1 case of malignant arrhythmia caused by nasal injection dilution

Patient, female, 29 years old, height 162 cm, body mass 51kgBecause of the "stopping with the overflow of milk april" hospital,diagnosisas "pituitary adenoma", the proposed period of full hemp down "through the nasal butterfly into the dorpitation tumor excision." Old and healthy, no special medical historyElectrocardiogram (ECG): sinus heart rhythm, ventricular early beat; dynamic electrocardiogram (Holter): full sinus rhythm, occasional room premature fight (5 times, single hair); ventricular early fight (353 times, single hair); echocardiogram (UCG): FS25%, left ventricle blood score (LVEF) 50%, left ventricular contraction and reduced function of the left heart muscle muscleThere were no obvious anomalies in the laboratory testsCardiofunction Level I, Cardiologist does not have special treatment advicesurgery day, the patient after entering the room open venous channels, parallel routine monitoring, heart rate (HR) 100 times / min, blood pressure (BP) 109/75mmHg, pulse oxygen saturation (SpO2) 100%Mask oxygen absorption downstream vein rapid sequence induction, in turn to the midazolam 2mg, relying on miede 16mg, Shufentani 20 mg, Roku bromine 40mg, 3min after the line of light cable guide trachea intubation, after the success of continuous mechanical ventilation, to maintain the end of the exhalation of carbon dioxide pressure (PETCO2) 35 to 40MmHgthe preparation of 1% heptafluoraetherine joint target propofol, riffintani maintenance anesthesia, the effect chamber concentration is 1 ?g / (kg ) and 1 ng / (kg / min) respectively , the patient's vital signs are stableSurgeons perform ediphine thinners (concentration sg/mL, capacity 3mL) after flushing 2 to 3min, monitoring the speed of the electrocardiogram chamber, HR140 to 160 times / min; After about 2min, the sinus law is re-converted, after which the intravenous pump is injected with norepinephrine 0.1 ?g/kg.min to maintain BP90 to 110mmHg/55 to 65mmHgBlood gas analysis: PH7.455, oxygen pressure 372.2mmHg, PETCO227.5mmHg, K-3.03mmol/L, Ga1.087mmol/L;55min patients recover from heart rhythm, can open their eyes as directed, but the recovery of autonomous breathing is not good; After the tube was unplugged, the patient complained of mild chest pain on both sides and numbness in both lower limbsFollow-up the next day, the patient complained of mild chest pain, chest tightness, lower limb seisples feel no abnormalityThere was no significant difference between eCG, UCG and preoperative reviewdiscuss in the preparation of certain operations (e.g nasal pituitary tumor removal, bronchoscopy and scalp encapsulation, dental surgery, etc.), the surgeon often fills the nose with gauze soaked in epinephrine or ephedrine dilution, mucous injections or sprays of dilution, locally soaked with low doses of epinephrine in order to reduce local bleeding, make the hepenpline effect The instructions recommend that the dilution concentration of epinephrine should be 1:20000 000 to 1:500000, and the total dose should not exceed 0.3 mg Srisawat and other monitoring of plasma drug concentration found that the nasal to give 5 mg of epinephrine can be similar to the absorption effect of 0.3 mg of muscle injection, it can be seen that the nasal to give epinephrine a safe range of a wider range Even so, very few patients develop adverse reactions such as high blood pressure , low blood pressure, pulmonary edema or arrhythmia, or even death, after low doses of epinephrine from the nose Yang and other 2006 has been found that the nasal mucosal injection of trace epinephrine dilution can cause patients with nasal butterfly pituitary tumor surgery in 3min to show tachycardia, blood pressure increase, heart output increase dispensed and other hemodynamic changes, and this change has dose-dependent It has been suggested that local immersion in 20 sg of epinephrine can cause severe heart vascular adverse events Other studies have shown that 2% of Lidoka, with local injections of gums containing 1:80,000 or 1:200000, can provide satisfactory and no significant difference in clinical effect, while for patients with combined cardio vascular , low doses of epinephrine at a concentration of 1:100,000 are relatively safe Therefore, under the premise that clinical can be guaranteed, the amount of epinephrine should be minimized to avoid the occurrence of serious adverse events Adrenaline-related cardiovascular adverse events are mostly in the form of case reports, most of the patients appear in the rapid arrhythmia-based clinical signs, which are associated with epinephrine activation of beta 1 receptors, and can be combined with high blood pressure or low blood pressure, the former is related to the agitation of the alpha1 receptor, the latter is caused by the effect of beta 2 receptor agitation most patients a short-lived cardiovascular response that can recover on their own, but very few patients can quickly develop malignant arrhythmia, at which point the appropriate anti-arrhythmia drugs, CPR and electro-defibrillation must be given urgently for reversal In this case, the patient has no special medical history, although the epinephrine through the nasal mucosa absorption into the blood as the main cause of malignant arrhythmia, but combined with preoperative, postoperative related test results, but also must consider the patient's primary disease and hidden disease factors first of all, pituitary tumors can be classified as functional and non-functional, the former can secrete prolactin, growth hormone, adrenal corticosteroids, thyroid-stimulating hormones or gonadotropins Postoperative hormone level tests showed mild increases in prolactin and T4 levels, but the evidence was not enough to support the diagnosis TSH pituitary tumor However, free thyroxine can enhance the action of catanophenols, so pituitary tumor-related hormonal level disorders may be the underlying cause of this adverse event In addition, diseases that can increase sympathetic neuroavulsion (e.g., acute period of subcavity bleeding in the cobweb scianet) or increased secretion of endogenous catalym (e.g., cytomegaloblastoma, paraneurocytoma) can lead to an increased incidence of cardiovascular complications during the perioperative period Secondly, although the patient has no history of heart-related diseases before surgery, but The UCG shows LVEF 50%, and there is a left ventricular section of the motor disorder, it is not possible to rule out the possibility of cardiomyopathy Related: A woman with a food allergy who suffered chest pain after injecting 0.15mg of epinephrine in her muscles, which led to the lowering of the eCG's new ST segment and the long QT period and the reduction of LVEF to 40%, was eventually diagnosed as a case of stress cardiomyopathy If there is a clear diagnosis of cardiomyopathy before surgery can be based on different types of preventive treatment, treatment measures include etiology treatment, drug control or implantation of cardiac rhythm restatement defibrillator, pacemaker and so on For such diseases, the use of additional monitoring (e.g esophageal echocardiogram, etc.) during surgery will help to detect cardiovascular abnormalities early and be useful for evaluating the effectiveness of treatment