A case of anesthesia management in patients with combined Bart syndrome thoracic conscoscopy lung wedge excision

Patient, female, 48 years old, 160 cm, 43kg, ASA CLASS IIIPatients with a history of renal abnormality for 18 years, kidney puncture biopsy prompted "cystic glomerular lesions, Bart syndrome." 18 years of history of hypokalemia, oral potassium chloride slow release tablet treatment, blood potassium control in 3.0 to 3.5mmol/LSelf-claiming potassium is as low as 2.1mmol/L, accompanied by symptoms of muscle weakness5 years ago due to hypocalcemia occurred systemic convulsions, calcium after treatment relief, after intermittent oral calcium chloride treatment, blood calcium control in the normal range14 years ago due to ectopic pregnancy all hemplaparoscopicright fallopian tube excisionThere is nothing special about the pasta year ago physical examination found the upper lung leaf shadow, considering tuberculosis may, in the outer hospital TB bacteria test (PPD) and radon-interferon release test (T-spot), the results indicate positive, the implementation of isoniazid, lifudin, left oxyfluoroxin triple anti-tuberculosis treatment for six months, no significant change in lung shadowIt was performed in this hospital in the chest mirror under the right lung upper lung leaf wedge excisionpatients admitted to hospital biochemical examination: potassium 3.1mmol/L, blood sodium 133.3mmol/L, blood chlorine 73.3mmol/L, blood calcium 2.45mmol/L, urea nitrogen 7.58mmol/L, creatinine 212.3 mmol/L, urea 721umol/L25-hydroxylvitamin D6.67 ng/ml (20 to 100ng/ml), full-section parathyroid initate 599.9pg/ml (12.4 to 76.8 pg/ml)The remaining laboratory tests were not unusualLung function is generally normal ECG, heart color super did not see abnormal, heart function grade I Chest CT shows the lesions in the upper upper lobe of the right lung, considering chronic inflammatory lesions There was no abnormality in the examination 1d intravenous potassium 1.5g before surgery, oral endoster 20mg BP 120/65mmHg, HR 60 to 70 times/min, SpO2 99% to 100% The left-hand elbow is a mid-venous puncture to establish an peripheral venous pathway, the left side of the line artery puncture is monitored by invasive arterial pressure, the artery pressure is maintained at 130 to 140/60 to 70mmHg, checkblood gas (Table 1) table 1 patient seisheophobes and biochemical indicators 1568155381902467.png anaesthetic induced midazolam 2mg, Shufentani 10 mg, relying on mister 8mg, propacophenol 40mg, Shun-Aquku ammonium 7mg Intravenous injection, waiting for the patient's consciousness to disappear, oxygen flow 5L/min mask ventilation, the left side of the throat mirror 35 double cavity bronchial catheter ization, depth of 26 cm, double lung ventilation two-sided breathing sound clear symmetry, single lung ventilation lung isolation is good, fiber bronchmirror to confirm the location of the double cavity tube is correct Mechanical ventilation oxygen flow 1L/min, VT320ml, RR 10 times/min, I:E 1:2, airway pressure 16 to 17 cmH2O connect FloTrac and BIS The patient is lying on the left side, anaesthetic maintains a continuous intravenous pump with propofol 22 ml/h, and a continuous intravenous pump of 15 ml/h Calcium chloride 1g continues to slow intravenous drip After single lung ventilation, mechanical ventilation VT250ml, RR 10 times/min, I:E 1:2, airway pressure 20 to 21 cmH2O In surgery to maintain PETCO2 36 to 38mmHg, BIS 45 to 50, per fight variation (SVV) 10% to 12%, heart displacement (CO) 2.6 to 3.8L/min surgery after the start of the addition of shun-type aquukammonium 2mg, surgical specimen after the removal of sputum puffed lung double lung ventilation, check blood gas (Table 1) The operation was carried out a total of 1h, the operation placed in the 28th chest cavity closed drainage tube one, inlet 1 100 ml of crystal fluid, urine volume of 100 ml, bleeding 20 ml Give Tramadol 100mg postoperative analgesia, the patient wakes up well, does not give muscle loose antagonist medicine, waits for the muscle strength of consciousness to recover, remove strain catheter, after surgery back to PACU The patient's postoperative vital signs were stable, there was no special body check, the blood gas was checked in the ward on the day of surgery (Table 1), and potassium chloride was 1.5g orally Potassium chloride 1g is taken orally on the 2nd day after surgery, and the chest cavity closed drainage tube is removed, and discharged from the hospital on the 3rd day after surgery discussion Bartter's syndrome with low potassium hypochloric alkali poisoning, increased hemoglobin, increased acetone, and plural glomerular hyperplifying and hypertrophy Patients usually have normal blood pressure and have no obvious reaction to the rise of angiogenesis strain II and norepinephrine drugs the disease is mostcommon in children under 5 years of age, the cause of the disease has not been determined, most scholars believe that it is autosomal recessive genetic disease, but also can be followed by a low-chlorine diet, chemotherapy and cystic fibrosis The incidence of Bart syndrome is only 1:1 000,000, which is extremely rare, and the associated literature on the treatment of the perinatal treatment of Bart syndrome patients is rare The only few documents do not address the post-surgery-related perioperative treatment of chest surgery in such patients Peres of the period of electrolyte, acid-base balance disorder, insufficient capacity, circulation fluctuations and kidney function are not all the focus of the of anaesthetic management Patients with Bart syndrome often come to the doctor for the first manifestation of hypokalemia It is generally believed that such patients have a barrier to the reabsorption of Na, Cl- and No treatment of Bart syndrome is mainly focused on hypokalemia, oral potassium supplementation is the most common treatment, but the efficacy is not necessarily accurate, because such patients to supplement potassium at the same time kidney tube potassium will also increase proportionally In this case, the patient regularly orwithted potassium or intravenously before surgery, even though the blood gas analysis of potassium is only 3.2mmol/L after entering the operating room Some scholars believe that for patients with Bart syndrome, potassium in the blood can tolerate surgery at more than 2.5mmol/L Considering the short duration of the procedure, hemopotassium 3.1 to 3.2mmol/L is also within the patient's daily blood potassium tolerance range, so there is no additional potassium supplementation during the procedure Of course, special attention should be paid to refractive arrhythmia caused by hypokalemia and the prolonged effects of non-depolarized myocardine patients with no such complications Low potassium alkali poisoning is also the main characteristics of Bart syndrome, this case of patients self-claimpH up to 8.2, although admitted to the hospital did not do blood gas analysis examination, after entering the operating room blood gas pH is 7.55, PCO2 52mmHg, for metabolic alkali poisoning compensating for respiratory acidosis status Overventilation should be avoided during surgery, as hypobicarbonate increases pH and further reduces potassium In this case, petCO2 36 to 38mmHg was maintained in both lung and single lung ventilation Although secondary renin and angiotensin secretion increased, blood vessels reacted poorly to them, so blood pressure was often normal Due to the Na-plus, Cl-reabsorption disorder, most of the patients are in a low blood volume state In the absence of contraindications, thoracic surgery often applies the anesthesia method of whole hemp joint high epidural analgesia, taking into account that the patient may have a low blood volume state, to avoid the epidural anaesthetic intercardinal nerve block caused by refractive hypotension, so there is no epidural analgesic Considering the thoracic surgery, the operation time is short, the pain stimulation is less, so there is no chest side obstruction However, this case patients do not have thoracic bypass taboo, if this technique, to avoid circulating fluctuations, reduce the amount of whole hemp drug, can better achieve the perinatal multi-mode analgesia Some scholars believe that the central vein puncture should be carried out during long-term major surgery, and CVP should be monitored and rehydration is convenient Vetrugno et al reported on a case of Bart syndrome anaesthetic management for cardiovascular surgery, and they recommend the use of invasive monitoring including CVP and pulmonary artery pressure for fluid management Nooh and others performed full hemp surgery for a patient with Bart syndrome in 2012, and given the low level of bleeding, they did not perform CVP monitoring, which provided hours of quick rehydration to patients before the start of the anaesthetic to avoid low blood volume during surgery Given the short duration of surgery in this patient, no central vein puncture was performed and replaced with Flotrac Some patients with Bart syndrome have oral angiotensin conversion enzyme inhibitors (ACEI) drugs to antagonistic synthesis of angiotensin, and the perination period should be guarded against the appearance of refractive hypotension due to renal tube insufficiency, patients sometimes have high urine calcium secondary low blood calcium clinical performance In this case, the patient had had convulsions caused by low blood calcium, and then intermittently treated with calcium chloride In-room blood calcium 1.09mmol/L, calcium chloride 1g continuous intravenous drip, blood calcium 1.34mmol/L before the chamber The patient's preoperative biochemical display of renal insufficiency, so the muscle pine medicine chose the smooth aquoramto, which was metabolized by Hoffman Anaesthetic management in patients with Bart syndrome is a challenge for anesthesiologists Understand the patient's preoperative medication, potassium supplementation Close capacity monitoring, if necessary, deep venous tube Intravertebral anesthesia should be careful, beware of the emergence of refracted hypotension anesthetics should choose the drug that has the least impact on kidney function There should be invasive arterial pressure monitoring, real-time monitoring of blood pressure and blood gas The perioperative period should pay attention to the regulation of electrolyte acid-base balance, but in fact, due to renal tube dysfunction, discharge is greater than intake, it is difficult to adjust the electrolyte to the normal range Beware of complications such as refractive arrhythmia caused by electrolyte acid-base balance disorders