2 cases of reflux of anaesthetic-related gastric contents in patients with elderly emergency surgery

Gastric reflux and translution (regurgitation and aspiration) is a very serious anaesthetic-related complication during the perioperative periodThe study shows that the incidence of misabsorption during anesthesia is 1/6500, and emergency surgery is one of its main risk factorsWith the aging of the society, the proportion of elderly emergency surgery patients increased year by yearDue to the reduction of gastrointestinal function, prolonged gastric drainage time and comorbidities in elderly patients, the risk of gastric content reflux and mis-suction during anesthesia increasesWe deal with 2 cases of elderly emergency surgery patients who experienced reflux misabsorption during anesthesia, as reported below1Clinical datacases 1, male, 80 years old, height 171 cm, weight 80 kgDue to "gallbladder stones, acute gallbladderitis" on December 26, 2016 emergency full-hemp hypothromycone gallbladder excisionPrevious history of reflux esophagitis, Barrett esophagus, chronic atrophic gastritis and atrial fibrillationchest (Figure 1A), echocardiogram and other auxiliary examination did not see significant abnormalitiesB overindication gallbladder increase of about 11 cm x 4.6 cm, CT shows gallbladder stones, gallbladder volume increase, part of the intestinal tube gasPreoperative retention gastric tube, fasting 12h, forbidden drinking 8hInto the operating room, monitorblood pressure 128/90mmHg, heart rate 93 times / min, pulse oxygen saturation (SpO2) 95%, negative pressure attractor suction tube and connect the drainage bag, mask to oxygen denitrogen, followed by static propofol 90mg, relying on the ester 16mg, Shufenteni 15 mg, Roku bromine 50mg fast inlet tubeDuring the mask-assisted ventilation process, the right mouth angle flows out of the stomach contents, immediately turns the head to one side, and at the same time adjusts the operating table from flat position to the high head and low feet, attracts the reflux of the pharynx, and places ID8.0 trachea duct tube under the Exposed Sound Door of the Macintosh direct throat mirror, and the trachea jacket sac injection Gas, in-line trachea attracted after the ventilator control breathing, oxygenation index (FiO2) 100%, moisture volume (Vt) 560ml, respiratory rate (RR) 12 times/min, exhalation end CO2 pressure (PETCO2) 35mmHgThe veins are given 10mg of dexamethasone, cephalosporine shubatan 3g added to 100 ml of physiological saline veins Fiber bronchoscopy checks visible trachea and right main bronchial mucosa with a pale yellow liquid, absorbing part of the secretion immediately line arterial puncture tube monitoring of invasive arterial blood pressure 117/55mmHg, heart rate 72 times / min, SpO299%, arterial blood gas analysis show pH 7.33, carbon dioxide pressure (PaCO2) 48mmHg, oxygen fractional pressure (PaO2) 137mmHg, arterial oxygen saturation (SaO2) 99% Continue the operation Intraoperative anaesthetic maintenance: 1.5% to 2% heptafluorane, rifentani 400 sg/h, intermittent addition of rocum bromide 20mg maintenance muscle pine the operation went well and the operation lasted 95min The chest tablets before the operating room showed double pulmonary oozing lesions, full of heart and shadow, a small amount of chest fluid on the left side (Figure 1B); With trachea catheter into the ICU, using synchronous intermittent instruction ventilation and pressure support ventilation (SIMV-PSV) mode mechanical ventilation 24h, intravenous cephalosporine ketone shubatan (3g, 8h once) anti-
infection 1 day, ammonia bromide sputum and other treatment Blood routine white blood cells 13.73 x 109/L after entering THE ICU, centilobin cell percentage 91.6% The trachea catheter and gastric tube were removed on the second day after surgery and transferred back to the general ward On the 4th day after surgery, the chest tablets showed the double pulmonary oozing lesions before the previous absorption (Figure 1C), the blood routine was normal on the 5th day, and the patient was discharged from the hospital on the 10th day Followed up for 6 months without any complications Figure 1 case 1 preoperative chest (A) suggests increased double lung texture, left upper lung hard knot tinge, left lower lung strip, left pleural thickening; Heart full, left rib angle fuzzy; the fourth day after surgery chest (C) suggests increased texture of the double lung, fuzzy, double lung spot-like fuzzy shadow decreased from the previous, the right lung door slightly blurred cases 2, female, 77 years old, height 153 cm, weight 55kg Due to "right groin inline ton" June 25, 2015 emergency row groin repair surgery There is hypertension, coronary heart disease, cerebral infarction, neck artery stent placement 5 months after surgery, oral sulphate clopidogrel 75mg 75mg daily, not stopped the drug The auxiliary examination of chest tablets (Figure 2A) and echocardiogram did not show any obvious abnormalities Full stomach before surgery, do not drink 2h Emergency room, monitoring blood pressure 146/77mmHg, heart rate 72 times/ min, SpO2 99%, mask oxygen absorption, intravenous giving midazolam 2mg, in ultrasound guide down the right abdominal transverse muscle plane block (transversus abdominis plane, TAP), anaesthetic medication is 0.3% ropone cadine 30ml After the success of anaesthetic, disinfection clothing, suddenly the stomach contents reflux, immediately turn the head to one side, the operating table from flat position to the upper foot, and with an attraction to attract the throat, at this time blood pressure 137/62mmHg, heart rate 72 times / min, SpO2 95%, listen to the right lung can smell and snarl Continue the operation The probe found that intestinal necrosis, the need for partial intestinal excision, changed to trachea intubation of full hemp Anaesthetic induction before the retention of the gastric tube, with a negative pressure attractor to suck the gastric tube, attract the contents of the stomach about 1000 ml, connect ingeliation bag rapid sequential induced intubation (rapid sequence induction and intubation, RSII), pre-given oxygen 5min, then given propofol 60mg, relying on the ester 10mg, Shufentani 10 mg, Rocum brominib 40mg backline trachea intubation, placed ID7.5 trachea duct, trachea sac injection, The trachea attracts the back-up ventilator to control breathing, FiO2 100%, Vt400ml, RR12/min, PetCO2 38mmHg, instant artery puncture tube monitoring of the invasive artery blood pressure 140/58mmHg, heart rate 67 times/min, SpO2 100% anaesthetic maintenance: 1% to 1.5% heptafluorane, rifentani 200 sg/h, intermittent addition of rhododendron ammonium 10mg maintenance myumazole Immediately after the operation, arterial hemogas analysis pH 7.45, PaCO2 42mmHg, PaO2 172mmHg, SaO2 99% The operation went smoothly, with a time of 190min and a tracheotomy into the ICU Blood routine white blood cells 10.02 x 109/L after entering ICU, 90.5% of neutrophils, arterial blood gas analysis pH 7.48, PaCO2 34mmHg, PaO2 76mmHg The bedside chest disc suggests the fluid build-up in the lower right lung and chest cavity, and the lower right pneumonia (Figure 2B) Ventilator-assisted breathing for 4 days, SIMV-PSV mode, SpO2 98% to 99% Intravenous cephalosporine shubatan (3g, 8h) anti-infection for 4 days, acid suppression, rehydration, nutrition therapy On the 4th day after surgery, the fluid in the lower right lung and chest cavity gradually absorbed, oozing changes than before the improvement (Figure 2C), normal blood routine, the 5th day of removal of trachea catheters transferred back to the general ward, the 9th day discharge Followed up for 6 months without any complications 2 cases 2 preoperative chest (A) suggest spotting increased double lung texture, right upper lung visible in the speckled high density shadow, right lower lung see cable shadow; Corners blurry, shallow blunt; the 4th day after surgery chest tablets (C) prompt the right lung multiple patch-like fuzzy shadow before absorption, two-sided rib angle sharp 2 discussion oral pharynx secretions or stomach contents into the lower respiratory tract is a common complication of critically ill patients, can lead to pneumonia or lung infection Anesthetic patients due to sedation or consciousness loss, esophagus sphincter tension reduced, and the throat protective reflexes are inhibited, so gastric content reflux is a high-risk group This group of example 1 reflux misabsorption occurs during the whole hemp induction period, and case 2 occurs after the decline of the state of sedation consciousness Depending on the nature of inhalation, the amount of inhalation, the frequency of inhalation and the body's response to the inhalation, different lung complications, such as airway obstruction, chemical pneumonia or acute respiratory distress syndrome, can be induced by cardiac arrest in severe cases the group of 2 cases of missofed gastric contents were significantly reduced by arterial hemooxygen fractionpressure (PaO2 dropped to 109, 76mmHg at the end of surgery), pulmonary osmotic changes, white blood cell count and neutrophil proportion increased, indicating that inhalation damage lung foam-caarline vascular barrier leading to acute pulmonary wound lung damage (acute lung lung, ALI), , and anti-
Most patients with anaesthetic do not experience misabsorption events, indicating the existence of a variety of induced factors that promote the occurrence of reflux-related reflux inhalation of anaesthetic, including gastroesophageal reflux disease, esophageal motor dysfunction, dysphagia, diabetes , gas or other gastric empty delayed signs, esophageal cancer obstruction, emergency surgery and satiety 2 emergency surgery in this group, case 1 combined with reflux esophagitis, case 2 full stomach and inline intestinal tube, all significantly increased the chance of anesthesia-related reflux inhalation Therefore, for emergency surgery of elderly patients, preoperative should focus on whether patients have risk factors for reflux and transverse suction, and then take appropriate prevention measures to reduce reflux of gastric content The anaesthetic treatment of elderly patients with high risk factors for the reflux of the gastric contents of the emergency department is very difficult The main measures to reduce the reflux of gastric contents include controlling the amount of gastric content and the of airway management Preoperative fasting is a commonly used method to control the amount of stomach content, however, for emergency surgery, it is often not possible to reach the time required for elective surgery fasting fasting, and there is no uniform standard for people with reflux risk factors preoperative placement of gastric tube drainage is another way to reduce the amount of gastric content, but there is no prospective and randomized controlled study to evaluate its effect A retrospective analysis of 85,000 anaesthetic cases over 5 years, 25 of which occurred by missuction, all of whom were all hemp patients, and the incidence of emergency surgery was four times higher than for elective surgery, but unless enterost obstruction was suspected, even in emergency patients, there was no evidence to support the routine placement of gastric tube drainage before surgery RSII and sobriety intubation are commonly used to control airway anesthesia in reflux and mis-suction patients this group of example 1 although fasting 12h before surgery, drinking 8h, and placegastri tube drainage, using conventional induced intubation method sier still occurs reflux misabsorption, suggesting that for the existence of reflux risk factors for high-risk patients need to be treated with caution If the patient adopts RSII, it is possible to avoid the occurrence of missuction Example 2 full stomach, consider the comorbidity, anticoagulant drugs are not discontinued, so tap blocking, however, in the delay of reflux misabsorption, consider with the application of medatamylenh sedation, the patient's state of consciousness decreased, the throat protective reflection weakened Therefore, for such patients, the regional block anesthesia should be used with caution sedatives In addition, due to the patient's surgical changes and the implementation of general anesthesia, so after placing gastric tube drainage to reduce the amount of stomach content, the use of RSII to control the airways, to avoid reflux misabsorption after the occurrence of accidental suction needs urgent treatment, first of all, the patient is placed at the low head, the situation allows the head to be tilted to one side, as far as possible to suck out the oral and throat reflux, if the misabsorption occurs in the whole hemp induction period immediately line trachea tube control airways If the accidental suction is particley, it needs to be sucked out under the bronbron mirror Antibiotic treatment is generally the primary supportive treatment and is not recommended because the routine application of antibiotics in the acute stage does not improve prognosis and the use of glucocorticoids is currently controversial for acute lung injury caused by accidental inhalation, mechanical ventilation support treatment is required Reduce the fatality rate by 10% with a low moisture volume (6 ml/kg depending on weight) and low ventilation in the case of allowed hypercarbonemia Two cases in this group took the above-mentioned measures and were discharged from hospital due to the need for antibiotic treatment due to surgical conditions in general, although the overall incidence of reflux and miscurrent of anaesthetic-related gastric contents is low, for elderly patients with emergency surgery, there should be a full assessment of the existence of risk factors for induced reflux and mis-suction, and appropriate measures to be taken