Patient informationpatient, male, 66 years old, height 178 cm, body mass 70 kg, due to "prostate cancer" admitted to the hospitalPrevious lyuing tumor history of more than 40 years (intermittent use of brominated hidden pavilion), dilated cardiomyopathy history of 7 years,hypertensionhistory of 7 years, blood pressure (BP) up to 180/120mmHg, oral lisoping, metolol and Benaplei control blood pressure, bp usually control at 120/80mmHg or so, there have beenheartdisease, improved by internal surgeryHe underwent surgery for a left eye injury 27 years ago and is now blind in his right eyeadmission: BP130/80mmHg, heart rate (HR) 80 times/min, respiratory rate (RR) 20 times/min, body temperature (T) 36.2 degrees CThe patient's limbend fat-like face, the limbs move well, the hands and feet thick, the nose lips thick, no double lower limb edemaAuxiliary examination: Electrocardiogram shows sinus heart palpitations, T-wave changes; chest tablets show double lung texture heavy; heart Doppler ultrasound shows left chamber enlargement (left chamber diaphragm 62mm), left chamber wall fat, aortic valve, two tip valve, three-tip valve mild reflux, left chamber contraction and diastolic function reduced, blood score (EF) 48%the cranial magnetic resonance show the saddle area occupatic lesions, the possibility of pituitary tumor is large, the size of 1.01 cm x 1.53 cm x 1.65 cm, the two-sided base section and the two-sided ventricle next to the multiple cavity cerebral infarctionPreoperative spinal magnetic resonance show L1-4 vertebral puffing out, L4-5 intervertebral disc protrusion with local vertebral stenosis, L1 vertebraevasculartumor, double hip degenerative changes, double hip fluid and surrounding sac formation laboratory examination: preoperative growth hormone (GH) 10.70 ng/mL (normal range 0.003 to 0.971 ng/mL); It is intended for the implantation of radioactive particles in the prostate in the whole hemp downstream the patient to establish an upper limb vein pathway, continuous monitoring of electrocardiogram (ECG), HR, noninvasive blood pressure, pulse oxygen saturation (SpO2), electroencephalogram double spectrum index (BIS), body temperature, exhalation of end carbon dioxide (PETCO2), the right side of the bureau linen Arterial puncture tube surgery, monitoring the invasive arterial pressure, connecting the FloTrac/Vigileo sensor (Edwards USA), monitoring heart output (CO), heart index (CI), per-beat output (SV), per-beat index (SVI), per-beat variability (SVV) the patient before surgery to carry out airway evaluation (before surgery, please otolaryngology laryngoscopy examination, assessment of the patient's azimuth distance, Mars grading, opening, head and neck activity, etc.), to judge the no difficulty airway, choose the rapid sequence of veins induction With 6L/min oxygen flow continuous mask oxygen absorption 5min, began anesthesia induction, in turn, static injection of medapyrifen 1.5mg, relying on miede 8mg, shufentani 10 sg, waiting for the patient to fall asleep, quiet injection of rocum brominated ammonium 50mg, 1min rear placed in the double-tube larynx cover, connected to the ventilator for mechanical ventilation, set moisture volume of 8mL/kg, suction ratio of 1:1.5, adjust the respiratory rate to maintain PETCO235 to 40mmHg anaesthetic maintenance: continuous infusion of propofol 2 to 4 mg / (kg-h) and riffinani 0.1 to 0.15 sg / (kg.min), maintenance of BIS45 to 60 Continuous infusion of norepinephrine 0.02 to 0.05 ?g/kg/(kg.min) and dopamine 2 to 5 ?g/(kg.min) maintained hemodynamic stability, and CO changes during anesthesia were shown in Figure 1 The operation lasted 83min, hemorrhage was about 5mL, and intravenous infusion of sodium lactic acid Ledring's fluid 500mL The patient was sober lysing removed the larynx cover, returned to the ward, 8d improved after the operation and discharged from the hospital Figure 1 The trend of CO changes in patients 2 Discussion the patient's proposed prostate radioactive particle implantation, can choose intravertebral anaesthetic or general anesthesia, because the patient's preoperative magnetic resonance imaging (MRI) examination indicates obvious lumbar lesions, in order to avoid the occurrence of complications related to anesthesia in the vertebral tube, the method of anesthesia to choose a laryngeal cover general anesthesia Placing the larynx cover is a small stimulation to patients, light intubation response, more suitable for patients with heart vascular , in addition, for patients with tracheal intubation difficulties, the larynx cover is also an important ventilation equipment The survival time of patients with terminal hypertrophy was reduced by 10 years compared to the control group, and the fatality rate increased by 2.0 to 2.5 times, and the excessive GH secretion mainly had serious adverse effects on the cardiovascular system, respiratory system, etc., therefore, the following problems needed to be considered in the of anaesthetic management 2.1 cardiac function assessment and circulation management limb hypertrophy is mainly caused by excessive GH secretion, GH plays a role in heart occurrence, development and maintenance, normal secretion of GH through THE RECEPTORofofs of GH and insulin-like growth factors in the heart muscle to participate in the regulation of heart structure and function GH over-secretion can directly adversely affect the heart, GH can directly play a positive myopathic effect on myocardial muscle through insulin-like growth factor, so that the relative increase of myocardial cells resulting in ventricular wall-to-heart thickening, called limb hypertrophy cardiomyopathy studies show that people with a history of GH adenomas with a history of more than 10 years, the incidence of heart complications is 3 times higher than that of patients with a medical history of 10 months to 10 years, of which the risk of left ventricular hypertrophy increased by 9.9 times, the risk of ventricular diastomy function decreased by 4.8 times, and the risk of hyperthyroidism in patients with hypertension (1.4 to 1.7 times), arrhythmia (4.9 times) and other heart dysfunction patients was significantly higher than those with severe heart function The mortality rate for patients with uncontrolled limb hypertrophy increased by 1.72 to 1.9 times compared to patients with terminal hypertrophy treated, the main cause of death was cardiovascular diseases (-60%) For patients aged 40 years and who combined 3 to 7 years of functional limb hypertrophy, 54% had left ventricular hypertrophy, and 72% of patients aged 41 to 60 with a combined 5-15-year medical history patient's history of pituitary tumor for more than 40 years, preoperative heart color super prompt left room enlargement, room interval thickening, in addition to the discovery of dilated cardiomyopathy for 7 years, previously has a history of heart failure, the current heart function II level As a result, there is a high risk of heart insufficiency during the perination period 2.2 Periscope induced heart failure factors 2.2.1 the pre-heart load is too heavy ventricle diastomy reflux blood too much can make the ventricle diastosis period overload, leading to heart failure The perination of liquid during the perioperative period is too much or too fast, the amount of backheart work increases, the left ventricle, right ventricle diastosis period load increases, may induce heart failure In addition to routine monitoring, the patient was also monitored by the Arterial Pressure Waveheart Displacement Method (APCO) In addition, in this case, the patient used SVV to guide the fluid management in surgery, maintain SVV 13% to avoid excessive infusion of fluid during surgery, maintain the front load in a suitable state, avoid the possibility of heart failure due to increased front load 2.2.2 after the heavy load perinatal period blood pressure increased, the heart load increased, can induce heart failure, therefore, the surgery to avoid the anesthesia caused by excessive sympathetic nervous system excitement, heart load increased After the patient was induced by anesthesia, CO and CI gradually decreased, and after intravenous infusion of the positive myoline drug dopamine, CO and so on gradually returned to preoperative level The patient's hypertension and cavity cerebral infarction, bp usually maintained at 120 to 130mmHg/70 to 80mmHg, the recommended blood pressure to maintain the preoperative calm blood pressure baseline level value of 20% 2.2.3 myocardial contraction the anaesthetic drugs used in surgery have different degrees of myocardial inhibition effect, which weakens the contraction of the heart, and it is recommended to use as much anesthetic drugs as possible with a small effect on myocardial inhibition 2.3 difficult airway assessment and respiratory function management limb terminal hypertrophy patients are mostly accompanied by thick lips thickening, high and wide nose, jaw bone front stretch, tongue fat, sound door thickening and narrow under the sound door, therefore, trachea intubation may encounter difficulties In this type of patients in anaesthetic induction prone to severe respiratory obstruction, ventilation difficulties, resulting in hypoxia and PaCO2 rise, should choose a large mouth pharynx and laryngoscope, to avoid its length is not enough and encounter the difficulty of sound door display the trachea intubation when the precautions include: (1) sober trachea intubation; (2) for the estimated intubation difficult cases, using fiber optic or bronchoscopy to complete the intubation, (3) limb-end hypertrophy patients with the sound door and sound door may be thick and narrow, should choose a slightly thin inner diameter trachea duct, reduce damage to the sound door and tracheal wall for patients with short surgery time and expected intubation difficulties (e.g patients with terminal hypertrophy), the use of a laryngeal mask may first be considered to reduce the risk of tracheal intubation difficulties The incidence of death due to respiratory disease in patients with terminal hypertrophy accounted for 25% With the growth of connective tissue, the body's internal organs increased thickening, the lung capacity increased, the blood vessel wall thickened, there may be ventilation / blood flow ratio imbalance For conventional mechanical ventilation in all-hemp patients, the ventilation capacity is usually set at 10mL/kg Blood gas analysis should be monitored dynamically during the operation, and breathing parameters should be adjusted at any time to try to conform to the physiological state Surgical tube indication: breathing air under the ventilation is close to preoperative level, PETCO2 35mmHg, SpO 95% or up to preoperative level, muscle recovery, full sobriety, no respiratory obstruction risk and good reflexes swallowing 2.4 postoperative management patients return to the urology ward with a awake tube in the operating room After-operative follow-up patients, no malignant arrhythmia, heart failure, cerebrovascular accident and sudden death occurred The patient was discharged from the hospital on the 5th day after surgery After surgery should pay attention to blood volume and liquid adjustment, if patients can eat freely should avoid excessive liquid infusion At the same time, strengthen monitoring, timely observation of the patient's condition changes, to prevent the occurrence of heart failure summarize the patient's anaesthetic management experience, for patients with combined limb hypertrophy, preoperative visit should pay attention to: (1) patients cardiovascular comorbidities assessment, assessment of the content of the heart function, whether there is heart structure lesions and arrhythmia, preoperative improvement of the relevant examination (echocardiogram and electrocardiogram), full treatment of co-existing diseases, as far as possible to improve the individual system function and heart function, and the specific conditions of the patient to develop a perfect anaesthetic management (2) do a good job before surgery difficult airway assessment, improve surgical safety; (3) intraoperative anesthesia management should avoid shallow anesthesia, pay attention to intraoperative fluid management and heart function monitoring, maintain hemodynamic stability through perfect monitoring, if necessary, give vascular active drugs and positive muscle drugs prevent and avoid the occurrence of heart failure; (4) strengthen the monitoring of fluid capacity management after surgery to avoid postoperative heart failure events, to ensure good return of patients