1 case of cardiac arrest in waist-hard joint anesthesia.

Venous thrombosis (VTE) is a group of diseases including deep vein thrombosis (DVT) and pulmonary arterial thrombosis (PTE).
VTE is one of the important causes of unelected death and perinate death in hospitals, and also the main cause of medical disputes.
Acute pulmonary embolism (PE) is a syndrome that causes pathological changes or clinical symptoms when an exogenous or endogenous hydrant enters the patient's pulmonary artery and branch, which leads to pathological changes or clinical symptoms, and is a major emergency in the elderly population, with high fatality rates.
studies show that pe during anesthesia has a clear correlation with the patient's basic condition, basic disease, anaesthetic mode, long bone fracture, clotting index, etc.
risk factors of PE occurrence in the first place also include: female, old age, high blood clotting state, preoperative braking and so on.
Female patients with high estrogen levels, prone to embolism, coupled with small amount of pyrenine exercise in female patients, long-term sedentary lead to slower blood flow in the lower extremities veins, blood clotting factor deposition, causing thrombosis, prone to PTE.
is now in our hospital 1 case of orthopaedic female patients after the waist hard joint anesthesia occurred PTE, respiratory cardiac arrest reported below.
1. Patient data patient, female, 64 years old, height 158 cm, body mass 65 kg.
right hip replacement on the right side of the lower anaesthetic due to a fractured right pelvic bone and neck.
preoperative routine examination did not see abnormalities, has a history of hypertension for 12 years, ASA grade III.
20mg1 tablets of oral nitrobenzene flat release tablets at 6:00 p.m. on the day of the operation.
open the upper limb vein passage when the patient enters the room.
monitoring: blood pressure (BP) 135/79mmHg, heart rate (HR) 76 times/min, pulse oxygen saturation (SpO2) 95%, mask oxygen SpO2 up to 100%.
9:20 anaesthetic start: take the left lying in the L3-4 gap line waist hard joint anesthesia, puncture smoothly, inject 0.5% left Bubikain 2.3mL to the cobweb lower cavity, tube.
9:35 flat sleeper plane is located in T10, patient BP dropped to 112/68mmHg, HR80 times/min.
9:45 retest plane is located in T8, 9:55 left horizontal preparation surgery, at this time the plane is located in T7, BP105/60mmHg, HR70 times/min, SpO2100%.
15min after the patient suddenly appeared a cough, when the patient BP, HR stable, did not immediately ask the patient.
3min after the emergence of heart rate sexual decline, blurred consciousness, shortness of breath, SpO2 gradually decreased, immediately gave atopine 1.0mg intravenous injection, HR continued to drop to 30 times / min below, trans-horizontal position, immediate CPR, while epinephrine 1.0mg intravenous injection.
this time, the patient appears room speed, chamber fibrillation.
immediately defibrillation.
electrolytic map (ECG) showed frequent chamber early beats, HR120 to 130 times/min, BP70/49mmHg, SpO295%.
recovers sinus heart rhythm after 10min and wakes up after 20min, but blood pressure is still at shock levels.
pumps up to epinephrine, dopamine.
observation of 1h, the patient's vital signs stabilized, BP115/65mmHg, HR135 times/min, SpO2 97%.
the operation and was admitted to the Intensive Care Unit (ICU) for observation.
5:00 a.m. the next day, stop pumping epinephrine and dopamine, the patient's vital signs are stable, return to the general ward.
afternoon patient line head chest CT examination and heart color super examination.
heart color super show: the right room increases, the right chamber abnormal light group (does not exclude blood clots or mucus tumors), the left chamber lysosis function decreased.
chest CT show: double lower lung traumatic wet lung, double-sided chest cavity fluid and double lower lung expansion incomplete.
D-D-poly 38.53mg/L.
In view of the patient's critical condition, immediately transferred to a higher hospital, arrived at the higher hospital ICU, immediately line the bedside B super, the patient's right heart room floating objects have entered the lung circulation, but the patient has no discomfort, after thrombosis treatment, a few days after the patient was discharged from the hospital.
2. Discussing the incidence of pulmonary embolism increases with age, clinical manifestations are not typical, the mortality rate is high, especially in orthopaedic patients, long-term bedtime after injury, reduced activity, easy to form deep vein thrombosis in the lower extremities, resulting in postoperative PTE.
who stay in bed for long periods of time are at high risk of pulmonary embolism, which is related to the physiological function of the elderly.
are thousands of times more likely than children to develop venous thrombosis in older adults.
clinically, pulmonary embolism is a serious complication of deep vein thrombosis in the lower extremities, mainly caused by deep vein thrombosis.
Elderly patients after the waist hard joint anesthesia, the change of position caused by cardiac arrest is reported, generally timely treatment of rescue, the probability of success is relatively high, if not timely treatment, may also lead to serious consequences and even death.
causes of cardiac arrest in lower back hard combination anesthesia are generally summarized as surgical factors, patient factors and anesthesia factors.
surgical factors include pulmonary arterial embolism caused by surgery, amniotic embolism, hemorrhage caused by surgery, the application of bone cement during surgery, and the application of airbag hemorrhage belt.
patients include cardiomyopathy, morbid obesity, deep vein thrombosis, and severe muscle weakness.
and anesthesiology factors mainly consider the changes in patient circulation caused by waist-hard combination anesthesia, which is the most concerned aspect of anesthesiologists and needs to focus on the content of research.
patients with cardiac arrest, the main consideration of patient factors and anesthesia factors 2 aspects.
Among the patient factors, the patient may have a deep venous thrombosis in the lower extremities before surgery, the patient has multiple thrombosis secondary risk factors: trauma/fracture, including hip fractures (50%-75%), obesity, brake/long-term bed for various reasons, elderly women.
The dilation of the blood vessel bed in the lower extremities after anesthesia, the change of blood flow rate, coupled with the change of position, make the deep veins embolism fall off, the embolism blocks the pulmonary artery and its branches to a certain extent, through mechanical blockage, coupled with the neurosomosis factor and hypoxic pulmonary artery contraction, resulting in increased lung circulation resistance, pulmonary hypertension, right heart chamber post-load increase, right heart chamber wall tension increased to a certain extent caused by acute lung disease.
the right chamber to expand the chamber interval left shift, so that the left chamber function is impaired, resulting in a decrease in heart discharge, and then the circulation of low blood pressure or shock.
Low blood pressure in the aorta and elevated right atrial pressure, so that coronary perfusion pressure decreased, myocardial blood flow decreased, especially in the lower perfusion state of the lower membrane of the heart, coupled with increased oxygen consumption of the PTE heart muscle, can cause myocardial ischemic.
patients with unsuperplained respiratory cardiac arrest, high-risk or large-area acute pulmonary embolism accounted for 8% to 13%.
fatal acute pulmonary embolism accounted for 0.2%, often within 1h of acute symptoms.
, on the other hand, we consider changes in the circulation caused by anesthesia, a combination of waist and hard anesthesia, that contribute to cardiac arrest.
lumbar hemp plane is too high, resulting in a wide block of the interspersion nerve, resulting in severe titlition to ease low blood pressure, and even cardiac arrest.
generally believed that the symectal block plane is 2-6 segments higher than the sensory plane.
The patient's side-lying measurement plane is located in T7, and the sensory plane at least T6 above, may be higher, blocking the heart-to-heart nerve, so that the characteristics of the vascular nerve show, the appearance of heart rate decline, while a wide range of interstition blocking caused the expansion of the outer blood vessels, especially the lower extremities.
severely reduces the amount of blood flow, can produce severe hypotension and severe cardiac arrest, further development may lead to cardiac arrest.
cardiac arrest is the most critical complication during the anaesthetic period and can have serious adverse consequences if not detected and properly treated in a timely manner.
the hidden incidence of VTE, it has the characteristics of high incidence, high death rate and high missed diagnosis, and it is very important to actively prevent and early diagnosis and early intervention.
prevention and control measures are an effective way to reduce the rate of VTE and death.
the proportion of people who used VTE preventive measures during perinameation increased, the death rate of perinate PE decreased significantly.
Although the case in the diagnosis and treatment in a timely manner, but in the preoperative preparation there are still shortcomings: preoperative routine examination is not perfect, did not do the lower extremities deep vein color ultra cardiac ultrasound and examination D-disaconed.
currently can only be based on the clinical performance of cardiac arrest and cardiac arrest after cardiac arrest, laboratory examination, follow-up examination diagnosis, thrombosis treatment to make the above inference.
the lessons of this case are far-reaching.
early identification of high-risk patients, timely risk assessment intervention, take preventive measures, can significantly reduce the occurrence of pulmonary embolism and deep vein thrombosis in hospitals, so as to ensure medical safety and reduce medical risks.
At the same time, throughout the anaesthetic process of hip surgery for lower limb fractures, especially in patients who perform invertebral anesthesia, anesthesiologists closely monitor changes in the patient's BP, HR, SpO2 and consciousness status before and after moving and changing the patient's position. We should also pay constant attention to the changes in the anaesthetic plane, to be aware of the decline of BP, HR, timely application of ephedrine and other booster drugs, early intervention, to avoid low blood pressure, in addition, to pay attention to preoperative visits, adequate preoperative preparation, in order to make anaesthetic more safe.
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