Atypical cytophilidoma combined with acute coronary syndrome anaesthetic case

Patient, male, 47 years old, 59kg, BMI 20kg/m2, ASA1Due to "seizure chest pain more than one month, and then 13h" into the cardiology1 month before the activity after intermittent seizure of chest bone suffocation, accompanied by a sense of oppression, nausea, sweating, radiation in the back, lasting about 10min symptoms relief13h before the chest pain, the nature of the same beforeNohistory of hypertensionadmission examination: body temperature 36.4 degrees C, HR70 times/min, RR19 times/min, BP110/70mmHgSlightly irritable, deep tenderness in the upper abdomen, obvious under the sword, no anti-jumping pain and muscle tension, no edema in the lower limbsLaboratory examination: WBC2491X109/L, N93%, RBC4.94X1012/L, Hb146g/L, Pit236X109/L; liver, kidney function, cardiomyopathy markers, etcECG show: Sinus heart rate is not aligned, Ding Bo high tip (V2)heart ultrasound: blood shot score (EF) 64%, left chamber short axis diastorate rate (FS) 33%, left chamber diastode structonosChest CT: A circular soft tissue shadow above the tail of the pancreasInitialdiagnosis: coronary aorsclerosis heart disease;given antiplatelet aggregation, stable arterial porridge plaque and other drug treatment, symptom relief, coronary artery imaging show: right coronary advantage type, RCA 1 section 10% stenosis, LAD6 section 20% stenosis, LAD7 section 40% stenosis, LCX12 section 90% stenosis Abdominal color super: pancreatic tail inside the underthess asacs mixed bag block Upper abdominal enhancement CT: pancreatic upper tail and stomach small bendside occupaster, considering tumor lesions (mesothelioma) derived from stomach After multidisciplinary consultation, trans-general surgery the next day in the full laparoscopic downward detection, in the stomach body near the small bend side of the back wall and the upper end of the pancreatic body see 3.0 cmX3.0 cmX20 cm size swelling, located in the rear peritoneum, soft, complete envelope, and the stomach body no obvious adhesion When the swelling was separated, the anesthesiologist noticed that the patient's BP had soared to 220/120mmHg, suspended the operation and BP dropped to normal Immediately consult with a urological surgeon and suspect cytophilidoma in view of the patient has coronary lineg stenosis, did not do the pre-surgery preparation of cytomalicinoma, surgery risk is greater, suspended surgery, transferred to urology surgery preoperative preparation Also examined: 24h urine free cortisol 765.51f, sg, urine paracetamol 277.97nmol, urine norepinephrine 248.7nmol Two-sided adrenal CT-enhanced scan show: consider adrenal hyperploff, left adrenal outside without small adenomas Preoperative diagnosis : cytophilidoma; coronary atherosclerosis heart disease; acute coronary syndrome cardiology level II patients oral alpha1 receptor blockdrug traquir, beta 1 receptor blocking drug metolor, appropriate expansion, improve circulation, nutritional heart muscle and other treatment 10d Before entering the operating room 30min regular application of pythnotossandandandandandandal and ethyl alkali, ready to laparoscopy under the left adrenal swelling surgery after the whole hemp joint epidural anesthesia down Open veins after entering the chamber to monitor ECG, SpO2, and BIS The line left artery and the right neck venous puncture tube pressure measurement, PiCCO has the invasive monitoring of hemodynamic parameters epidural anesthesia: puncture point for T9 1T10 clearance, placed in the epidural catheter, 2% Lidoca because of the test volume of 4 ml, confirmed that no whole spinal anesthesia after the sub-injection 1% Lidocain 12 ml, maintain the anesthesia plane up to T5-T6, release L3-L4 nerve section Full hemp induction: intravenous medazole 2mg, relientce on mitene 16mg, Shufentani 20 ?g, propofol 50mg, shun aqualku press 14mg Visual laryngos gounder tube intubation, ID7.5mm, depth 23 cm anaesthetic maintenance: Shufenteni 10 sg intermittent push, Riffenteni 200 sg/h continuous pump injection, right metormi fixed 16 sg/h, 1.5% heptafluoreel inhalation anesthesia, every 40 minutes to add the smooth aquor ammonium 0.15 mg/kg, maintain BIS value 40 to 60 Mechanical ventilation: RR12 times/min, VT500ml, airway pressure 13 cmH2O, PaCO2 at 35 to 40mmHg During the surgery left adrenal swelling removal process BP suddenly rose to 210/110mmHg, immediately intravenous phenol tolamine pressure, BP maintained at 90 to 120mmHg, Aislor control HR in 90 to 100 times / minute After the swelling is removed, BP drops to 80/40mmHg, immediately accelerates the rehydration fluid, removes the norepinephrine 40?g static push, after which the patient BP is stable The operation lasted about 3h, after 15 min after the patient was conscious and the trachea catheter was removed Pathological results confirmed chromosomal tumors Good postoperative recovery and no outbreak of acute coronary syndrome during hospitalization Three months after the operation, he was again admitted to the cardiology clinic with chest pain discussion according to the literature, BP's normal atypical cytomocytes accounted for 13.5% to 55% of accidental chromosomal tumors, of which more than 25% were accidentally detected through imaging This case patient shaded no hypertension history, chest CT accidentally found tumor, postoperative pathology confirmed chromophilioma, combined acute coronary syndrome, coronary imaging showed that many coronary veins were different degrees of narrowness, 3 months after tumor removal, chest pain again, thus excluding egocelloma-based catarosis omesomyopathy, diagnosis of atypical cytomophilioma combined with acute coronary syndrome the first test surgery suspended surgery is due to the patient combined with acute coronary syndrome, multiple coronary veins stenosis, catecholamine mass release can increase oxygen consumption in the heart muscle, aggravate coronary spasms, resulting in myocardial cell ischemic necrosis Necessary preoperative expansion preparation is beneficial to reduce the risk of hypertension and severe hypotension caused by dramatic fluctuations in hemodynamics during surgery In addition, no pre-surgery preparation for cytomophilia, immediate removal of the tumor, the concentration of catecholamine in the cycle plummeted, BP decreased, prone to circulatory failure, the risk of anesthesia is greater Although some scholars believe that this kind of patients have insufficient blood-free capacity before surgery, only after the of the blood vessels, resulting in a relative blood capacity shortage, no need to suspend surgery for preoperative preparation But there is no shortage of literature reports of serious complications such as pulmonary edema during preoperative lymicoma surgery Therefore, the suspension of surgery, adequate preoperative preparation and control of coronary disease is the key to ensure patient safety the whole hemp joint epidural anesthesia is the first choice of this type of surgical anesthesia, can block the sympathetic nerve, promote coronary blood blood vessel dilation, slow down HR, reduce the oxygen consumption of the heart muscle and heart front and rear load; For the operation of chromologoid celloma in patients with combined acute coronary syndrome, bp, HR and CO in surgery need to be closely monitored, and invasive hemodynamic monitoring, such as Swan-Ganz catheters, if necessary Reduce HR, control BP, increase cardiomyopathy, reduce cardiomyopathy, maintain balance between cardiomyocardial supply and demand, so as to ensure that the blood supply of important organs to avoid accidental heart risk