A successful case of sudden ventricular fibrillation and acute myocardial infarction in hidden coronary heart disease

The patient, male, 58 years old, 53kg,diagnosisas "gallbladder stones", intended in the whole hemp down thelaparoscopybile tube cutting stoneSmoking for more than 20 years, 20 a day, has quit smokingIn the past,diabeteshistory for more than 10 years, blood sugar concentration is controlled at 8 to 9mmol/LDeny the history ofdiseasesblood vessels, such as high blood pressure, coronary heart disease, etcBlood routine seisciated mild anemia, chest tablets, liver function, clotting four normal, ASA II, cardiopulmonary hearing shear and abnormalECG show: sinus heart rhythm, ST segment changeAfter entering the room, the peripheral intravenous fluids are opened, the ECG, SpO2, NIBP, HR, recorded in-room BP 127/65mmHg, HR 65 times/min Full hemp induction: Medaaalen 2mg, relying on miede 20mg, Shufentani 30 sg, shun aquku ammonium 10mg, trachea intubation smooth, induced smooth The artery puncture is then performed to monitor the ABP anaesthetic maintenance: propofol 3 to 5 mg kg-1 h-1, Riffentani 0.1 to 0.2?g-kg-1-min-1, continuous inhalation of 2% heptafluoroethee, intermittent giving shun aquku ammonium, maintenance of BP 100 to 120/60 to 70mmHg, HR 60 to 80 times / minute, BIS 40 to 60 The operation went smoothly, the bleeding was not much, and when the abdominal cavity was flushed with physiological saline (37 degrees C), electrocardiogram showed ventricular heart rhythm, HR 110 times/min, BP 90/60mmHg intravenous lydocain 20 mg, HR does not significantly slow down, check arterial blood gas: pH 7.34, Na 141mmol/L, K-3.9mmol/L, Ca2-1.25mmol/L, Hb 96g/L After 1min immediately turned to chamber fibrillation, BP 35/25mmHg, fine tremorwave Immediately suspended surgery, chest pressure, while intravenous lydocain 100mg and epinephrine 1mg, actively prepare for electric defibrillation After the above drug treatment, electrocardiogram monitoring chamber fibrillation, coarse tremor wave In vitro bidirectional 200J electric defibrillation reshearsing 1 time, converted to sinus heart rhythm, HR 98 times/min, ABP 88/66 mmHg Arterial blood: pH 7.16, PaO2 90mmHg, K-5.1mmol/L, PaCO2 60mmHg intravenous drip 5% sodium bicarbonate 50ml, according to blood gas pickle Twelve concales by the bed show: sinus heart rhythm, acute lower wall myocardial infarction Troponin I 0.28 ng/ml, myoglobin 196.60 ?g/L, creatine kinase isoenzyme 6.09 ng/ml The intravenous pumping of norepinephrine and nitroglycerin is used to maintain the circulation Quickly shut down and into the heart ICU After 10h, the patient is conscious, vital signs, blood gas is normal, the trachea catheter is removed After 4d, coronary artery angiography is performed in the cardiology intervention chamber The contrast shows that the left trunk is not narrow, the front lowering center section is 40% narrow, the right crown near the middle section is 90% narrow, and the rear reduction near section is 80% narrow A heart stent is then placed in the middle and far end of the right coronary artery After 6d patients were discharged from the hospital with no obvious sequelae discussion the patient's chest pain before surgery, before the high blood pressure , coronary heart disease and other vascular disease history, electrocardiogram only ST segment changes Combined with the clinical performance and coronary imaging results of , the diagnosis can be as hidden coronary heart disease This case of patients for middle-aged and elderly patients, there are type 2 diabetes , smoking history, preoperative fasting to blood concentration, coupled with mental stress and surgery with physiological saline when the abdominal cavity when the surgical trauma stress-induced tachycardia, resulting in increased cardiomyocardy consumption, the final heart due to insufficient blood supply to the fibrillation chamber and acute myocardial infarction hidden coronary heart disease is also known as asymptomatic myocardial ischemia, which occurs in patients with stable angina, unstable angina, or vascular spasms angina These patients often have no myocardial ischemia clinical , but there is an objective manifestation of myocardial ischemia, i.e electrocardiogram, echocardiogram, or coronary artery angiography shows that the heart has been affected by insufficient coronary artery blood supply As a result, some patients may be early-stage coronary heart disease and may suddenly turn into angina or acute myocardial infarction It may also evolve into cardiac enlargement, heart failure or arrhythmia, and sudden death in individual patients The pathogenesis of hidden coronary heart disease is not known may be related to the following factors: (1) 25% of patients with coronary heart disease diabetes , diabetes can cause autonomic neuropathy, often masking the clinical manifestations of coronary heart disease (2) With long-term, large-scale smoking related to the production of a large number of endogenous opioids (endorphins), resulting in higher pain threshold in patients (3) The degree of myocardial ischemia is lighter, or has a better lateral circulation The value of conventional electrocardiogram diagnosis of hidden coronary heart disease is limited, and some coronary heart disease patients have a sexual ST segment (up or down) and T-wave (low flat or inverted) change, but the dynamic change of electrocardiogram can disappear completely or partially with the relief of angina For elderly patients with etclisted eliosis having ST segment changes combined with diabetes and/or chronic smoking asymptomatic, clinicians should be alert to the possibility of hidden coronary heart disease and review the electrocardiogram Conditional lying coronary artery angiography to improve the rate of diagnosis of hidden coronary heart disease Acute myocardial infarction is prevention For preoperative arrhythmia, we should make a careful assessment, improve the examination, find the cause, and find out early During anesthesia should maintain hemodynamic stability and appropriate red blood cell pressure accumulation, as far as possible to maintain the balance of cardiomyocardial oxygen supply and demand, blood pressure fluctuations should not be too large, heart rate control should not be slow (fluctuations in 60 to 100 times / minute), strengthen the acid-base balance during anesthesia and electrolyte monitoring and temperature management In addition, postoperative treatment in such patients is also very important, it is generally believed that the wake-up phase is more dangerous than the induction stage, and most myocardial infarction occurs between 24 and 48h after surgery Therefore, the anesthesia wake-up period to strive for stability, wake up to ensure full ventilation and oxygen supply satisfaction, the pain, chills, low blood capacity, anemia, tachycardia, etc are not conducive to the balance of cardiomyocardial oxygen supply and demand, to be timely treatment, in the anesthesia wake-up room, to be closely monitored, at any time the changes in the condition should be treated in a timely manner in short, the treatment of sudden acute myocardial infarction in surgery is more difficult The key is to prevention , that is, we should attach great importance to preoperative assessment and preparation, strengthen postoperative monitoring, to avoid myocardial infarction