A case of misabsorption of lung during general anaesthetic of the SLIPA larynx

1Case Introductionpatient, male, 13 years old, height 165 cm, weight 58 kgDue to "the congenital ness of the left lower extremity
vasculardeformity with ulcer" was admitted to the hospital on November 4, 2017, the proposed general anesthesia down "left lower extremityvascularintervention embolism"Preoperative medical history, physical examination (check body), auxiliary examination are not specialthe patient's information and confirm that the fasting time has exceeded 8h, monitor pulse oxygen saturation (pulse oxygen saturation, SpO2), non-invasive arterial blood pressure, electrocardiogram, establish intravenous channels and start anaesthetic induction: intravenous midazolam injection 2mg After the injection of the sufentanil 20?g, the injection of the ammonium 9mg of the panphenyl sulfonate, the 90mg4min of propofol injection, insert the throat cover of the 49-slipatATM (the Stream liner of the Pharynx Airway)Placed in the larynx cover can be seen in the mouth overflow about 20mL clear liquid, fully attracted after the intravenous injection of acetate ethyl ether injection 0.4mg, using the anaesthetic machine pressure control mode ventilation, parameters set to: suction oxygen concentration (fractional concentration of inspired inspired oxygen oxygen) 50%, FiO2) 50%, breathing rate 12 times/min, airway pressure 12 cmH2O (1 cmH2O - 0.098kPa), suction ratio 1:2, moisture volume 400mLInhalation of 2% heptafluorane, supplemented by hydrochloric acid right metamine injection continuous pump injection to maintain anesthesiabefore the operation to place the left body slightly cushioned high body position, airway pressure suddenly increased to 25 cmH2O, moisture volume is only 250mL, immediately adjust the position of the larynx but the ventilation effect is not improved, and the airway pressure continues to increase to 30 cmH2O, moisture volume to 150mL, SpO2 from 100% to 75%Immediately remove the laryngeal cover and change the trachea intubationThe intubation process sees the cavity of the mask cavity and the patient's mouth and overflows with clear liquid about 25mLFully attracted to 6L/min pure oxygen mask hand-controlled ventilation, resistance is greaterThe ventilator uses a pressure mode to control ventilation, with a limit of 35 cmH2O, a frequency of 12 times/min, and a moisture volume of only 200mLSpO2 gradually recovered to 83%, exhalation end carbon dioxide pressure (partial pressure of end-tidal carbon dioxide, PetCO2) 60mmHg (1mmHg -0.133kPa)check body: the patient's right chest wall collapsed, the mechanical air-to-air degree significantly weakened, the rib gap narrowed; An X-ray chest perspective shows that the right side of the full lung becomes smaller, the light transmission decreases, and the trachea and heart move to the right (Figure 1a)Fiber bronchoscopy check left lung no abnormality, right lung no foreign material and viscous secretions, only a small amount of clear liquidConsidering it all as right lung dissonance and hypoxemiaTreatment methods: (1) physiological saline right lung irrigation; (2) injection with methyl-sprinklenylon sodium amber at 80mg, Psiemi 5 mg intravenous injection; (3) the use of anaesthetic machine to implement pulmonary resuscitation 3 times; (4) ventilator mechanical ventilation increased exhalation of the end of the positive pressure (positive-enda pressure, PEEP) to 12 cmH2OAfter 10min, ventilation improved, SpO2 rose to 92%, lung compliance improved, airway pressure gradually decreased, moisture increased, PetCO2 dropped to 55mmHgBut again X-ray chest x-rays show that the right lung has not been re-opened (Figure 1b)The trachea duct was inserted into the right main bronchial tube under the guidance of a fiber bronchoscopy, and the pulmonary resuscitation was carried out 3 times in a row using 30 cmH2O pressureAfter 5min X-ray chest perspective: the right lung transmission significantly improved, the right lung has been re-opened (Figure 1c)And SpO2 immediately rose to 95%, airway pressure gradually reduced to 20 cmH2O, moisture volume rose to 350mL, PetCO2 gradually decreased to normalTemporarily cancel the operation and continue with the ventilator support treatment 4hThe patient recovers from his own breathing, turns to the anaesthetic recovery room, is completely awake and successfully removes the trachea catheter and returns to the wardAfter 2 weeks, the patient under the trachea intubation and the throat cover under general anesthesia performed 1 operation, all of which were not special, 1 month after recovery and dischargeFigure 1 Patient chest X-ray image aImmediately after tracheotomy intubation, the right lung is visible, and with the right rib gap narrows, the trachea, vertical and horizontal shift to the right, the right shin muscle is raised, the left lung substitute emphysema; After treatment of comprehensive measures such as fiber bronchoscopy and attraction, technique pulmonary rescopy, PEEP positive pressure ventilation, it is visible that the right lung has not been re-opened; c after the one-sided bronchial intubation and positive pressure technique lung resuscitation, it can be seen that the right lung has been re-opened 2 Discussion of the use of laryngeal masks for general anesthesia, has generally become a commonly used short surgery a of ventilation management SLIPATM larynx is a pre-shaped, inflatable-free sound door ventilation device based on anatomical structure, which is widely used in many large medical centers at home and abroad, especially in China Although the body has been designed to accommodate a cavity that can accommodate liquid, theoretically to maximize the prevention of reflux and misabsorption, but such a laryngeal cover shape fixed and hard texture, throat cover model selection or /and anaesthetic during the hood shift can seriously affect its airway isolation and confined effect, so THE SLIPATM throat cover during general anesthesia reflux misabsorption occurs In this case, the oral and pharynx secretions occurred during general anesthesia of the SLIPATM larynx, causing the patient of acute right lung incongruity to conjugate hypoxemia, and the patient sit in the SLIPATM laryngeal mask after general anesthesia developed hypoxemia and hypercarbonemia After clinical performance, chest X-rays and fiber bronchoscopy, diagnosis reflux error caused acute pulmonary insacphyding (inhalation pulmonary influx) is clear The treatment of comprehensive measures such as fiber bronchoscopy flushing and attraction, pulmonary resuscitation, PEEP positive pressure ventilation, etc., was not effective After the one-sided bronchial intubation, positive pressure lung resuscitation, the treatment effect is satisfactory the pressure of the esophagus sphincter under general anaesthetic decreased by up to 15%, increasing the risk of reflux the stomach of , with the incidence of misabsorption of the first generation of laryngeal hoods being about 0.02% In this case, there is a large amount of secretion in the mouth and throat of patients, moving the position in the operation process, resulting in secretions along the laryngeal hood and sound door gap with breathing air flow into the airways, with gravity into the right main bronchial tube and its branches, the occurrence of non-solid substance trace misabsorption, blocking the right side of the lung all bronchial system, resulting in acute right pulmonary incontining and hypoxemia At present, domestic and foreign cases of laryngeal shroud causing micro-inhalation of non-solid substances caused by acute pulmonary insrephis are very rare The patient's treatment is difficult is: pull out the SLIPATM larynx tube tube positive pressure ventilation, still can not make the wilted side lung resuscitation, can not guarantee satisfactory ventilation and oxygenation Theoretically normal people have about 86% of the lung reserve function, so only one side of the lung ventilation can maintain normal oxygenation, however, this case patients alone in one side of the pulmonary ventilation oxygenation is difficult to maintain, the main reasons are the following two aspects: (1) the right lung continued to have more blood flow; the corresponding pathophysiological mechanisms of are as follows: (1) the left breast of the patient is higher than the right side, the right lung is affected by gravity factors and more blood flow persists; The two-sided ventilation technique lung recombination is invalid, may be because the left lung and the right lung at the same time receive positive pressure, the left lung compliance is better, weakening the expansion effect on the right lung for this situation, decisively put the trachea catheter into the patient side (right) targeted right lung pressurized ventilation, not only can prevent the ventilation pressure is too high to cause damage to the left lung, but also locally increase the right lung pressure, is a simple and effective treatment Through the treatment and rescue of patients in this case, we believe that the use of laryngeal hoods (especially inflatable laryngeal hoods, such as SLIPATM) for a longer period of mechanical ventilation, should pay attention to the following points: (1) Although the larynx cover to the airway stimulation is minor, the anaesthetic depth requirements are low, can be used to retain the auxiliary ventilation of autonomous breathing, but when autonomous breathing throat muscle tension increases and difficult to avoid swallowing reflexes may cause the throat cover to shift, so the optimal throat pressure mode The best ventilation gas position of the larynx is flat or head high and low on the back, so it is necessary to strictly grasp its indication and contraindication evidence when using the larynx for mechanical ventilation; (2 ) closely monitor the ventilation situation in the operation to detect the occurrence of reflux miss early; (3) if reflux missishes are suspected of occurring, should promptly check the body and listen to the double pulmonary respiratory sound; ;( 5) early chest X-ray to confirm the diagnosis; (6) timely replacement of the larynx with trachea intubation, to ensure effective ventilation and respiratory treatment, such as pulmonary recombination; (7) early adoption of comprehensive treatment measures, such as full attraction, oxygen absorption, addition PEEP, intravenous glucocorticoids, if necessary bronchoscosis irrigation, (8) early use of the affected side bronchial intubation for the patient side technique pulmonary resuscitation; (9) when the lung is resuscitated, respiratory support treatment of 2 to 4h is necessary in short, the use of larynx cover general anesthesia, should attach great importance to reflux and mis-suction caused by lung insepity, anesthesia before the use of drugs to reduce respiratory secretions, close observation, early detection of early treatment of hypoxemia is particularly important