A case of reflux under general anaesthetic in elderly patients with chronic gastritis

Chronicgastroenteritis is a commondigestivesystem disease inclinicalStudies have shown that chronicgastriccan cause delays in gastric emptyingGastric drainage delay is one of the high risk factors of gastric content reflux and mis-suction, which increases the risk of reflux and mis-suction during general anesthesiaAt present, there are few reports of such cases at home and abroadThis paper reports on a case of elderly female patients who have a preoperative combination of chronic gastritis during general anesthesia,clinicaltreatment and re-return, analyzes in detail the possible causes of reflux misabsorption, summarizes experience, and provides reference for clinical1Medical records summarypatient female, 78 years old, body mass 46kg, preoperativediagnosis: gallbladder stones associated with inflammation, intended in the Opler larynx general anesthesia under the glandal excisionPatients have a history of chronic gastritis for 11 years, when feeling full of discomfort, intermittent medication, 1 month ago in a three-a hospital gastroscopy examination show chronic superficial gastritis accompanied by erosion, deny inglion sonofly medical history of other systemspreoperative laboratory examination, chest tablets, electrocardiograms, heart color super did not see obvious abnormalitiesPatients regularly fast for 10 hours before surgeryThe chamber monitors vital signs, body temperature of 36.5 degrees C, heart rate 93 times/min, 16 times/min breathing, blood pressure 129/67mmHgAnesthetic induction: static injection Medaaalen 2mg, Shufentani 20 mg, relying on miede 10mg, Viku bromine 5mg, 3min after the smooth placement of the mouth into the 4 - Opal larynx cover, double lung hearing breathing symmetry, no dry wet sound, stomach hearing unheard and air water soundSet moisture volume 400ml, breathing rate 13 times / minute, anaesthetic maintenance: intravenous pump propofol 4 to 6 mg / (kg-h), Riffentani 0.10 to 0.15 sg / (kg ?min), interval 40min static injection viku bromine 2 mg, after anesthesia 30min artery blood gas analysis: pH7.36, PO2 421mmHg, PCO2 38mmHg, HCO3-22.1mmol/L, SPO2100%, patient moisture volume 395 to 410ml, airway pressure 14 to 17 cmH2O, surgery time 2 hours 10 minutesstatic injection of Andansjong 4mg, to the total dose of propofol 460mg, Riffentani 1mg, Viku bromine ammonium 9mg, good intraoperative muscle pineSuture end stop pump intravenous anaesthetic, 7min after the patient's independent breathing began to recover, static injection Atropine 0.5mg, Xins Ming 1mg antagonist muscle pine, 1min after the patient's intolerance throat cover, moisture reached 380ml, breathing frequency 14 times / min, exhaling can open eyes, pull out the larynx cover, see the front cover has a coffee-colored liquid Attached, considering gastric contents reflux, to the throat attraction, absorb ingefluids about 5 ml, mask oxygen absorption (FIO2 80%), 2 minutes after SPO2 began to drop to 88%, patients slow response to stimulation, give the mask pressure to oxygen SPO2 rose to 92%, stop rising, airway resistance is great, double lung hearing all over the wet Luoyinconsider the gastric contents reflux mis-suction, leading to acute respiratory distress syndrome, the patient's head low foot high head left side, throat again attracted to suck out the coffee-colored stomach contents about 20 ml, rapid trachea intubation, through the trachea attracted out of about 10 Ml coffee-colored liquid, then intravenous injection of methylene nylon sodium amber at 40mg, ammonia mosobase 0.25g static drops, fiber mirror underthearchised trachea and bronchial saline 10ml repeatedly washed, until the absorbed liquid colorless transparentExhalation of the end of positive pressure (PEEP value 5 cmH2O) mechanical ventilation, airway pressure 28 cmH2O, urgent blood gas analysis: pH7.23, PO2 68mmHg, PCO2 51mmHg, HCO3-21.4mmol/L, SPO2 89%, put in the gastric tube, about 200ml of coffee contents absorbed by gastric tubeAfter about 45min, the patient can open his eyes, SPO2 98%, double pulmonary wet tone is less than before, review blood gas analysis: pH7.28, PO2 125mmHg, PCO2 45mmHg, HCO3-21.9m/L then turn ICU to continue breathing machine support treatmenttreatment such as anti-
infection , correcting internal and environmental disorders, 14h patients fully recovered consciousness, double lung wet tone disappeared, checked blood gas analysis: pH7.44, PO2 89mmol/L (FIO233 33%), PCO2 38mmol/L, HCO3-25.1mmol/L, SPO2 97% Remove the trachea catheter, 22h after transfer to the general ward, 13d after the patient recovered discharge 2 Discussion patients with chronic gastritis have gastric function and power disorders, which causes the gastric emptying to be significantly delayed The stomach intestinal blood flow decreased in elderly patients, the gastric mucosa had some degree of atrophy, and the gastric emptying time was prolonged Although the patient fasts for 10 hours, he may still be full of stomachs The patient has a history of chronic gastritis for many years, sucking out the stomach fluid for coffee color, the patient may have gastric mucosa bleeding, causing an increase in the amount of gastric fluid When the mask is positively pressed to oxygen, some of the gas may enter the stomach, forming acute gastric gas, resulting in an increase in intra-gastric pressure and increased reflux risk surgery to squeeze the stomach area, which can also cause the contents of the stomach to reflow During the patient's awakening, the depth of anesthesia is reduced, sputum suction operation can cause reflux misabsorption In addition, when removing the larynx, the patient's degree of sobriety is not good, the pressure of sphincter under the esophagus and the protective reflex of the upper airway are not fully recovered, which is easy to cause the occurrence of misabsorption after reflux Reflux missuction is a serious complication during anesthesia, and reflux missuction may cause airway obstruction, Mendelson syndrome, inhalation pulmonary instruos and other serious complications of the lungs, resulting in a 30-day mortality rate of 44 percent for inhalation pneumonia in elderly patients After the occurrence of reflux should be used fiber-optic mirror deep to reach all levels of bronchial examination and remove the mis-sucking gastric fluid and eating water and other solids and physiological saline 5 to 10 ml by the fiber boshiman into the trachea, side injection, side suction, repeated flushing, so that can dilute or rinse off the misabsorbed acid gastric fluid, can effectively prevent and reduce the occurrence of various lung complications after mis-suction studies show that the throat cover application of whole hemp ventilation is safe and reliable, can significantly reduce the heart vascular response, and less complications, especially in elderly patients The main contraindications of the larynx cover are patients with high risk of gastric content reflux, such as full stomach, cleavage of combined severe gastroesophageal reflux, morbid obesity, intestinal obstruction, etc The patient's long history of chronic gastritis, the existence of gastric emptying delay, is the main cause of the patient's reflux misabsorption Bedside ultrasound gastric content assessment technology is a newly developed method, with non-invasive, fast and accurate characteristics, can reflect the nature of gastric content, and can assess the stomach capacity, guide the risk of reflux misabsorption assessment In addition, acute gastric gas is also a high-risk factor for reflux mis-suction, the study found that during the general anesthesia induction, pre-oxygenation without positive pressure ventilation, the impact of changes in stomach volume is minimal, reduce the probability of acute gasation during anesthesia induction, thereby reducing the risk of reflux mis-suction in summary, chronic gastritis patients may have gastric emptying delay, stomach residual fluid increase, although strictpredes before fasting, may still be "full stomach" state, increase the risk of reflux in the whole hemp process, before surgery should fully assess the risk of reflux mis-suction and carefully select the throat cover full hemp