A report on the management of perinatal anesthesia in patients with ultra-old patients with a full uterine double attachment excision.

The patient, a 96-year-old woman, was born on February 24, 2019 at Xuanwu Hospital of Capital Medical University for "47 years of menopause, irregular vaginal bleeding 9d".
the history of hypertension for more than 28 years, blood pressure of up to 145/70 mmHg (1mmHg - 0.133 kPa), regular use of benzodiazepine chloride tablets (live joy), normal blood pressure (130-135)/70 mmHg.
action vein splinter 28 years ago and right cataract surgery five years ago.
auxiliary examination: HR 80/min, BP 130/70 mmHg, respiratory rate (respiratory rate, RR) 18 times/min, SpO2 93%.
double lung breathing sound clear; heart rhythm is not uniform, frequent early fighting, no murmurs and horse rhythm; the heart turbid sound world is normal.
no peripheral edema.
Laboratory Examination: Blood Routine: WBC 12.57 x 109/L, Hb 106 g/L.
biochemical examination: TP 62.34 g/L, ALB 31.86 g/L, SCr 62 mmol/L, BUN 10.08 mmol/L, glucose (Glu) 7.25 mmol/L, K-3.9 mmol/L.
clotting all: PT 16.7 s, APTT 34.9 s, FIB 4.40 g/L, D-dipolymer 4.59 ?g/ml.
ECG: sinus heart rhythm, occasional chamber early with differential conduction.
blood gas: pH 7.426, PaCO2 34.6 mmHg, PaO2 70.8 mmHg, K-3.5mmol/L, Hb 10.8 g/L, lactic acid 1.6 mmol/L.
lung function: 1 second rate of 67 percent, residual total ratio of 49%, restrictive ventilation dysfunction, the degree is suspicious, the total lung volume is normal, ventilation function is reduced, ventilation reserve 68%.
the lower extremities venous ultrasound showed the right femoral shallow vein wall thrombosis (oldness).
the keratial artery ultrasound showed uneven thickening of the bi-neal artery in the two-sided carotid artery with plaque (single hair), and left vertebral artery stenosis (V1 section.lt;50%).
abdominal B super shows the separation of the bi-nephrotomy.
gynecological B super-show pelvic uneven echo envelope (6.8 cm x 5.9 cm).
echocardiogram shows a blood score of 61%, a light (38 mm) in the left room, calcification of the aortic valve, calcification of two-tip valve, reflux of the main and pulmonary valves (mild), reflux of two-tip valve (moderate), reflux of three-tip valves (mild), reduced function of left ventricle diastorium, and frequent early fighting can be seen during examination.
admission was diagnosed as endometrial malignancies, hypertension, cerebral aneurysm clamping, and cataract removal in the right eye.
proposed to open the abdominal full uterus plus double attachment excision.
it is proposed to use tracheal intubation general anesthesia compound abdominal fascia blocking anesthesia.
1. Preoperative assessment of treatment 1.1: preoperative ASA Grade III, Metabolic Equivalent (metabolic equivalent of task, MET) level 4.
multidisciplinary consultation opinion in the hospital for the patient's super-age, no absolute anaesthetic taboo, but the risk of perioperative period is large, should be fully accounted for by the patient's family.
the organs that focus on: (1) Heart: Patients combined with arrhythmia before surgery, and the Improved Heart Risk Index (reviseded cardiac risk index, RCRI) predicts a 0.9% risk of heart-related death, non-fatal heart attack, and non-fatal cardiac arrest.
(2) Lung: Advanced age, lower abdominal surgery, Arozullah postoperative respiratory failure predicted the risk of acute respiratory failure after surgery was 4.2%.
(3) Brain: Ultra-old age, combined cervical artery plaque and vertebral artery stenosis, brain aneurysm surgery, care should be taken to prevent cerebrovascular accident and cognitive decline.
1.2 Anaesthetic Management (1) Anaesthetic Monitoring: Routine monitoring of ECG, HR, SpO2, NIBP and urine volume, special monitoring includes invasive arterial pressure, electroencephalotherial in-depth monitoring (Angle-6000, Shenzhen Weihaokang), nasopharyngeal temperature monitoring, cerebrooxygen saturation monitoring (Fore-Sight), preoperative chest ultrasound screening.
(2) Pre-anaesthetic Management: Patient In-room, Lucie Cooperation; ECG Prompt Room Early Triple Law, NIBP 130/60 mmHg, HR 105 times/min, RR18/min, SpO2 93%, body temperature 36.0 ?C; After the creation of the artery, the invasive arterial blood pressure is 157/60 mmHg.
urgently check 12 guide ECG show frequency chamber early fight.
emergency row bed by chest echocardiogram (transthoracic echocardi, TTE) check: basic preoperative.
brain oxygen saturation (left/right): 68%/66%, electroencephalic awareness index (index of 1, IOC1) is 99, injury sensitivity index (index of consciousness 2, IOC2) is 99, and facial myoelectric index is 99.
at this time observed that the patient entered the room after the urine bag has clear urine 700 ml, preoperative doctor's instructions to supplement ALB, the ward daily urine 20 mg.
: pH 7.51, PaCO2 33.9 mmHg, PaO2 78.1 mmHg, K-3.0 mmol/L, Hb 10.8 g/L, Glu 8.3 mmol/L, lactic acid 1.7mmol/L.
consider the frequency of the chamber early and patient tension and low blood potassium.
veins given lidocain 20 mg and potassium chloride 0.5 g into lactic acid ringer 250 ml of still drops after completion, began intravenous induction.
during anaesthetic preparation, a bilateral abdominal diaphragm block is applied to 0.2% ropica in 50 ml.
(3) In anaesthetic management: anaesthetic induction in turn to rely on the ester 6 mg, shun phenyl sulfonate ammonium 8 mg and rifentani 75 sg; bp 145/55 mmHg, HR 70 times/min after
intubation.
anaesthetic maintenance options are based on intravenous anesthesia, propofol maintenance dose of 2 to 2.5 mg / (kg.min), IOC1 maintained at 50 to 60, Riffenteni maintenance dose of 0.4 to 0.5 sg / (kg -min), IOC2 to maintain 50 to 60.
intermittent supplementof the ammonium aquorsacul of paraphenic sulfonate (total of 15 mg in the operation).
continued potassium supplementation during surgery, and the heart rhythm of 15 min after the operation began to change to the occasional chamber early.
(4) circulation management: norepinephrine before induction to start continuous pumpinjection, during surgery maintenance dose of 0.08 to 0.15 sg / (kg .min), blood pressure maintained at (135 to 155) (/50 to 65) mmHg, HR 60 to 80 times / min, to ensure important organ perfusion.
to implement a target-oriented liquid management guide lactic acid fluid infusion through pulse pressure variability (pulse pressure variability, PPV), maintaining the PPV below 13%.
the use of brain oxygen saturation monitoring, to maintain the reduction of brain oxygen saturation by less than 15% of the baseline value.
(5) Respiratory function management: (1) the use of "small moisture volume and exhalation of the end of positive pressure (positive end of the pressure, exhalation) and the lung re-sheeting" of the lung protective ventilation strategy, trachea intubation, moisture volume is set to 6 ml/kg, frequency of 12 times /min, PEEP is 6 cmH2O.
FiO2 adjusted to 40%, SpO2 maintained at 97% to 100%.
performed a pulmonary resuscitation once an hour during the
.
(2) to ensure a full recovery of the nerve muscle joint block, give sin1 mg plus atropine 0.5 mg antagonist, in electromyogram (electromygram, EMG) monitoring back to 75 or more of the pull tube.
(3) effective analgesics to avoid lack of ventilation due to pain.
the use of "non-steroidal anti-heat analgesics and receptor agonists and preoperative transverse fascia blocking" multi-mode analgesia, preoperative with 0.2% roptopain 50 ml implementation of the two-sided abdominal transverse plane (transversus abdominis plane, TAP) blocking, pre-surgery 30 min to give oxycodone 1 mg and Parisib sodium 20 mg.
(4)PPV-directed target-oriented liquid management to prevent pulmonary hydrostatic pulmonary edema.
(5) active anti-inflammatory management to prevent pulmonary permeable pulmonary edema.
(6) optimize the left ventricle diastode function of patients with fragile heart function, avoid ingesting heart rate and prevent pulmonary circulation blood clots.
oxygenation index has been maintained above 400, pre-room blood gas show: pH 7.44, PaCO2 31.8mmHg, PaO2 75.6 mmHg, K-3.3 mmol/L, Hb 10.2 g/L, Glu 9.2 mmol/L, lactic acid 2.2 mmol/L.
(6) inflammatory reaction control: before induction to give A-strong dragon 40 mg and ustadine 5,000 U/kg, during surgery to maintain the body temperature at 36 to 37 degrees C.
3. Transfer after surgery: 110 min surgery time, anaesthetic time 150 min. In
, 800 ml of lactic acid ringer, 1 100 ml urine and 50 ml of blood loss were entered.
suspended drug 5 min patients awake, autobreath recovery, surgery 17 min removal trachea intubation, intensive care unit (ICU) stay 22 h.
30 h exhaust after surgery and 6 d discharge after surgery.
period of perioperative did not see heart, lung, brain, kidney and other important organ complications.
2. Discuss the risk of complications and death in the perinatal period significantly increased in elderly patients due to reduced organ reserve function, combined multiple diseases, especially in older patients, and adequate preoperative assessment and preoperative preparation should be recommended. The purpose of
preoperative evaluation is to objectively evaluate the tolerance and risk of anaesthetic surgery in elderly patients, and to make recommendations on preoperative preparation to maximize the patient's tolerance to anaesthetic surgery.
heart risk assessment for elective surgery in older patients recommends the use of MET grading and RCRI indexes.
due to the weakening of the trachea and bronchial mucosal cilia movement in elderly patients, insufficient cough reflection power, easy to lead to dismounting lung failure, postoperative risk of respiratory failure increased, so selective surgery patients recommend the adoption of Arozullah postoperative respiratory failure prediction score.
the elderly had degenerative changes in the nervous system, increased sensitivity to narcotic drugs, and increased the risk of perioperative delirium and postoperative cognitive decline.
kidney tissue shrinkage in elderly patients, decreased renal glomerular filtration rate, renal concentration function was reduced, and the elimination of anaesthetic drugs and their metabolites needed to be removed by kidneys was prolonged.
can lead to temporary renal function loss due to the suppression of circulation by narcotic drugs, surgical trauma and blood loss, low blood pressure, etc.
in order to protect the fragile brain function of elderly patients, "China's elderly patients perinatal anesthesia management guidance" recommends the use of nerve blocking technology under conditions that can meet the level of surgical anesthesia.
therefore, this study for patients to choose the peritoneal fascia block compound general anesthesia, as far as possible to reduce the amount of opioids, to avoid adverse reactions.
the anaesthetic induction of elderly patients in principle recommended to intravenous anesthesia induction mainly, should be gradually titration from small doses, until the appropriate anaesthetic sedation depth.
the study selected the dependent cesteres, which had less effect on the circulatory function, titrated induction under the guidance of IOC1, and at the same time ensured IOC1 in 50 to 60, so as to avoid too much sedation.
induction and maintenance of analgesic drugs to short-acting riffintanis-based, titration use of oxycodone, in the process of anesthesia maintenance, through IOC2 monitoring and titration analgesic drug dosage, not only can maintain the dynamic balance of injury stimulation and the interaction of anaesthetic inhibitors, but also avoid the effect of the residual effects of medium- and long-acting narcotic drugs on the patient's wake-up period respiratory function.
the choice of narcotic drugs in elderly patients to do not harm the function of organs as the principle, for this case of ultra-old fragile brain function patients, to avoid the application of drugs affecting neurotransmitters such as anticholindrugs toxonic, long toonin and benzodiazepine drugs.
at the same time, the patient's preoperative BUN level is high, kidney function is fragile, so the choice of non-peremic intracellular drugs, such as shun-type aquukammonium.
in general, lactic acid ringer or acetic acid ringer is the preferred type of liquid for the perinatal period for older patients.
elderly patients due to the reduction of systemic blood capacity, heart, lung and kidney function and venous vascular tension in the anaesthetic state of the susceptibility to loss, perination period is easy to maintain circulatory stability leading to liquid infusion overload.
the study selected alpha1 epinephrine receptor agonist (norepinephrine) in conjunction with PPV-directed goal-oriented fluid management, a management strategy that has been proven effective and can improve patient return.
for elderly patients, should choose the "China's elderly patients perinomic anaesthetic management guidance" recommended on the implementation of the bundled comprehensive program in the lung function protection, including: (1) mechanical ventilation to implement low tide air volume and moderate exhalation of the end of positive pressure strategy; 5) ;(4) the implementation of the target-oriented fluid management program during surgery; (5) the patient's wake-up period to prevent sedation, analgesia and muscle pine drug residues; (6) patients with surgically related acute inflammatory reactions, should be actively given anti-inflammatory treatment; (7) preoperative consolidation of severe left ventricular diastolic dysfunction patients, surgery needs to maintain a slower HR (reference to the preoperative calm state HR value).
, due to the combination of diseases, organ function loss, the elderly patients have a significant increase in perioperative complications.
but through full preoperative assessment and preparation, the development of a perfect perisation period hemp.