2 cases of airway management in tracheotomy surgery anesthesia

1General informationcases 1: patient, female, 47 years old, height 155 cm, body mass 58kg, car accident, concussion, left 6, right 4, 5, 6 rib fracture, pelvic fracture traction outside fixed 6d, chest CT prompt left lunginfection, respiratory department recommended tracheotomy to facilitate the gash -pulmonaryPatients enter ingested, naseury, pulse oxygen saturation (SpO2) 98%, blood pressure (BP) 140/80mmHg, heart rate (HR) 90 times/min, light sleep can wake up, Glasgow coma score (GCS) 10 points (M5V3E2), can be combined with the anesthesiologist's active opening of the mouth, negative pressure to attract the removal of oral fillet secretions, coughing thick, partly dry sputumopen venous channel, before the operation 15min micropump injection right metorite 120 sg/h, maintenance of 20 sg/h during surgery; Wake, retain autonomous breathing, local anesthesia under tracheostomy surgery, patients can listen to the instructions of anesthesiologists to complete trachea incision, 3 consecutive times into the trachea casing assembly failure (pull out the inner core no airflow), the patient's body movement is intense, BP raised to 200/105mmHg, Sp O2 dropped to 75%, suspended surgery, cleaned tracheostomy, local high-flow nasal catheter to oxygen (5-10L/min), intravenous labellor 7mg, 5min after SpO2 rose to 96, BP130/78mmHgsurgeons think that when placed in the trachea casing assembly, the formation of false passages, local edema, emphysema direction is not clear, it is difficult to re-place successThe anesthesiologist connected ID5.5's trachea catheter to the threaded tube, close to the tracheotomy, had the regular CO2 waveform appear, gradually deepened, the CO2 waveform disappeared, the patient became irritable, i.eexited the trachea catheter, and the CO2 waveform appeared againTry again, bend the front of the trachea catheter to make the insertion parallel to the chest wall, the patient cough, the blood-stained yellow pus gushing out of the trachea, the trachea suction clean-up, the connecting ventilator, synchronous auxiliary breathing, chest fluctuations, SpO2 quickly rose to 1 Exit trachea catheter, by the anesthesiologist follow the path smoothly inserted trachea casing assembly, pull out the inner core, threaded tube, the rule carbon dioxide waveform appears, fast injection mode pump refentanil 8 sg, intravenous dizosin 2mg, stitched fixedcases 2: patient, male, 57 years old, height 172 cm, body mass 80kg, cerebral hemorrhage (right base section bleeding), left open cranial hematoma removal after 12d, tracheotomy surgery 11d, tracheotomy hemorrhage, neck hematoma, hematoma, proposed trachea inlet general anaesthetic under trachea siesia, tracheotomy, trachea sleeve resetPatients are sober, GCS score 12 points (M6V2E4), tracheotomy, trachea sleeve in place smooth, deoxygenation SpO 298%, BP138/78mmHg, HR78/minReview medical history: patients after surgery hypoxemia, emergency tracheostomy, found throat edema, 2 attempts failed, changetracal incisiontrachea casing connected to ananesthetic ventilator to implement intravenous anesthesia, intravenous fentanyl 0.1mg, propofol 100mg, psychebenzene sulfonate ammonium 3mg, continuous micropump injection riffentani 300 sg/h and propofol 200mg/h Airway Management Scenario One: Try to insert the trachea duct with airbag ID5.0 from the trachea sleeve, resistance is high, attempt fails, give up Airway management scheme II: through the mouth video throat tube intubation Under the eyepiece will see anorexia pale, edema, "U" arc disappeared, will wear aversion to the lower tissue edema, did not see the forecourt crack, left and right acoustic, spoon-shaped cartilage and other structures appear, no exact crack revealed, deep revealed esophagus entrance (
stomach tube placed in) anesthesiologists based on clinical experience in the atire below the discovery of suspicious mucosal wrinkles, the center of the gathering place with a polyps "blood clots" protruding outwards, sputum tube traction but can not suck out, can not be ruled out is the last trachea tube damage of the mucous membrane, dare not force pliers out; ), large resistance, replace the more thin trachea catheter (ID5.0), pull out the guide wire, left and right rotation into, there is a clear sense of resistance breakthrough, insertion of the trachea , patient cough; Re-place the trachea sleeve, stitch it, pull out the trachea duct, bring out 2.0 cm x 0.8 cm blood clots, analysis caused by trachea cut opening bleeding retrograde into the sound door 2 Case Analysis Case 1: In the case of trachea incision completion can not be placed in the trachea casing assembly open airway, repeated attempts to form a false channel; You can also try to use a visual endoscope, which can display characteristic ring cartilage when entering the trachea, and then import the trachea duct or trachea sleeve from the tail end Hydrochloric acid right metomisurehashashashashashashashashashashasand has hypnosis, anti-anxiety, analgesia and other effects, but also has wake-up function, and rarely the occurrence of respiratory inhibition, is an excellent easy-to-wake ideal sedative pre-injection of 15min micropump 25 to 30 sg of right metoric, during the operation micropump injection of small doses of riffentani (200 ?g/h), effectively inhibit cough, irritability, body movement, etc., no obvious respiratory inhibition The patient car accident, concussion after admission 6d, GCS score 10 points (M5V3E2), can be ordered to cooperate with the anesthesiologist to carry out various operations, there is a lung infection, you can choose through the sound door tracheotomy intubation under the conditions of the fiber bronchoscopy local inflammatory clean-up, whether it is necessary to have tracheatos If the tracheotomy surgery, need more adequate preoperative preparation: atomization inhalation antibacterial anti-inflammatory, softening sputum, promote sputum, reduce the operation of sputum surgery affect surgery operation; Case 2: The general experience gained in Case 1, without screening, simple transplants into case 2, is the most common error in the clinical work Both the five doctors and anesthesiologists are committed to the idea that the priority of establishing the sound gate trachea intubation channel is the safest and most reliable clinical path for trachea casing component replacement Review the medical record, after the failure of the second trachea intubation to carry out trachea incision, trachea infection after bleeding edema, neck hematoma has been formed, the difficulty of trachea intubation through the sound door can be predicted, in the case of trachea cut casing open is the choice of the sound door trachea intubation is redundant; Without affecting trachea mouth cleaning and hemostatic surgery, consideration may be given to placing a trachea catheter through a gas incision (the guide core may be left before the tube change) instead of the trachea intubation through the sound door It is particularly important to develop the implementation plan of personalized anesthesia in the work of anesthesia If the anaesthetic path is not selected properly, even if there are skilled technical skills (such as case 2 through the sound door intubation technology), the wrong path of the operation itself will cause a certain degree of damage to the patient: aggravation of throat edema, delay the healing of the upper respiratory tract; The retention and maintenance of the original open airways in airway management is a top priority for anesthesia 3 Summary the main steps of tracheotomy: (1) tracheotomy, the patient can exchange gas through an open trachea vent; In the primary medical units, due to lack of systematic training, lack of clinical practical experience, after the completion of the first step, often blocked in the second step, repeated operation to form a false channel, resulting in tissue edema, local swelling, wound bleeding, blood clots and oral and pharynx secretions by mistake, blocking the trachea caused by asphyxia, endangering the patient's life in order to prevent such malignant events, in addition to improving the technical level of surgeons, the careful development of anesthesia implementation program is particularly important 3.1 priority to retain autonomous breathing priority to retain patients' independent breathing, can avoid the danger of emergency difficult air way treatment: retain self-breathing, tracheostomy after even if the opening is covered by blood pollution, there are still bubbles coming out, clean up blood stains, local high-flow oxygenation, patients can obtain adequate oxygenation, In preparation for further disposal, the surgeon can judge the position and direction of the trachea cut in the mouth according to the air flow, guide the correct placement of the trachea casing assembly, and after the trachea casing assembly is inserted and pulled out of the inner core, there is a high-speed air flow injection, otherwise further examination and confirmation of the trachea sleeve assembly insertion position is correct In order to avoid the formation of the airway, after confirming the trachea cut, priority is given to the fiber bronchoscopy guide insertion into the trachea duct, allowing sufficient time for the wound treatment, or placing the trachea sleeve directly under the guidance of the fiber bronchoscopy 3.2 trachea incision scheme under the sound door trachea intubation trachea intubation under general anaesthetic trachea incision surgery, revealing the trachea catheter catheter as a clear sign of trachea incision; The gas incision opens the back trachea duct (but does not exit the sound door), can see the trachea tube blue air bag slide from the trachea cut window and stay at the end of the head, if the trachea casing assembly fails, the trachea catheter is pushed to the far end, still can control breathing, to ensure the patient's life safety Qiu Baojun, etc proposed that in the trachea catheter built into the airway exchange catheter, the back trachea catheter can be observed through the airway exchange catheter to observe the patient's independent breathing, if necessary, injection ventilation or guide re-insertion of the trachea duct; Ensure scavemable trachea and trachea duct ingerified seamlessly Before the operation 10 to 15min to give 0.5 sg/kg of right metamine, combined with the use of trachea surface anesthesia, oral jaw facial tumor patients to implement wakeful trachea intubation, tracheotomy or transdermal dilated tracheotomy (PDT) can effectively inhibit the adverse reactions induced by injury stimulation, no obvious respiratory suppression, reduce adverse memory, hemodynamics more stable 3.3 trachea sleeve replacement scheme in the case of the original gas cut channel opening, (1) do a good job of cleaning the lower respiratory tract before surgery, atomizing, humidification, softening secretions, fully attracting sputum; When replacing the trachea sleeve, various types of trachea ducts need to be prepared The trachea casing is large in angle, close to 90 degrees, adult No 7 casing can only be placed in ID5.0 and below without a sac trachea duct, before placement, can use Lidocain gel to fully lubricate the outer wall of the trachea 3.4 Other prepared conduct a routine airway assessment of all patients who intend to have a tracheotomy prior to surgery, and equipment such as video laryngoscopes, visual endoscopes, ETView visual tracheotomy stubs, etc The visual laryngosis combined fiber bronchoscopy can improve the success rate of trachea in patients with obstructive sleep apnea (OSAHS) Some patients because of respiratory insufficiency or accompanied by lung infection, thick sputum blocked trachea, exhalation of the end of carbon dioxide waveform display irregularities, chest fluctuations are not obvious, combined with two-sided lung hearing clearly diagnosis , if necessary, the use of fiberbrongasoscope to clean up the trachea thick sputum or inflammatory secretions, improve pulmonary ventilation and oxygenation ensure that two negative pressure attractors are effective: all the way to the surgeon to clean up the surgical surface and trachea endocrine clean up; Two negative pressure attractors can be used simultaneously, non-interference Throat cover ventilation, storage Corning and other believes that obesity, neck short with OSAHS patients do tracheotochonis, is one of the best proof of throat cover full hemp, pediatric patients, neck burns patients, severe brain brain injury, brain vascular accident and other reasons caused by coma patients can also use throat cover full castor tracheotochoncut Oral throat and acoustic door above disease or anatomical variation, it is not appropriate to choose the throat cover ventilation full hemp surgery, sound door tumor, narrow and sound gate tumor, growth, foreign body blockage and other conditions also need to use fiber bronchoscopy, visual endoscope, video laryngoscopy and other technical examination, exclusion in short, the establishment of sound door or through the sound door trachea path can ensure the smooth progress of trachea incision surgery; In the process of the implementation of tracheotomy surgery anesthesia, priority is given to retaining the patient's independent breathing, adequate preoperative evaluation and preparation, designing personalized anesthesia program, protecting and making full use of the established airway open path, and avoiding the occurrence of emergency dangerous airways and high-risk tracheostomy