1 successful case of hemorrhagic shock resuscitation in the venous full hemp mirror uterine fibroid excision

1Clinical datafemale, 29 years old, 55 kgDue to the "menstrual extension of the associated longitude increased by 2 years" admitted to the hospital, diagnosed as uterine mucosal fibroids, the proposed full hemp downstream uterine fibroid excisionIn the past, he was healthy, four years after the caesarean section, denied allergic historyThe routine examination of blood in hospital showed moderate anemia, and no obvious abnormalities were observed in other preoperative routine examinationsGive blood transfusions and other relevant preoperative preparationsThe patient enters the surgery room, gives oxygen absorption, and opens the venous pathway of the right upper limbroutine monitoring: 5 electrocardiograms (ECG), non-invasive sleeve blood pressure (BP), pulse oxygen saturation (SPO2), electrocardiogram (ECG), exhalation of end carbon dioxide (PetCO2)In-room SPO2 100%, HR 66bpm, BP 118/60mmHganaesthetic induction: intravenous infusion medaquin 3mg, propofol 80mg, fentanyl 0.2mgThe anaesthetic depth is appropriate, the vital signs smoothly inserted into the No3 larynx cover and control breathing, airway peak pressure (P peak) 17 cmH2O, Pet-CO2 32mmHg, propofol 20ml/h pump injection to maintain anesthesiaThe operation lasted 20min, during the infusion 500 ml, the amount of dominant bleeding was about 100 ml, after the operation, the contraction of uterine 30u plus 0.9% sodium chloride 500 ml intravenous dripsurgery at 15 min when the patient HR95bpm, BP88/50mmHg, SPO2 100%, accelerate the colloidal long source snow infusion, reduce the amount of propofol, give norepinephrine 4 sg/ml repeated static push, while placing a venous pathwayAfter the operation 10min patient heart rate gradually increased to 140bpm, sinus rhythm, SPO2 irregular waveform display, data can not be measured, non-invasive sleeve band blood pressure can not be measured, P peak 17 cmH2O, PetCO2 25mmHg, to give methoxygenin 2mg static push, metha-strong dragon 80mg static push, disable the long source snow-borne hydroxyethyl starch and the speed of the most successful blood analysis touch the carotid artery without throbbing, immediately start chest compression, adrenaline 1mg static push 2 times, 0.2 mg/kg/min pump injection, norepinephrine 50 sg/ml repeated static push, dexamethasone 10mg static push, emergency blood, ice cap cranial temperature, emergency line trachea tube intubation, arterial puncture tube pressure test and neck venous puncture tube Postoperative 30 min traumatic blood pressure (IBP) 105/72 mmHg, HR123bpm, SPO2 100%, arterial blood gas: pH 7.42, PaCO2 34 mmol/L, PaO2 249 mmol/L, H CO3-std 23.2mmol/L, hemoglobin 47g/L, blood sugar 18.0mmol/L, give pressurized blood transfusion, acid, potassium supplementation, calcium supplementation, sugar reduction and other measures to maintain internal environmental stability, and adjust the blood pressure according to the patient's blood pressure drug use after 35min found that the patient's abdomen slightly bulging, vaginal bleeding, color bright red amount is not much, urine color clear Ultrasound examination see a large number of fluids in the abdominal cavity, ultrasound-guided lower abdominal cavity puncture stab sculletation, because it can not be ruled out the expansion of the media (5% glucose) and uterine fibroid sutures removed from the wounded surface blood flow into the abdominal cavity, after suddenopening of the uterine cavity pressure reduced there is the possibility of aggravated bleeding, temporary static contraction of uterine, uterine filling, abdominal pressure control uterine bleeding, observation of changes 30min found that the patient's abdominal puffin for sexual enlargement, squeezing the uterus, vaginal bleeding about 100 ml, arterial blood gas hemoglobin value is not measured, blood cell ratio (HCT) 15%, at this time has been entered concentrated red suspension 3U, plasma 370ml, after comprehensive consideration decided to perform caesarean section Given fentanyl 0.1mg, Shun aquku ammonium 10mg, inhalation of 1% heptafluoroether, patient vital signs stable, during surgery see the uterine narrow front wall scar rupture bleeding, not probed and inflated injury, pelvic cavity hemorrhagic fluid and blood clots a total of about 4,000 ml, uterine rupture repair The operation lasted 1h15min, the total infusion of 17 units, plasma 1,780 ml, cold precipitation 20 units, infusion 3,900 ml, resulting in urine about 2,000 ml, color clear continuouspump into the vascular active drug, blood pressure 110/70mmHg, heart rate 110bpm, hemoglobin 87g/L, blood sugar 10.4mmol/L, patient conscious, can cooperate, independent breathing, with trachea catheter into the ICU The next day the patient consciousness is clear, the vital signs are stable, drainage and incision seepage less, vaginal bleeding less, dark red color, no other complications, after the removal of trachea catheters into gynecology Patientdischarge after 10 days 2 Discussion of conoscopy surgery with its safe, effective, simple, minimally invasive, body table insatiable and other advantages, in the uterine cavity and cervical disease diagnosis and treatment has been greatly developed and promoted, uterine procedure complications have also been greatly accumulated Common complications of uterine surgery include bleeding (0.76-2%), uterine perforation (0.12%-1.6%), cervical tear (1-11%) and fluid overload (0.1%-0.2%) Among them, uterine perforation is the most common complication, and can be secondary blood loss, visceral damage, and even life-threatening According to prospective studies of Aubrt A and others, most uterine perforations can be found in surgery, only 1 case (1/2116) was not detected in time to cause low blood capacity shock, after rescue coeliac izedes under the uterine perforation repair improved Lee and others also reported a case of uterine perforation during uterine surgery, which did not detect the timely detection of intracoaoral space spacing syndrome caused by the flow of intrauterine fluid into the abdominal cavity Because the uterine cavity surgery requires energy equipment, uterine media, intrauterine pressure, as well as the surgical space is small, can not be stitched, so that its complications are different from traditional surgery This paper discusses the identification of high-risk uterine surgery, the choice of uterine surgery anaesthetic method, and the prevention and treatment of complications of uterine surgery before the the general preoperative inquiry medical history and preoperative examination, anesthesiologists should also know whether the patient has uterine cavity adhesion, scarring of the uterus uterus, uterine cavity stenosis, uterine over-frontal flexor atrophy and other high-risk factors of uterine surgery complications, as well as the positional relationship between the pre-confined lesions and the uterus and pelvic cavity, the size of the surgical wound and the duration of surgery, combined with the experience of the patient's experience and other factors to comprehensively assess the risk of uterine surgery complications B ultra-monitoring under the guidance of the implementation of uterine chamber surgery, can dynamically observe the uterine cavity, uterine muscle wall and lesions and the whole process of operation, and has simple, economical, safe, effective and other advantages, become the preferred monitoring method of high-risk uterine chamber surgery patients have a history of caesarean section surgery, is a scarred uterus, the patient preoperative uterine hemorrhage has not been controlled, affecting the field of vision of uterine cavity surgery, prolonging the surgical time, increasing the possibility of uterine perforation, should be treated according to high-risk uterine chamberoscope treatment, recommended use of ultrasound monitoring Alternative anaesthetic methods are intravertebral anesthesia and general anesthesia Motti Goldenberg et al reported that the time of full intrauterine laparoscopic surgery was no different than that of epidural anesthesia, while the absorption of intrauterine fluid was significantly lower than in patients with epidural anesthesia Excessive absorption of puffin liquid can affect the patient's blood sugar, blood sodium and lead to the occurrence of fluid overload Although there are no reports of fluid overload in these patients, for patients with poor cardiopulmonary and renal function, sensitive fluid load and complex long-term uterine surgery with high risk factors for surgical complications, it is advantageous to choose general anesthesia under-the-house conuterine surgery patients have the potential to circulate blood volume before surgery is insufficient, before the start of anesthesia should be actively rehydration, blood preparation blood, anesthesia mode to full hemp as appropriate The management of uterine chamber surgery should pay special attention to its especial complications such as uterine perforation, hemorrhage, fluid overload (Fluid Overload), intravenous air embolism (Air Embolism), etc (1) this case of patients, when the heart rate increases faster, blood pressure gradually reduced to undetectable, the process of pulse oxygen irregular waveform, first consider the circulatory blood volume caused by the heart rate fast, low blood pressure, but the operative apparent bleeding about 100 ml, although the preoperative patient sequester patients have insufficient circulating blood volume, after rehydration treatment, is not enough to explain the hemorrhagic shock, but should be thought of the abdominal hemorrhagic hemorrhagic (2) liquid overload and high-permeable hyperglycemia were clinically characterized by pulmonary edema, acute left heart failure, cerebral edema, electrolyte disorders and signs The high risk factors of liquid overload are the use of low ostoxiosis or non-electrolytic fluid puffing, excessive pressure of puffing uterine (greater than 100mmHg), excessive time of puffing (greater than 1h), large area vascular exposure of the uterine muscle layer This case of the patient is a young woman, good heart function, short surgery duration, not considered, can be diagnosed by intraoperative blood gas analysis and calculation of the amount of puffed uterine fluid intake (3) gas embolism in the surgery of the whole hemp chamber chamber surgery will have a sudden drop in the end of the exhalation of carbon dioxide (PetCO2), low blood capacity can not explain the persistent low blood pressure, tachycardia, tachycardia, ventricular early beat, S-T segment change or even stop, but almost all gas embolism patients have blood oxygen saturation (SpO2) decreased Although the patient has PetCO2 drop, persistent hypotension and tachycardia, but SpO2 has been 100%, and tachycardia is sinus heart rhythm, the surgery did not see early beat, so the diagnosis of gas embolism can be excluded It can be diagnosed by esophageal echocardiogram, doppler ultrasound in the pre-cardiac region, and diagnosis can also be supported by pre-cardiac hearings and hydrolysis (4) had a variety of clinical manifestations of aphorisms and weak specificity This case patients denied the history of allergies, although there is low blood pressure and tachycardia, but there is no airway spasms and systemic skin red rash and other clinical manifestations, the surgery of anaphylactic shock is not considered first, to find a more reasonable reason before excluding this diagnosis According to the above analysis, still consider hemorrhagic shock, hemoglobin analysis to see hemoglobin continued to decrease, abdominal puffing, ultrasound see a large amount of fluid in the abdominal cavity, abdominal puncture extraction of non-coagulation confirmed that there is indeed intra-abdominal bleeding Blood in the abdominal cavity may be derived from uterine perforation during laparoscopic surgery, or it may be derived from the flow of intrauterine fluid from the fallopian tube to the abdominal cavity during surgery Fluid flow from the fallopian tubes into the abdominal cavity does not explain the patient's severe circulatory system performance and the persistent low hemoglobin According to Janka PS's research, premenopausal female uterine fluid flows from the fallopian tube to the abdominal cavity at a rate of 1.5 to 0.2 ml/min, which does not cause the above-mentioned performance when seepage, can be basically confirmed as uterine perforation in the uterine chamber surgery, and subsequent opening surgery confirms this In this case, the patient's vital signs are unstable, have been life-threatening, the bleeding site is uncertain, obviously should immediately open the abdomen to investigate the bleeding The short time for uterine surgery is small, but conoscopy surgery has its unique risk factors and complications in surgery Patient perioperative safety requires the anesthesiologist to maintain a high degree of vigilance during surgery, but also need to work closely with the surgeon during surgery