Analysis of 3 cases of emergencies closely related to anesthesia monitoring during the anaesthetic induction period.

. Clinical anesthesia is one of the most risky areas of medicine. Failure to monitor patients in time and comprehensively during anesthesia is one of the main causes of anaesthetic complications during perioperative. The World Federation of Anesthesiologists (WFSA) issued the International Standard for the Safety of Clinical Anesthesiology in 1992 and was further revised in 2008 and 2010 to require pre-induced examination of the monitoring equipment to function properly and anaesthetic monitoring to continue until the end of the anesthesia recovery period, in addition to regulating the basic elements and conditions of anesthesia monitoring. The latest domestic results of the results of the anesthesiology quality and patient safety survey show that only 77.9% of the anesthesiologists involved in the study routinely perform continuous electrocardiogram monitoring of all patients.
incomplete anaesthetic monitoring project, inadequate custody statute of limitations, and incorrect evaluation of monitoring results are the main causes of adverse events during perioperative period. By analyzing 3 cases closely related to electrocardiogram monitoring, this paper emphasizes the significance of standardized anaesthetic monitoring during the perioperative period.
1. Patient data
case 1: patient, male, 36 years old, height 168 cm, body mass 72kg, ASA grade I, selected line right groin oblique repair, no hypertension, heart disease history, no vertigo, heart palpitations, chest tightness and other discomfort, preoperative electrocardiogram (ECG) check normal. Blood pressure measured (BP) 128/75mmHg, pulse (P) 78 times/min, refers to pulse oxygen saturation (SpO2) 99%, open peripheral venous pathway, left lying line L3-4 waist-hard joint anesthesia puncture, removed sleeve BP and SpO2 monitoring during anaesthetic operation. Cobweb subcavity puncture smooth, push 0.4% equivalent of ropicain 11mg, reclining position, ready nasal catheter oxygen absorption, patientself complaint dizziness, chest tightness, consciousness disappear, lip purple, monitoring SpO2 75%, P26/min, start emergency cpr (CPR) first aid: mask plus Pressure to oxygen-assisted ventilation, chest heart compression, 2min after patient cyanosis correction, SpO2 99%, BP88/56mmHg, heart rate (HR) 83 times / min, patient cough wakeup, double-sided pupils and other large equivalent circles, good light reflection, clear answer, no heart tightness and other discomfort. At this time, the test of the anaesthetic block plane, indicating that the anaesthetic block plane up to the 10th thoracic plane (T10), no full hemp performance; Successfully completed the operation, after the operation 4d recovered from the hospital.
cases 2: patients, female, 52 years old, height 160 cm, body mass 52 kg, ASA grade II, history of hypertension for 10 years, when there is panic chest tightness, take heart-care pills effective relief. Due to "metastatic right lower abdominal pain 1d" in the whole emergency line laparoscopic appendectomy, open peripheral venous pathways, routine ECG, SpO2, sleeve band noninvasive blood pressure monitoring, BP150/100mmHg, Sp O2 99%, sinus tachycardia, HR125 times / min; before induction found SpO2 waveform anomalies, amplitude and wave width size is not the same, electrocardiogram monitoring found in the burst chamber sex
arrhythmia
, atrial fibrillation suspicious. HR155 to 167 times/min, "short veins", P85 to 125 times/min, BP138 to 148/88 to 93mmHg, intravenous hydrochloric acid Airol 20mg, 80mg hydrochloric acid Asrol added 100mL physiological saline continuous intravenous drip, HR138 times/min, BP115/65mmHg intravenous injection Aron0.8mg, Fentanyl 0.25mg, Reliance Estee emulsion 16mg, Psabenzene Sulphate Ammonium 12mg, Mask Pressure to Oxygen 3min, Insert ID7.0 trachea catheter for mechanical ventilation, maintenance in surgery: intravenous pump propofol 150mg/h, riffinteni 300 mg/h, heptifluoride concentration of 0.6%-1.0% of the ether.
co2 abdominal, non-invasive blood pressure cuff repeated inflatable pressure measurement is not measured, SpO2 waveform disappeared, exhalation end carbon dioxide pressure (PETCO2) from 34mmHg sudden drop to 27mmHg, HR100 to 120 times / min, weak throbbing pulse, P 60 times / min, no neck vein anger. Temporarily stop conosic gas, stop intravenous drip hydrochloric acid Aeslow, intravenous atropine 0.5mg, restore fast chamber on HR150 times/min, SpO2 waveform recovery display, P92/min, BP rise to 85/min 53mmHg, carotid artery puncture and continuous arterial blood pressure monitoring, intravenous hydrochloric acid deoxyrepinephrine 0.05mg, BP elevated to 92/50mmHg, continuous pump injection hydrochloric acid deoxygenation 0.5 to 1.0mg/h, BP Maintained above 95/50mmHg, continued to complete appendectomy surgery under conoctory abdominal conditions, during the operation BP stable, HR gradually slowed down to 120 times / min, by the rapid recovery of sinus heart rhythm, HR stable at 90 to 95 times / min, Surgical treatment patients conscious, vital signs smooth pull tube, stop hydrochloric acid deoxyrepinephrine, HR96 times / min, BP121/65mmHg, breathing smooth, double lung breathing sound clear, no dry wet sound, heart beat normal, No pathological murmurs, no swelling of the double lower extremities; surgical arterial hemogas reported normally: PH7.38, arterial blood carbon dioxide pressure (PaCO2) 32mmHg, arterial hemolytic oxygen pressure (PaO2) 196mmHg, whole blood alkali residual -5.5mmol/L, extracellular alkali remaining -6.2mmol/L, lactic acid 0.5mmol/L, no significant poor injection. Review the bedside electrocardiogram: sinus heart rhythm, ECG normal, 4h chacardiocardocalcin (cTn) I 0.01 ng/mL, excluding
myocardial infarction
. The intensive care unit stayed at 24h, no arrhythmia, after 3d cured and discharged from the hospital.
cases 3: patient, female, 63 years old, height 153 cm, body mass 51 kg, ASA grade III, hypertension history of 24 years, nearly 3 years oral satan 80 mg, 1 /d, nitrobenzene flat release capsule 60mg, 1 time /d, hospital BP 165/90Hgmm. 24 years of history of cerebral hemorrhage, loss of right muscle strength, 2 years history of cerebral infarction history, right paraplegia (myose level 0). Due to "right thigh trauma malformation" admitted to hospital 3d, to correct anemia, the proposed right femur fracture cut-off reset intra-fixation. Laboratory examination and blood gas, biochemical examination is generally normal, preoperative ECG: sinus heart rhythm, II, III, aVF lead ST segment mildly depressed (0.05mV), reverse clock transposition, HR88 times/min. The right neck is punctured in the veins, the left artery puncture tube, the continuous monitoring has the blood pressure of the artery, the electrocardiogram monitoring. In-room BP165/82mmHg, HR105 times/min, whole hemp induction with fentanyl 0.2mg, relying on misoest 16mg, shun phenyl sulfonate aquor ammonium 7mg, insertion of laryngeal cover for mechanical ventilation, BP120/70mmHg, HR90 times/min, ECG show extensive ST-T segment change (I, II lead joint ST segment under the oblique low of 0.1mV, BP continued to decline, HR slowed down to 51 times / min, preliminary
diagnosis
myocardial infarction, the patient adjusted half-bed, sustained intravenous injection of nitric acid ggas500 g / h, while continuouspumping hydrochloric acid deoxygenated epinephrine 1200 g/h, to maintain BP smooth, control ventricle rate, please cardiology consultation.
30min post-bed electrocardiogram inspection report: left ventricular high voltage, extensive ST-T change (I, II, V4-6 inline ST segment sloping down to 0.1mV, V4 conductor T-wave upright), sinus tachycardia, HR56 times/min, Q-T Extended period, preliminary diagnosis: acute non-ST segment elevated myocardial infarction; extraction of peripheral blood, myocardial infarction triple test results: MB-type creatine kinase ilysase (CKMB) 17.2ng/mL, cTnI111.2ng/mL, confirmed acute non-ST-stage elevated myocardial infarction.
anaesthetic induction after the start of 1h anesthesia resuscitation, patients awake, circulating smooth, after 30min, the patient's chest tightness symptoms have improved, can be normal answer, nasal catheter oxygen absorption, sent to the catheter room for emergency coronary imaging and coronary interventional surgery, coronary imaging tips: The near section of the left front is 50%, the middle section is 99%, the blood flow TIMI3 level, the left cyclotron near section is 90%, the blood flow TIMI3 level, the near section of the right crown is narrow edgy 80%, the middle section is completely closed, the blood flow TIMI0 level. 2.0mm x 20mm balloon in the left front reduction (LAD) in the middle of the narrow lesions expansion and placed in Excel 2.5mm x 33mm rapamycin coating stent, patient symptoms significantly alleviated, diagnosis: acute non-ST section elevated myocardial infarction, killipII level. The outer fixing bracket is towed 10d, and the plaster tots is fixed and discharged from the hospital.
2. Discussion
2.1 case analysis
cases 1-3 of the cases were caused by unknown "fainting", rapid ventricular arrhythmia and acute non-ST-section elevated myocardial infarction during the anaesthetic induction period. Case 1, the patient during the anaesthetic puncture operation did not carry out continuous BP, SpO2 and electrocardiogram monitoring, the cause of the patient fainting is unknown, can not be ruled out as syndrome, but before the patient's cardiac arrest started effective CPR, the patient's prognosis is good, no sequelae. Case 2, the patient had a history of heart palpitations before surgery, oral heart retention pills effectively alleviated, the induction period found "rapid arrhythmia" and "short veins", and the arrhythmia has caused more violent fluctuations in hemodynamics, if not treated in a timely manner, may induce myocardial infarction,
stroke
and other adverse events. Case 3, anaesthetic monitoring in place, electrocardiogram monitoring found electrocardiogram waveform changes, although not able to determine the type of abnormal changeof the electrocardiogram, combined with the basic physiological condition of patients, suspension of surgery, timely search for professional department help, myocardial infarction triple testing, confirmed as "acute non-ST section elevated myocardial infarction", proper lying, save the patient's life.
during the intra-vertebral anaesthetic puncture, especially small doses of insepsis, low-level intravertebral anesthesia, generally will not cause severe circulation, respiratory fluctuations. A small number of anesthesiologists ignore BP, SpO2, and electrocardiogram. Case 1 gives an important warning that during the entire anaesthetic operation,
management
, it is important to monitor the patient's vital signs such as effective circulation and breathing. In addition,
, in clinical work, there is a widespread emphasis on The monitoring of SpO2 and the phenomenon of contempt for electrocardiogram monitoring, mistakenly believethat that SpO2 monitoring can cover the connotation of electrocardiogram. Case 1, the absence of electrocardiogram monitoring, so that it is not clear the cause of "sickness", after surgery can not provide valuable guidance and help. Case 2, before anesthesia induction of electrocardiogram monitoring, found "short veins", should seek specialist consultation, clear arrhythmia type, exclude myocardial ischemia. If the diagnosis of atrial fibrillation, combined with the clinical manifestations of myocardial ischemia prior to surgery, but also to prevent the perinatal surgery
thrombosis
shedding and embolism (stroke) risk, before surgery need to improve the heart ultrasound examination, to eliminate the heart wall thrombosis. The patient, preoperative pain, tension and other stimulation of sympathetic nerve excitatory, sinus tachycardia caused by myocardial oxygen consumption and oxygen supply imbalance; preoperative nausea, vomiting, long-term fasting may lead to electrolyte disorders, carbon dioxide gas and abdominal and other adverse stimulation induced rapid ventricular arrhythmia, leading to cycle instability, aggravation of myocardial ischemia hypoxia. The focus of intraoperative disposal is to maintain circulation stability, ensure important organ perfusion, and improve the balance of cardiomyocardial oxygen consumption. Therefore, for patients with perioperative breathing and circulatory instability factors, including tracheotomy general anesthesia, intravertebral anesthesia, and neuro-blocking anesthesia surgery, the establishment of invasive sustained arterial blood pressure monitoring prior to surgery is essential.
cases 3, patients with long-term hypertension, preoperative II, III, aVF-conductive ST segment mildly depressed, there is a history of cerebral hemorrhage, stroke history (old myocardial infarction wall hairloss may occur), highly suspected non-ST section of the elevated acute
coronary syndrome
(NSTE) - ACS), the operation should be suspended to further improve the preoperative examination, including 24h dynamic electrocardiogram, 12 conductor or 18 electrocardiogram, if necessary, coronary imaging examination, to avoid the whole hemp induction period of acute myocardial infarction and acute heart insufficiency. The incidence of NSTE-ACS in China is increasing year by year, and cTn is the most sensitive and specific biomarker of NSTEACS, and it is also an important basis for diagnosis and risk stratification. Compared with standard cTn testing, hypersensitivity cardiocalcal (hs-cTn) testhas have a high erstiny diagnostic value for acute myocardial infarction, which can reduce cTn "blind time" and diagnose acute myocardial infarction earlier.
2.2 The importance of electrocardiogram monitoring and invasive blood pressure monitoring
a wide variety of arrhythmia, continuous electrocardiogram monitoring provides the basic electrocardiogram form of patients before anesthesia induction, which can be used as a reference reference for changes in electrocardiogram caused by anaesthetic and surgical adverse stimulation; The synchronicity analysis of arterial waveforms can evaluate the blood-injection function, capacity and peripheral
vascular
resistance, SpO2 can reflect the end perfusion situation only limited, but combined with electrocardiogram can better analyze the causes of end perfusion abnormality, before abnormal changes in end perfusion, electrocardiogram monitoring can detect signs. For sudden arrhythmia, it is required to be able to identify and exclude ventricular arrhythmia, and to strengthen the identification and mastery of various complex types of arrhythmia or abnormal cardiac blood function other than ventricular arrhythmia.
in clinical anesthesia work to master the following two principles: (1) consider and analyze the underlying disease, the cause and the main measures taken; Continuous arterial blood pressure monitoring of the arterial puncture tube is the most effective guarantee to maintain the smooth circulation of perioperative period. Real-time, dynamic arterial waveform changes and blood gas collection, timely detection of heart blood rhythm, circulatory capacity and peripheral resistance changes; The arterial pulse waveform continuous cardiac blood volume monitoring (APCO) also known as the arterial pressure heart hemophilia measurement system, is in the arterial catheter connection connected to the FloTrac monitor, FloTracTM system by analyzing the arterial pressure waveform, to obtain the heart index (CI), per boon (SV), peripheral vascular resistance, per-stroke variation (SVV) and other dynamic blood flow indicators. APCO has been shown to be an ideal tool for clinical monitoring of cardioerate (CO) in normal or low-dynamic circulation conditions and not severe changes in vascular elasticity.
2.3 new technology.