1 case of cardiac arrest at the center of rectal mucosal circumcision surgery

Cardiac arrest is the most serious emergency in the course of surgical anesthesia, the mortality rate is high, some patients can lead to neurological complications, seriously threatening the life safety of patients and affect ingression qualityThe factors that lead to cardiac arrest during perioperative period are lack of oxygen, surgical factors, drug factors, poor preoperative heart function, pulmonary embolism, electrolyte disorders, adverse cardiovascular reactions and neuroreflectionIt is reported that in a single cobweb sub-cavity blocked downtherectal mucosal cyclosis (procedure for prolapsed and hemorrhoide, PPH) and exoskeleton, the operation occurred in a cardiac arrest case, as reported below1Patient informationpatient, male, 48 years old, height 174 cm, body mass 77 kgDue to swelling out of the intermittent seizure of 1 year, aggravated 2d, to mixed hospital admission, in the right knee inthem down the PPH plus extrecitecal excisionPreoperative history of hypertension, blood pressure (BP) fluctuates between 140 to 175/90 to 109mmHg, intermittent oral nitrospheride tablets, no other special medical historyHeart function Level Ielectrocardiogram (ECG) shows sinus heart palpitations, heart rate (HR) 53 times/min, right chamber guide suspicious ST segment elevation, V1, V2 consider early repolarBlood routine white blood cell (WBC) 13.1 x 109/L, neutrophil (PMN) 9.00 x 109/L, blood potassium 4.62mmol/L, random fasting blood sugar 5.09mmol/L, no significant abnormalities in other examinationsroutine electrocardiogram in the operating room, establish an intravenous channel, monitorHR71 times/min, pulse rate 71 times/min, BP127/80mmHg, respiratory rate (RR) 15 times/min, pulse oxygen saturation (SpO2) 99%Intravenous given tothean 4mg, nabmorphine 5mg after-line cobweb membrane cavity punctureThe puncture is made with an L2/3 ratchet clearanceAfter the tip of the needle enters the subcavity of the cobweb, pull out the needle core, and can see the cerebrospinal fluid flow inglision, injecting 0.65% of the ropone in 1.8mLAfter the injection of 13min, the anaesthetic plane was tested up to T8 The patient's vital signs were basically normal before the operation began routinely placed with a matchmaker, the patient complained of pain, and the pain was slightly relieved after 10 mg of nabmorphine intravenously After 19min of the injection, the monitoring show patient sinus heart rate 59 times /min, pulse rate 59 times /min, BP112/67mmHg, RR23/min, SpO2100, at this time, the surgeon stimulates the match, the patient has a slow heart, HR30/min, the surgical doctor immediately stop the operation The anesthesiologist instructed the roving nurse to call the patient and immediately intravenously injected 0.5mg of atropine Patient HR quickly become0/min, ECG monitoring shows a straight line, pulse wave in a straight line, call should not immediately call a superior doctor and prepare to re-position CPR for first aid When the patient's left shoulder is repeatedly hit and the patient is called, the patient's heart rate restores sinus heart rate, monitoring the patient's sinus heart rate 64 times/min, pulse rate 64 times/min, BP119/77mmHg, RR12/min, SpO2100% The patient HR is 0 times/min, the duration is 20s, due to the time is not long, did not change the flat position of CPR treatment Ask the patient about the conscious disappearance process After further observation and evaluation, the patient's vital signs are stable and the surgical process continues HR71/min, pulse rate 71 times/min, BP110/74mmHg, RR16/min, SpO2 100% A total of 400mL of compound sodium chloride was entered, the hemorrhage was 10mL, and the urethra was not left sent to the anaesthetic resuscitation room for further observation, and asked eCG inspection of the electrocardiogram chamber, the results show sinus heart rate 61 times / min, V1, V2J point shift, can consider the early repolar The patient is returned to the surgical ward Postoperative blood routines of WBC14.62 x 109/L, PMN14.62 x 109/L, myocardial enzyme spectrum and other examinations were not shown to be significantly abnormal After surgery, patients with 10d recovered and discharged from the hospital Two telephone follow-upvisits in 1 week and 3 months after discharge were not reported abnormally 2 Discussion This case of patients in the trigger matchmaker occurred cardiac arrest, analysis of its cause seiswell scarlet tube caused by vagus nerve reflexes The surgeon stimulates the matchmaker before SpO2 100%, less bleeding during surgery, basically excludes lack of oxygen, blood loss caused by cardiac arrest In 1942 Morty's more complete proposal for the central nucleus of the vagus nerve and the surrounding heart suppression center, whose excitement can lead to a slower heart rate and even cardiac arrest When the PPH stimulates the matchmaker during pPH surgery, it directly stimulates the rectum mucous membrane or (and) pulls the intestinal tube, causing the vagus nerve to excite, activating the heart suppressor center, which can lead to cardiac arrest In addition, patients have a history of hypertension, ECG prompts V1, V2 early repolar recent studies have shown that early repolar syndrome may be associated with sudden cardiac death ERS ECG is mainly characterized by the obvious J-wave and ST segment bow back elevation, the mechanism may be related to the intercom exoplanet of the outer membrane of the heart membrane Ito mediated action potential diaphragm and autonomic nerve dysfunction abnormality Buried cardiac rehydrater is the only proven effective method to prevent ventricular fibrillation in patients at high risk of ERS in summary, the patient has a history of hypertension before surgery, ECG prompt early repolarization, and in the stimulation of the matchmaker directly stimulater rectum mucosa or (and) pull the intestinal tract, the emergence of cardiac arrest, can not exclude the patient's own ERS factor, and found timely, rescue quickly, cardiac arrest duration is short, recovery success, no sequelae PPH is a common surgery in and intestinal tracts with a short operating time Because it is mostly done in the tube block or a single cobweb under the cavity block or local anesthesia and often not be paid attention to by anesthesiologists However, the and colorectal regions are rich in nerves, the subsympathetic nerves of the colon, rectum and the skin mucous membranes around the anus are mainly dominated by the nerves emitted by S2-4, while the sympathetic nerves that dominate the rectum, colon muscle layer and mucous membranes are accompanied by the corresponding spinal nerve sending from the later column of the spinal cord of the thoracic lumbar, but the upper and upper secondary nerves of the colon are directly extended and subject to myelin tube blocking can only block the S2-4 region, but it cannot block the sympathetic nervee emitted by the spinal cord of the thoracic lumbar section and the vagus nerve that enters the central extension When the block plane reached T8-S4, the sympathetic nerve and the parasympathetic nerve can be blocked at the same time, in order to eliminate the internal organs such as the left curvature of the colon, etc , can be assisted by the use of internal nerve bureau hemp closure or the application of analgesic sedatives When the tube blockcane, the vagus nerve reflex esctic can be caused by the rapid injection speed and the pressure is too high rectum by pull, compression, dilation and other stimulation can cause vagus -vagus reflexes, especially when anesthesia is incomplete will occur vagus nerve reflexes, light people appear pain, nausea, vomiting, irritability and other symptoms, heavy can cause HR, BP rapid decline and even neurogenic shock This case during the operation to stimulate the matchmaker, may be due to vagus nerve reflexes caused by sudden cardiac arrest, because of the discovery of timely, rescue quickly, medical care tacit cooperation, did not lead to serious consequences Intra-vertebral anesthesia is an important part of modern anesthesia, is widely used in clinical practice, is safe under proper management, but there is still a risk of complications clinically encountering incomplete cases of blocking is not uncommon, and anesthesiologists are not very active in changing the method of anesthesia, more use of auxiliary medication to complete the operation In this case, the patient's preoperative ECG suggests tachycardia, early repolar, and may be covered by the tachycardia after entering the chamber because of tension that increased HR to 71 times/min Complaining of pain when placing a matchmaker, intravenous lying with naphragon, and heart palpitations when the pain is relieved and stimulating the matchmaker Although nauphine relieves pain, it fails to eliminate the reflexes of the intestinal tract, and there is a possibility that it can cause heart palpitations Anesthesiologists quickly give atropine when they find that they have a slow heart, which may be one of the reasons for reversing cardiac arrest In excitation matchagent intravenous injection of atropine, waiting for HR to rise to 70 times / min or more of re-surgery, may avoid cardiac arrest studies have shown that preventive use of symita, heat treatment and other measures can reduce the intestinal tube pull reflex In addition, the sudden occurrence of cardiac arrest in the patient's center, some important data are not saved in time, such as the sudden drop of the heartbeat to 30 times / min and the monitoring of a straight line when the electrocardiogram monitoring picture, resulting in the cause of cardiac arrest analysis of insufficient evidence The most important measures to prevent and reduce cardiac arrest are to pay attention to the management of anesthesia during perioperative surgery and to strengthen the monitoring of vital signs during anesthesia surgery In view of this case, we believe that: (1) ECG tips sinus heart thystic, early repolarpatients, it is necessary to further improve the relevant examination: 24h dynamic electrocardiogram, Atropine test, heart color super, if necessary, preoperative buried heart translrid defibrillator; To avoid cardiac arrest, patients who are necessary to place buried cardiac resorfide devices in advance, (3) regardless of the size of the operation, anesthesiologists should attach great importance to all anaesthetic patients, strengthen supervision, be prepared to rescue drugs and equipment to respond quickly to emergencies in surgery; (4) in the event of poor anaesthetic, change the epidural gap or apply analgesic sedatives or, if necessary, change the general anaesthetic to complete surgery may be a better choice