A report on the management of epilepsy lesions and anaesthetic in children with a combination room interval defect

The patient is 2 years old, body mass 11kg, height 80 cmDue to "seizure convulsions of more than 1 year and 10 months" on January 7, 2016, diagnosed as a symptomatic epilepsy, the proposed epilepsy lesionsThere has a history of congenital heart disease, for central room space spacing defects (left-to-right shunt)admission: clear mind, mental response, HR100 times / min, blood pressure 85/50mmHg (1mmHg - 0.133kPa)The heart is strong, the heart rhythm is consistent, and can smell and the second heart tone of the pulmonary artery valve hearing area, and fixed split, contraction period blow-like noiseThere were no obvious abnormalities in the nervous systemAuxiliary examination: EEG show the left forehead of the seizure period, a large number of sharp waves in the precinics region, sharp slow wave intermittent bursts; Echocardiogram congenital heart disease, central room space gap defect 12mm (left-to-right shunt), room interval expansion tumor tri-tip valve reflux (mild), blood score of 74%Afterthe child entered the chamber, the patient was given 20 mg intravenous injection of methyl-spraying nylon, the ustartadin5000U intravenous injection, followed by a punctured tube of the artery, and monitoring the blood pressure and pulse pressure variation of the artery (pulse force dhof, PPV)Anesthetic induced the use of fentanyl, propofol, rocum bromide ammonium, tube intubationInduced post-cervical venous puncture tube, open central intravenous infusion pathway and monitor CVPanaesthetic maintains the continuous pumping of propofol and riffintaniThe tMA load is given to 10 mg/kg, followed by 5mg/kg-hThromboelastogram, TEG when the epidural is closed: reaction time 6.4min, maximum blood clot strength 45mm, coagulation factor activity and fibrinpygenic levels are normalThe operation lasted about 8h and the amount of bleeding during the operation was about 75 mlPostoperative analgesia using a multi-mode analgesic regimen, i.e to give 1mg/kg of sodium perise/kg when sewing the epidural, and 0.15% of the incision to give 0.15% of the roponicain 10 ml of local immersion The catheter was removed, the child's vital signs were stable, returned to the ward, and 7d was discharged smoothly after surgery discuss
this case of children combined room interval defects, before surgery should be detailed medical history, a comprehensive assessment of heart function Due to the presence of 12mm central room space dissonance (left-right shunt), surgery should prevent due to the pulmonary artery pressure significantly increased reversal to right-left diversion and abnormal air embolism, can take the following measures: (1) preoperative implementation of basic anesthesia, after surgery to give multi-mode analgesics, to avoid restlessness; Pulmonary inflated blood vessels; (3) through target-oriented liquid management, to give appropriate liquid load, to protect microcirculation perfusion; (4) intravenous infusion and intravenous administration are strictly excluded from bubbles; (5) placement to avoid the child's head higher than the heart level; (6) in the operation, surgeons should adequately stop bleeding, to avoid gas damage through blood vessels into the vein system at the same time, anesthesiologists also need to pay attention to the presence of upper respiratory tract infections in children, as room gap defects can lead to pulmonary circulation congestion, elevated pulmonary artery pressure, will increase the risk of pulmonary infection during perioperative surgery In addition, long-term use of anti-epileptic drugs can lead to liver damage, reduction of whole blood cells and abnormal clotting function, before surgery should pay attention to the evaluation of blood biochemistry, blood routine and clotting indicators In terms of anesthesia induction, due to the majority of anti-epileptic drugs can cause changes in the body quality of children, while long-term seizures also affect the growth and development of children Therefore, the dose of the induction drug should be based on the actual development of the child In addition, in polio induction, it should be noted that high concentrations of heptafluorane induction may induce seizure-like seizures anaesthetic maintenance, because inhaling anaesthetic can expand cerebrovascular, inhibit brain electrical activity, so the use of intravenous anaesthetic drugs, such as propofol, riffinite, its characteristics for the rapid effect, rapid elimination, help to quickly wake up after surgery Attention should also be paid to the higher removal rate of narcotic drugs in children than adults, and the long-term use of anti-epileptic drugs in children with epilepsy can induce the expression of liver particulate splin P450 enzyme, further increasing the demand for non-depolarized myamins and opioids Epilepsy lesions ectomyis due to the surgical trauma, intraoperative bleeding is generally more, and a large number of allogeneic red blood cells infusion will increase the incidence of postoperative infection, and with postoperative complications and increased mortality rate is closely related TXA is an anti-fibre drug that uses TXA in children's heart surgery, spinal surgery, and neurosurgery to significantly reduce blood loss and the need for blood transfusions , Goobie and others have shown that applying TXA in pediatric cranial surgery can significantly reduce postoperative adverse events and treatment rates in intensive care units (ICU) According to the pharmacokinetic characteristics of TXA in children, the child in this case was given a TXA load of 10 mg/kg, after which 5mg/kg.h was continuously pumped At the same time, in order to accurately judge the blood clotting status of children and on-demand blood transfusion, the use of TEG for real-time dynamic guidance during perioperative can significantly reduce the rate of blood transfusion and the use of various blood products this case, TEG testing was carried out when the epidural was closed, and the indicators were found to be normal and no additional clotting material was required At the same time, through insulation, according to blood gas results to adjust blood calcium and pH, to maximize the protection of the blood clotting state of children Overactivation of inflammatory response during perioperative can be caused by surgical trauma, anaesthetic invasive operation, pain activation of sympathetic nerves, surgical cycle instability, and high blood volume of medical sources In non-drug anti-inflammatory treatment, insulation and target-oriented fluid management can reduce inflammatory factor levels on the surface of plasma and white blood cells and reduce the incidence of postoperative lung and wound infections in terms of drug treatment, methylized nylon reduces inflammatory symptoms by inhibiting capillary dilation and permeability, reducing oedema and edema, and inhibiting white blood cell immersion and phage By inhibiting the activity of a variety of enzymes, ustadine stabilizes lysozyme membranes such as matrix metalloprotein-9 (matrix metalloprotein, MMP9), trypsine, tissue protease, etc At the same time, ustartathin can also inhibit the release of lysosome enzymes, inflammatory media, reduce systemic inflammatory reaction and the migration of endotoxins and play a good anti-inflammatory role Therefore, the use of ustadine 5000U/kg and methyl-spray nylon 2mg/kg, etc., and through the perinatal multi-mode analgesia, insulation and target-oriented liquid management, can effectively avoid the inflammatory response is over-activated with the development of pediatric neurosurgery, pediatric epilepsy surgery will be on the rise Due to the effects of anti-epileptic drugs and the characteristics of this type of surgery, anesthesiologists face many challenges of perinatal management, need to fully assess the child before surgery, in surgery to achieve fine, personalized management, so as to successfully complete the operation, improve the prognosis of children