A case of parathyroidectomy in patients with Sagliker syndrome

The patient, male, 40 years old, 58 kg, was admitted to hospital with 19 months of bone pain associated with an elevated parathyroid hormonea history of hypertensionfor 7 years, up to 190/100 mmHg6 years ago due to "chronic renal failure (uremia period)" began to regular
hemodialysis, 2 years ago appeared bone pain symptoms, 19 months ago found that parathyroid hormone elevated, about 3,600 pg/ml, no treatment1 year ago the face began to deform, the current patient's jaw obviously protrusion, double bulge, nasal inset, lips can not be closed (Figure 1);laboratory examination: parathyroid hormone 5,000pg/ml, blood calcium 2.44 mmol/L, hemophosphate 2.14 mmol/L, potassium hemophos4.28 mmol/L, alkaline phosphatase 1 811 IU/L, red blood cell count 2.58 x 1012/L, Hb 68 g/L, Hct 0.22, blood cell average hemoglobin 6.pg2A-shaped side gland color over-the-counter: the lower back side of the lower thyroid leaf see the real-oriented hybrid echo, size of about 2.5 cm x 2.1 cm, morphological irregularities, the real part of the blood flow more, inside and see more than block-shaped strong echo, the middle side of the left thyroid leaf see low echo, size of about 1.59 cm x 0.64 cm x 1.26 cm, boundary clearThe lower left thyroid lobe is an echo of the same properties, about 1.5 cm x 1.4 cm in size, and more blood flowheart color overdisplay: two-tip valve front leaf valve root and rear lobe ring calcificationThe left room is enlarged, the left room is fat and diastotightHead CT show: The density increase was seen in the skull bone, in the subcutaneous soft tissue and in front of the front wall of the upper jaw sinus (Figure 2)bone density examination showed: lumbar spine, double-sided hip jointosteoporosisdiagnosed: Sagliker syndrome, chronic renal failureIt is proposed to monitor parathyroid excision in the whole hemp downstream nervepreoperative assessment: ASAIII, Mallampai IV, two horizontal fingers, and a distance of 7 cmPreoperative electron laryngoscope examination: will tire of good form, lift normal, tongue root lymphatic follicle growthHistory of renal failure,history of hypertensionHeart Function LEVEL IIIRegular preoperative fasting waterRegular monitoring after admission, BP 170/100 mmHg, HR 75 times/min, SpO2 99%, establishment of the left forearm venous pathway, perbureauation of the perm of the lower artery puncture tube, monitoring of invasive arterial blood pressure, monitoring of body temperature and BISPatients half-sitting, with dental protective gear, 1% dinka in the tongue root, throat surface anesthesia, 10 min after intravenous injection of midazolam 2 mg, shufentani 10 ug, retain the patient's self-breathing shallow anaesthetic, visual laryngos put into the mouth, the degree of sound door display level IIWithdrawal of the larynx, intravenous lysing aloof ammonium 3 mg, propofol 140 mg, shufentani 20 mg, 5 min after the trachea inlet back to the throat neuromonitoring trachea catheter, one success, the ventilator mechanical ventilation, VT 450 ml, RR 12 times / score, I:E 1:2inhalation of heptafluoroetheride to maintain anesthesia, heptafluee ether exhalation concentration 1.0 to 1-2 MACThe BIS value is maintained in surgery 40 to 60, BP 140 150/80 to 90 mmHg, HR 70 to 90 times/min, PETCO2 35 to 40 mmHgAfter the operation began, 35 min measured neuromuscular electrical signal value of 1306 ?V, intraoperative neuromyostosis monitoring smoothly, intraoperative blood gas analysis monitoring, while through arterial bypass blood pumping to monitor the level of parathyroid hormone, perioperative blood gas analysis results no significant change, the parathyroid altrui on the full removal of the parathyroid 30 min measured aparathyroidin level of 334.2 pg/ml, surgery duration of 3 40 minSurgical end of anaesthetic inhalation, after 8 min BIS return to 75, independent breathing recovery and open eyes, handshake strong, 10 min after ventilation returned to normal, PETCO2 35 to 40 mmHg, RR12 to 18 times / minute, BIS 90, conscious, fulls of sputum removal trachea catheter, observation 30 min after returning to the wardAfter the follow-up, the patient did not have nausea, vomiting, chills and other complications, incision VAS pain score of 2 points, after surgery 8 d discharged discussion 2004 Sagliker and other reports, in patients with chronic renal failure dialysis, due to parathyroid dysfunction, resulting in calcium, phosphorus metabolism disorders in the body, a series of changes under the bone membrane, resulting in a group of facial appearance changes mainly caused by the syndrome, and named it Sagliker syndrome The patient's face is mainly manifested as: the upper jaw is increased forward and down overall, the front of the lower jaw is increased vertically, which eventually leads to the patient's entire face showing a significant larger face height than before the onset of the disease, and the face is like a "hippopotamus" change due to facial deformities in the jaws of Patients with Sagliker syndrome, changes in oral structure, spongy skull bone, brittle bone, susceptibility to damage, as a predictable difficultaire At the same time, thyroid surgery under nerve monitoring requires the use of non-depolarized myocardine drug when induced by anesthesia to ensure the need for monitoring of neuromyostosis during surgery, as well as the accompanying symptoms of ion disorders caused by chronic renal failure, renal anemia, hypertension, and other symptoms, the of anaesthetic management increases In this case, the patient passed an electronic laryngoscope test before surgery to confirm that the patient would suffer from no change in the regional anatomical results According to the difficult airway management guide, the first surface anesthesia with the retention of autonomous breathing shallow anaesthetic method, line visual laryngostology examination, sound door visibility is level II, in order to meet the needs of nerve monitoring trachea catheter positioning, to give a small dose of shunaquku ammonium, tube intubation, not only to ensure the smooth intubation process, but also to meet the needs of intraoperative nerve monitoring anaesthetic maintenance phase using full inhalation of heptafluoroetherine, the patient naturally awakened, successfully completed the patient's anesthesia Sagliker syndrome is a special condition in the function of parathyroid glands, which should be paid more attention to in surgery by the anaesthetic management of parathyroidectomy (1) Due to abnormal calcium and phosphorus metabolism in patients, before surgery should pay attention to blood calcium levels, prevent heart rate disorders caused by high blood calcium (2) This type of patient is often accompanied by osteoporosis, spontaneous fractures, etc , so after surgery should gently move the patient, to prevent the occurrence of pathological fractures (3) This type of patient's jaw facial deformity, tracheotomy may be difficult, teeth loose, and the upper jaw connection is not strong, should be used to protect the teeth of the apparatus (4) These patients are accompanied by chronic renal failure, therefore, the principle of the application of narcotic drugs to minimize the damage to kidney function Tang's voice and other studies show that the above drugs were not followed by wake-up delay, respiratory inhibition and other complications (5) Such as the degree of sound door exposure for work or II grade, can be used throat surface anesthesia plus retain the method of independent breathing shallow anaesthetic, first visual laryngoscopy examination, understand the exposure of the sound door, the use of 1 x ED95 shun aquor ammonium with conventional dosepropofol, shufentani induction, not only to ensure the smooth intubation process, but also to ensure the need sediton of the surgical nerve myostology monitoring needs If the sound door is exposed to a level of III or IV, the use of fiber bronchoscopy can be inserted reinforced trachea intubation, which is consistent with the recommended method sandadima and other methods, in the course of thyroid doctors need to insert needle electrodes to complete the neuromyelity monitoring