1 case of caesarean section anesthesia in patients with spinal muscular atrophy III

1Case Report1.1 Backgroundspinal muscular dystrophy (SMA) is an autosomal recessive genetic disease associated with motor neuron survival gene 1 (moto neuron1, SMNl) mutationSMA patients in the front corner of the spinal cord motor neurons denatured, gradually appear tired of the whole body muscle weakness, muscle atrophySMA patients can be divided into 4 types, the type of the disease is related to the age of onsetdiagnosedsMA Type I babies generally live no more than 2 yearsSMAIpatients can survive into adulthood, but have a high eryre rate due to muscle weakness and respiratory complicationsRespiratory effects in patients with Type SMAIII were not significant, and life expectancy was normal or near normalPatients with SMA IV mainly suffer from near end muscles in the limbs, with fewer other complicationsWhen patients whocombined SMA need surgical anesthesia, the main difficulties faced are the difficulty of intra-spinal anesthesia puncture, the uncertainty of the spread plane of local anaesthetic, the possibility of general anesthesia difficulties in the airways, the unpredictable metabolism of myaminic satiety agents, etcWe used ultrasound-guided nerve blocking techniques to complete a caesarean section in a single sma type III patient using ultrasound-guided nerve blocking techniques, and the cases are now reported as follows1.2 medical history review
patient, female, 31 years old, height 160 cm, weight 59 kg Due to "pregnancy 38" week, required to give birth" to be admitted to hospital As a child appeared difficult to climb the stairs, unable to run and jump and squat, was diagnosed in 2013 as SMA III, the past MRI results suggest "spinal diffuse atrophy smaller." The patient was admitted to hospital in a wheelchair and proposed to perform a "cross-sectional section of the lower part of the uterus" physical examination: Mallampati airway grade II, normal opening degree, breathing and swallowing function is not affected, double upper limb muscle force decline, muscle strength level 4, double lower limb muscle strength 2-3 level, spinal deformity There were no obvious abnormalities in preoperative ECG and laboratory examinations 1.3 Anaesthetic after 1.3.1 anaesthetic patients on the day of surgery routine preoperative preparation, into the operating room to monitor cuff blood pressure 128 mmHg / 68 mmHg (1 mmHg - 0.133 kPa) Heart rate 90 times/min, Sp02100% Normal mask gives oxygen (6 L/min) and opens the venous passage of the upper extremities Vibrant iodine disinfection local skin, according to Mei and other reported methods, under ultrasonic guidance using in-plane technology, in the two-sided armpit line near the guide 22 G nerve stimulation needle (model: 1275, PAJUNK company, Germany) needle tip to reach the inner oblique muscle and abdominal transverse muscle, each side injection 0.375% ropyridine (production batch number: NAWW, AstraZeneca, Sweden) 15 ml ultrasonic probe in the two-sided tibia before the upper ratchet and umbilical cord wire to guide the nerve stimulation needle tip close to the outer side of the abdominal groin nerve under the abdomen, each side injection 0.375% ropyrican 10 ml, the two-sided abdominal abdominal groin nerve block After 15 min, the patient's skin chill loss area is assessed at 5 cm on both sides and near the front line, about the right side to the T8 level, and the left side about the T12 level surgery begins When peeling and separating muscles, the patient did not complain of significant discomfort Intravenous ketamine (production lot number: 1707031, Fujian Gutian Pharmaceutical Co., Ltd.) 70 mg, propofol (production batch number: X17143B, Corden Pharma, Italy) 80 mg Patients retain edile breathing, disappear from sexual awareness, blood pressure 138 mmHg/72 mmHg, heart rate 99 times/min, SpO2 100% Newborns are born within 3 min, with Apgar scoring 8 to 10 After the newborn disconnects the umbilical cord, the patient's vein schofenteni (production lot number: 81A11141, Yichang Manfu Pharmaceutical Co., Ltd.) 20 sg, continuous intravenous pump riffentani (production lot number: 80809031, Yichang Manfu Pharmaceutical Co., Ltd.) 0.05 sg.kg-1 min-1 and propofol 10 to 20 ml/h The patient is drowsy, can wake up, the mask to oxygen (6 L/min) to maintain SpO2 100%, the breathing rate 18 to 24 times / min, no use of larynx and trachea intubation The operation lasted about 1 h, the patient's bleeding volume was about 300 ml, the amount of urine was about 300 ml, the infusion of sodium chloride infusion was about 1,800 ml, and no blood products and artificial colloids were infusions The patient was completely awake after 5 min after the intravenous suspension and was safely returned to the ICU after observing 0.5 h in the wake room 1.3.2 Postoperative condition
patients with less vaginal bleeding after surgery and good uterine contraction Sodium dissophinate (production lot number: 180602, Hubei Dongxin Pharmaceutical Co., Ltd.) postoperative analgesia, 8 h or so nerve block completely subsided; No intravenous analgesics were used after surgery, nausea, vomiting, and no anti-vomiting drugs were used After 5 d, the patient is discharged from the hospital 2 Discussion 2.1 SMA patients exhibit edidenal motor neurons due to genetic mutations, which exhibit muscular dystrophy, breathing difficulties, respiratory dysfunction and scoliosis due to their range During pregnancy, SMA patients may experience more severe muscle weakness symptoms, or even premature birth More than half of SMA patients give birth and muscle weakness remains When SMA patients undergo caesarean section anesthesia, they need to consider the feasibility of punctures in the vertebral tube, whether there are difficult airways, whether lung function is limited, the need to use myaminics and the metabolism of mysabolic agents 2.2 Although scholars have tried to anaesthetize the vertebral tube in Patients with SMA, the feasibility of intra-vertebral anesthesia in Patients with SMA is still worth considering Bollag et al reviewed 18 cases reported by SMA patients, of which 8 cases of non-vertebral anesthesia (including general anesthesia, partial immersion of incisions and sub-birth) and intra-vertebral anesthesia (including epidural and sub-cobweb cavity blockage) failed to turn to general anesthesia, and 5 cases of successful intravertebral anesthesia In addition to the patient's spinal malformation affecting the puncture, even if the puncture is successful, the anesthesia may fail due to the insufficient diffusion of local anaesthetic in the vertebral tube Therefore, the operation effect of intra-vertebral anesthesia is difficult to predict, which increases the patient's risk on the other hand, cases of successful general anaesthetic in SMA patients have been reported How to manage the airways when choosing a general anaesthetic strategy is the main problem SMA patients may exhibit increased and prolonged sensitivity to myaminizers, and it is debatable whether to use myaminics When general anaesthetic is performed, it is important that the anesthesia is induced to the time of delivery of the fetus If tracheal intubation is selected, the time for anesthesia to be induced to the fetus will be extended, the patient will receive more anaesthetic, and the ammyosis will be used In some patients with normal respiratory function and a lower risk of misabsorption, the laryngeal mask should have more advantages 2.3 We chose to combine ultrasound-guided nerve block with intravenous anesthesia to complete a caesarean section with the surgeon's procedure Shorten the time between intravenous anesthesia and fetal delivery, peeling, separation of muscles and other operations are done in the nerve block analgesia, while removing the time of airway management The abdominal transverse muscle plane blocking technique refers to the nerve blockofing of the front abdominal wall, which is mainly used in clinical operation for postoperative analgesia nerve block of the groin under the abdomen can provide analgesics for the groin area Therefore, the abdominal transverse plane block joint abdominal groin nerve block can provide a certain analgesic for the skin incision area of caesarean section, and in that range, the skin is cut and the muscles are separated However, there is the possibility of imperfection of blocking, so we have prepared a lidocain incision partial immersion program to deal with the blocking incomplete situation While intravenous anesthesia will provide analgesics for uterine incisions and visceral pulldurings during fetal delivery, the choice of medication refers to miller anesthesiology (eighth edition) that: conventional intravenous-induced doses of propofol (2.5 mg/kg) do not affect the neonatal Apgar score, but repeated or high doses (9 mg/kg) can produce significant neonatal inhibition; also refer to Mei and other reported propofol and ketamine combined with low-dose intravenous-assisted medications Alternative throat cover to control the airway seisile when the patient has respiratory inhibition Due to joint nerve block, the amount of intravenous anaesthetic is reduced compared to direct general anaesthetic After the delivery of the fetus, more intravenous anaesthetic drugs for the patient to provide follow-up enough sedation, analgesic At present, there are very few clinically successful cases of neuro-blocking anesthesia for caesarean section Coffman et al report different from this case in that the use of pre-fetal opioids, as well as the concentration and dosage of nerve-blocking drugs According to Mei et al., 0.375% of the roponcain can achieve the purpose of nerve blocknear near the incision, the use of larger amounts to facilitate the spread of the drug in the abdominal muscle plane This case confirms the feasibility of this programme In addition, the safety of use of fentanyl before delivery of the fetus has yet to be further clinically proven This case confirms that the unused use of opioids before delivery of the fetus can also achieve the desired anaesthetic effect 2.4 Compared to traditional surgeon-operated Lidocain local immersion anesthesia, this study provides longer analgesic time and higher comfort, reduces the total use of intravenous anaesthetic at the end of surgery, and can provide additional postoperative analgesic effects, increasing patient satisfaction Among them, the postoperative analgesia effect of abdominal transverse plane blocking technique has been reported in meta-analysis