1 case of coronary heart disease anesthesia treatment in elderly patients with simultaneous multi-primary cancer in the lungs

1Patient informationpatient, male, 65 years old, height 160 cm, body mass 53kgDue to coughing and coughing sputum with chest pain in March 2016 in Yunnan Cancer Hospitaldiagnosedfor right lung lower leaf cancer, parallel chest mirror under the right lung fooclustculose cancer radical treatment, 6 months after the surgery review found the left lung lower leaf substrate section of the new nodules, lung CT as shown in Figure 1Preoperativediagnosis:(1) postoperative treatment of lower right lung foomelate cancer; (2) the nature of the genotys of the lower lobe of the left lung to be checked, and (3) coronary atherosclerosis heart diseaseProposed TV-assisted thoracic surgery (video-assisted thoracic surgery, VATS) left lung lower loin section excisionFigure 1 Patient's lung CT2Anaestheticmanagement2.1 preoperative assessmentpreoperative assessment is divided into two parts, the first part is the assessment of heart function: (1) coronary CT shows the patient's right coronary artery middle tube cavity about 35% stenosis, left coronary pre-drop near middle section tube cavity local about 80% narrow, on The angle near end tube cavity is about 65% narrow; (2) dynamic electrocardiogram (Holter) suggests 24h multi-source chamber early beat 586 times, continuous ST segment change; heart rate variability is normal; (3) heart color super-tip chamber interval thickening, left ventricular diastomoric function decreasedPatientsclinicalsymptoms of stable angina, the last 3 months did not attack, aspirin has been discontinued for 2 weeksHeart Function IIDynamic blood pressure is basically normal, and no obvious abnormalities were observed in the after-pumping blood testThe second part of theis to evaluate the patient's respiratory functionAccording to the classic "three legs" theory of respiratory function, we evaluate the following three aspects: (1) the indicator of respiratory mechanics: the first second after surgery, the strong exhalation volume (FEV1) prediction (predicted postoperative FEV1, ppoFEV1) Pre-FEV1% x (1-cutlung segment percentage), the patient's ppoFEV1% is 44.80% greater than the critical value 40% ;(2) reflects the gas exchange indicator: postoperative estimated carbon monoxide dispersion ppoD LCO is 52% is also greater than the critical value of 40%, arterial blood gas analysis indicates arterial blood oxygen pressure (PaO2) 50mmHg, arterial blood carbon dioxide pressure (PaCO2) 35mmHg;from the above indicators can be seen that the patient's respiratory function is OK, should be able to withstand surgery, but the patient six months ago has had the upper right lung lobe removed, which means that he lost 29% of functional lung tissue, but also suffering from coronary heart disease, so how to maintain a good balance of oxygen supply and oxygen consumption in surgery is the top priority of this case anesthesia, choose how to breathe is crucial2.2 anaesthetic treatmentIn view of this situation, we carry out selective pulmonary leaf isolation technology, that is, the use of bronchial blockage catheters placed into the left lower lung lobe bronchial bronchial tube, only blocking the left lower lung lobe, non-surgical lung loin and healthy lung ventilationAfter smooth anesthesia induction, first insert 8.0mm (or above) internal diameter ordinary trachea catheter, fiber bronchoscoscopy FOB observation put the bronchial blocking catheter sleeve near end under the left bronchial protrusion, the bronchial blocking catheter sleeve sleeve inflatable, does not clog the left upper lung lobe bronchial openingThe specific bronchial blocking catheter is shown in figure 2Figure 2 The bronchial blocking catheter diagram1: Plug;2:Sac;3: Bronchduct;4: Conversion connector;5: vents;6: Bronchmirror operating holes;7: Automatic inflating valves;8:side tube; 9: Cap joint;10: Anti-check valve with airbags;11: airbags;12: pre-inflated tubes;13: indicator sacs;14:we are taking mechanical intermittent positive pressure ventilation mode, inhalation of oxygen 1L/min, moisture (VT) 6 to 8mL/kg, respiratory frequency (RR) 12 to 15 times / min, exhalation of positive pressure (PEEP) 5 cmH2O, airway pressure 18 to 21 cmH2O, maintenance of end-of-air cotues (PET2) carbon dioxide ( PET2) for 35 to 50 mm carbon dioxide Intraoperative arterial hemogasie analysis showed PaO2 105.2mmHg, PaCO2 48.4mmHg, SpO2 97.3%, and indicated a lower rate of intrapulmonary shunt Surgical evaluation satisfaction, surgery to maintain arterial blood pressure 110 to 140/60 to 80mmHg, heart rate (HR) 50 to 80 times / min, SpO2 93% to 98%, no ST-T segment change The operation lasted 128min, the blood gas analysis showed ph7.4, PaCO2 35mmHg, PaO2 110mmHg, the fluid intake was 500mL (hemorrhage 100mL, 400mL), 1600mL (Crystal Fluid 1000mL plus colloidal fluid 500ML) 13min after the operation, the patient sobered up the tube, observed 50min after the return to the ward Patients recovered well after surgery, no obvious sore throat and hissing and other anaesthetic-related complications occurred, while in the good peripic period analgesic management , the patient VAS score has been below 2 points, the second day after surgery is removed chest cavity drainage tube, in the 7th day after surgery to recover discharge fiber bronchoscopic oscopy: (1) use a syringe through the stop valve to inject 3 to 5mL air into the air bag (Figure 2-11), press the automatic inflatable valve (Figure 2-7) to inflate the indicator jacket (Figure 2-13), Check whether the sac is leaking, make sure that the sac seal is good, empty the sac to completely empty, close the cap joint (Figure 2-9), fully lubricate the sealer under 1/3 and the surface of the bag; 5) Connect the anaesthetic circuit; (3) push the bronchial tube through the trachea intubation (Figure 2-3), while using the fiber bronchoscopy mirror through the gasbron mirror through the conversion joint's bronchoscopy working hole (Figure 2-6) under the bright view, the rotating cap (Figure 2-2) to reach the need to block main bronchial tube, and determine the position of the airbag (the airbag is at least 1 cm under the trachea), adjust the blocking duct clip lock blocker; (4) inject the air in the air tank sac with the appropriate amount of air (at this time the air sac is similar to the amount of the sac inflated in the bronchial tube), Pressing the automatic inflatable valve to expand the jacket and block the target side bronchial tube; (5) the operation starts to inflate into the chest to the pocket, press the check valve switch, open the cap joint negative pressure attractor to continuously attract or use a 20mL syringe to extract the affected side lung gas, in order to achieve the rapid decline of the surgical side lung Blind detection: (1) (2) up; (3) push the bronchial tube through the trachea, place at a certain depth (encounter edited with appropriate resistance and suddenly disappear, then rotate 90 degrees to the left into the left main bronchial tube or rotate 90 to the right the change of air duct pressure of the anaesthetic machine before and after the injection into the right main bronchial tube ( ;(4) is repeatedly injected into the sac, and the change of the airduct pressure of the antithesis before and after the bronchial tube is carefully carried out to adjust the position of the bronchial catheter sac (the air duct pressure increases significantly after the sleeve is inflated and the double lung breathing sound All are weakened, suggesting that the blocker position enters the main bronchial tube of the affected side lung too shallow, the airduct pressure after the jacket is inflated is not significantly changed and the sound of double lung breathing is not obvious, suggesting that the blocker position enters the main bronchial bronchial tube of the patient's side too deep, and the bag is inflated after gas The pressure of the channel increases slightly, the affective lung breathing tone is weakened and the health side lung breathing tone is not significantly changed, suggesting that the blocker position is placed into the main bronchial bronchial tube of the patient's side lung), after determining the position is intact, the adjustment blocking duct clip locked the bronchial catheter) ;(5) is the same 3 Discussion of the patient in the right lung lower leaf cancer surgery within six months after the recurrence of lung tumor, is currently considered for the pulmonary conteminal multiple primary cancer, there is a sign of surgical removal of the lesions of the lung section Preoperative lung function index evaluation of pulmonary excision indication has gradually formed the evaluation mode of resting lung function, pulmonary ventilation perfusion scan and cardiopulmonary movement test The classical lung function assessment method is based on the premise of the integrity of the lung tissue, the view and minimum standard that is generally accepted for pulmonary loytomy is the FEV 1% (50%) estimate, the ppoFEV 1% (0.8L), PaCO2,50mmHg There is no definitive determination on how to accurately assess lung function in patients with missing lung tissue before surgery We assume that the patient's residual lung completely compensates for the function of the missing part, so that the indicators assessed according to the conventional method will be higher than the actual, especially the patient combined with coronary heart disease, lung function assessment indicators are just stuck on the standard line For patients who have had a side pulmonary lobe excision surgery, the use of a double cavity bronchial catheter to perform single lung ventilation will become single lung leaf ventilation or two lung loal ventilation, even if the use of increased FiO2, non-ventilation lung sustained airway positive pressure ventilation or blow into low-flow oxygen, pressure control of the vented side pulmonary ventilation or increase PEEP and other methods may not provide sufficient oxygen If a single cavity tube is selected for low-tidal double lung ventilation, this will inevitably affect the surgical field exposure and surgical process in thoracic surgery Therefore, the selection of bronchial blocking catheters can maximize the retention of ventilation pulmonary leaves during surgery, avoiding oxygen supply and demand imbalance Because of the reduction of pulmonary hypoxia region, the oxygenation and respiratory mechanics index in surgery improved significantly, the pulmonary diversion rate decreased significantly, the complications of pulmonary incontinity after surgery decreased, the arterial blood gas index was better, and the average hospital stay was shortened after surgery secondly, compared with the double cavity tracheal catheter, bronchial blockage catheterhasied catheters have the advantages of minimally invasive, postoperative patients in intensive care unit do not need to replace the trachea catheter, not only wide range of use, but also improve the success rate of difficult airway intubation, suitable for difficult airways, pediatric single lung ventilation and such low lung function and patients who need selective pulmonary blockage However, due to the thinness of the intercession cavity and the difficulty of attracting secretions, it should be considered taboo for patients with wet lungs, large haemorrhage and lateral lung secretions At this stage, there is no normative guidance on the mechanical ventilation strategy of selective pulmonary leaf isolation, which is not only different from the single lung ventilation of the double cavity tube, but also different from the double lung ventilation, how to make the choice of the inoperative ventilation mode also needs further research