1 case of difficulty in the removal of trachea catheter after full hemp surgery

1Patient informationpatient, female, 60 years old, height 150 cm, body mass 46kgDue to "injury caused by the right knee swelling and pain with limited activity 3h" hospital, after admissiondiagnosisfor "right tibia fracture" proposed surgical treatmentPatients deny the history of heart disease and infectious diseases, nodiabetes,hypertensionand surgical anesthesia historyAnesthesiologist preoperative consultation to measure blood pressure (BP) 115/75mmHg, heart rate (HR) 78 times/min, pulse oxygen saturation (SpO2) 98%, cardiopulmonary hearing is no special, predicted no trachea intubation difficultieschest tablets showed increased double lung texture, right lung valve growth;B super-
show schistosomiasis liver disease, spleen swelling, electrocardiogram (ECG) test showed normal;blood biochemical determination of albumin valueand ratio, creatinine, urea nitrogen are normal range, blood sugar 5.34mmol/L, blood potassium 4.1mmol/L, calcium The blood routine results show hemoglobin (Hb) 88g/L, red blood cell press (Hct) 27.3%, platelet (Plt) 42 x 109/L, ASA grade II taking into account that the patient Plt is below 50 x 109/L, select the trachea intubation static suction composite full hemp downstream right tibia fracture cut-out reset intra-fixation After entering the operating room, the patient scored BP135/80mmHg, HR97 times/min, SpO2 98%, and was continuously eCG, non-invasive blood pressure, HR, SpO2 monitoring Oxygen absorption denitrogle 3min after the static injection medapyrine 2mg, fentanyl 0.2mg, propofol 75mg, Viku bromine 6mg line full hemp induction, waiting for muscle relaxation perfect after the smooth insertion of ID7.0mm belt through the mouth Wire reinforced trachea catheter (Sino-foreign joint venture Jiangxi Ogelan Medical Device Co., Ltd.), hearing double lung breathing sound clear symmetry fixed trachea catheter followed by anaesthetic ventilator positive pressure ventilation (IPPV) (VT) 300mL, F12 times/min) Continuous low-flow inhalation of 1% to 2% heptafluoroetherine, propofol continuous micropump (20mL/h) to maintain full hemp Inoperative hemodynamic stability, the operation process was smooth, lasted 75min, at 10:15 am on the same day, the end of surgery at 10:15 am, after 10min patient strain recovery, VT about 250mL, to the new Ming 2mg plus Atropine 0.5mg antagvesic residual muscle pine, patient VT increased to 350mL, can According to the instructions to head up, tongue, grip strong fist, independent breathing air after 5min SpO297%, BP, HR normal, fully absorb the trachea and oral endocrine after 10:40 ready to pull the tube (at this time distance induced intubation 100min, surgery 25min), exhausting the air inside the air bag found that the trachea tube extraction difficulties considering that the patient's wake-up vocal cord tension has been restored or throat spasms caused by immediate oxygen absorption and static propofol 30mg after the patient sleeps (considering that the patient has completely awakened, at this time the addition of a small dose of propylene phenol sedative tube is safe, equivalent to a certain amount of anaesthetic depth under the pull tube) again test, still not successful After the replacement of 2 anesthesiologists failed once each At this time, suspected trachea tube jacket gas tube blockage or indicative jacket one-way flap failure, failed to completely drain the gas inside the trachea duct sleeve, then injected the saline 5mL into the sleeve, found no resistance and smooth extraction of 5mL physiological saline, thus ruling out the reason why the sleeve can not be released in order to avoid the vocal cord damage that may result from forced tube extraction, urgently consult with a higher hospital specialist Doctors at the higher hospital understand that after the treatment of the patient's double lung breathing sound is clear, with sputum tube to check the trachea catheter smooth Again static propofol 30mg after patients fall asleep with video throat mirror to check the sound door, found that the vocal cord edema is obvious and close to the trachea catheter, the catheter and the vocal cord between a few gaps Immediately static note A strong dragon 40mg, and use the throat hemp tube in the throat, sound door around the spray 2% Lidocain 5mL, spray 2% Lidocain 3mL through the trachea catheter, continue to inhale pure oxygen, 10min after again with video laryngoscope to observe the sound door, at this time found that the trachea duct and the sound door crackunder under the gap, then gently rotated under the direct look With a tightrope trachea catheter, found that the crumpled sleeve stuck in the right vocal cord under, continue to rotate the catheter counterclockwise so that the crumpled sleeve is located on top of the sound door crack, the trachea catheter finally slightly resistance smoothly pulled out (at this time, the distance from the surgery of about 120 min, the patient before the extraction of the tube wakes up perfect, the vital signs are stable, autonomous breathing air when SpO 297%)) the catheter pullout after the patient's pronunciation hoarse, the appearance of inhalable whirlrating sound (but the hearing double lung breathing sound clear no dry wet sound), consider the presence of throat, sound door and sound door water swelling, immediately atomized mask inhalation of epinephrine (0.25mg plus 0.9% sodium chloride 10mL), static injection semi-misson 10mg; blood dynamics are stable, breathing air SpO2 97%, returned to the ward, 1 week after surgery, no respiratory infection
, trachea-related complications occurred 2 Discussion the removal of trachea ducts after full hemp surgery is a routine operation of the anaesthetic department, relative to the difficulty of trachea intubation, trachea duct extraction difficulties are relatively rare The most common causes of tracheostomy removal difficulties are still in an expanded state, and serious and rare tracheostomy difficulties include trachea catheter fixation, tracheotomy stitched in head and neck surgery, knotted stomach tubes, swollen or strained sound doors, accidental catheter "inverted" and so on However, this case can obviously exclude the first 4 reasons, combined with medical history and video laryngoscope observation results, this case catheter pull out difficulties are the sound door swelling, vocal cord tension and crumpled column sacs played the role of the catheter "inverted stabbing" and other factors caused by a combination of several factors this case trachea intubation after smooth, short surgical anesthesia time (about 100min), smooth anaesthetic procedure, no allergy and other accidents, leading to the cause of vocal edema is speculated to be improper selection of trachea catheters (150 cm elderly women insertID 7.0mm with wire trachea catheters) and sac injection gas overdose The pressure inside the sac is too high, the thick trachea catheter and the sleeve inside the high pressure pressure sound door and trachea mucosa tissue, resulting in the sound door and the sound door water swelling, the patient wakes up the tube when the sound door is tense, coupled with the pumping after the wrinkled up the sleeve accidentally played the role of the catheter "inverted stabbing" further aggravated the difficulty of pulling the tube Clinical on the bladder exhaust catheter still can not be pulled out, should be preferred video laryngostosis or fiber optic examination, clear reasons, and then consider other auxiliary means including surgical means to pull the tube, should avoid blind excessive force of the pull pipe action leading to vocal cords or vocal door tissue damage, intravascular bleeding and other serious complications This example uses the video throat mirror under the clear vision of the use of the throat of the throat and tracheostomy with the rapid effect of the corticosteroid astrong dragon, alleviated the vocal cords of edema spasms, on this basis, the rotating catheter lifted the so-called catheter "inverted" the effect of the column sleeve formed by the contraction after pumping, successfully pulled out the trachea ductal duct Another feature of this example is that the trachea duct after sac gasdischarge is not leaking, suggesting that the patient's catheter selection is improper and /or the presence of sound door and sound door water swelling, therefore, before and after the tube actively prevent and control the sound door and sound door water swelling is very necessary has found that the sac leakage test can be to a certain extent foreshadowing the possibility of blocking and re-intubation of the upper airway after the tube, if the air leak should be alert to the high risk of blocking the upper airway after the tube, there is a high
clinical guidance and reference value Although the effect of the use of steroid hormone prevention vocal door edema has not been confirmed, the current clinically high-risk patients with -based asthma are still prevent ingesting the use of corticosteroids; studies have shown that the glyces of hydrogentest scans cannot significantly reduce the incidence of laryngosis after the extraction of the tube, but dexamethasone is effective after treatment of wheezing after the extraction of the tube In this case, the patient's intravenous use of dexamethasone and epinephrine atomized inhalation of the disease subsided rapidly and with good effect In recent years, with a coil wire-enhanced trachea duct duct because of its difficult to bend the advantages of the application gradually increased, but it is worth noting that because of its production needs to be lined with spring wire in the inner wall of the catheter, some products of the catheter wall thicker than the ordinary trachea duct duct, therefore, the same inner diameter with a wire duct tube tube outside the tube diameter slightly thicker than the ordinary trachea duct guide, which in children and small size, small sound door female patients should choose the normal tube in addition, the clinical use of the discovery of part of the spiral wire-reinforced trachea duct sac sacs into a cylindrical rather than oval (Figure 1), when the sac gas is exhausted, the upper end of the cylindrical sleeve often forms a circle of bulges, forming the so-called catheter "inverted" (Figure 2)), this type of catheter "inverted thorn" has little effect on the general adult, but has special significance for children and small, small female patients with small vocal door cracking, "inverted stabbing" on one side or two-sided vocal cords can lead to difficulty pulling the tube (or vocal cord damage), this case is a lesson Therefore, the choice of catheter models for these patients should be personalized (the outer diameter of the catheter is equivalent to the diameter of the patient's small finger, the trachea catheter with an oval sleeve to prevent postoperative catheter extraction difficulties or vocal cord damage Figure 1 Different shapes after injection of air in three catheter sleeves 1: The normal catheter airbag gas is oval after gas injection, 2: the domestic reinforced duct airbag gas is cylinder-shaped after gas injection, 3: imported reinforced duct airbag gas injection is roughly oval figure 2 Different shapes after exhausting three catheter sleeves 1: Ordinary duct airbag exhaust close to the pipe wall; 2: domestic reinforced duct airbag exhaust after the formation of "inverted sting"; 3: imported reinforced duct airbag exhaust close to the pipe wall