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A case of minimally invasive surgery, but the patient did not come down.
.
.
If the tracheal tube strayed into the esophagus, if it was not detected, it would be the most dangerous event in anesthesia.
It is often due to difficult airway or inexperience of the intubator or intraoperative posture changes.
The catheter inserted into the airway slips out into the esophagus.
A recent case in a department where a tracheal tube was mistakenly inserted into the esophagus without being found to cause death is as follows.
Case data: Male, 65 years old, farmer, hospitalized with intermittent upper abdominal pain for more than ten years, had a history of gallbladder stones, cholecystitis, and pancreatitis for many years; had a history of right inguinal hernia surgery, denied diabetes, hypertension, and heart disease , No history of drug sensitivity and family history of genetic diseases.
Vital signs: body temperature 36.
8℃, pulse 69 beats/min, breathing 18 beats/min, blood pressure 124/89 mmHg.
Physical examination: normal development, good nutrition, entered the ward, cooperated with physical examination, clear, no yellowing of the skin and sclera all over the body, no swelling of superficial lymph nodes, no liver palms and spider moles, soft neck; breathing in both lungs The sound is clear, there is no obvious dry and wet rales; the heart rhythm is uniform, no murmur; there is no percussive pain in the kidney area, and no obvious deformities of the limbs and spine are seen.
Specialty status: flat abdomen, soft abdominal muscles, no tenderness, no rebound pain, Murphy's sign (-), liver and spleen not reach under the ribs, liver dullness, no moving dullness, unheard and qi and water sounds, intestines The beeping sound is OK.
The initial diagnosis was gallbladder stones and cholecystitis.
Auxiliary test: Novel coronavirus pneumonia nucleic acid RNA negative (nasopharyngeal swab), new coronavirus pneumonia antibody test: new coronavirus antibody IgM negative, new coronavirus antibody IgG negative.
Three infections: hypersensitive C-reactive protein 0.
90 mg/L, C-reactive protein <5 mg/L, procalcitonin 0.
08 ng/mL, B-type natriuretic peptide precursor (BNP) 285.
00 pg/mL.
Blood amylase: blood amylase 82 U/L.
Liver function: total bilirubin 10.
8 μmol/L, direct bilirubin 4.
9 μmol/L, aspartate aminotransferase 17 U/L, and alanine aminotransferase 8 U/L.
Blood routine: white blood cells 5.
4×109/L, red blood cells 4.
80×1012/L, hemoglobin 164 g/L, platelets 188×109/L.
Chest CT showed lobular emphysema and gallbladder stones in both lungs.
The electrocardiogram showed sinus rhythm, left ventricular hypertrophy and abnormal repolarization.
Cardiac color Doppler ultrasound showed reduced left ventricular diastolic function and 52% EF.
Pre-anaesthesia visit: Elderly patients are in general condition, ASA 2-3 level, and plan to undergo laparoscopic cholecystectomy (LC) under general anesthesia.
The patient asked a well-known professor at the provincial hospital to perform the operation.
After the preoperative preparation is completed, the patient enters the room to open the vein, and routinely monitor the non-invasive blood pressure (NIBP), blood oxygen saturation (SpO2), heart rate, respiration, etc.
, take the T8-9 epidural puncture in the right decubitus position, and place the head after success Tube 3.
5 cm, withdraw blood and cerebrospinal fluid, and fix it properly for use.
After supine, the patient was given 5 mL of 2% lidocaine epidurally, and T4-L1 was measured 5 minutes later, that is, the first dose of 0.
5% levobupika was given Because of 8 mL.
At this time, the professor arrived in the operating room, the anesthesiologist gave oxygen and denitrification with a mask, and immediately induced intravenously: midazolam 2 mg, penehyclidine hydrochloride injection 0.
2 mg, etomidate emulsion 20 mg, sufentanil 25 μg, vitamin After intravenous injection of Curonium 8 mg, an ID7.
5 endotracheal tube was inserted through a clear vision intubation, and an anesthesia machine was connected to control breathing.
The monitor was all normal, and the anesthetist was handed over.
After 10 minutes, the surgeon spread the skin and cut the skin, and found that the blood was purple-black.
At this time, the monitor alarmed, SpO2 dropped rapidly, as low as 69%, blood pressure was 164/99 mmHg high, heart rate increased 120 beats/min, and lips were cyanotic.
The pupils on both sides are slightly larger with a diameter of 5 mm. The succeeding anesthesiologist immediately pulled out the tracheal tube and reintubated it.
After auscultation was correct, the SpO2 slowly rose to 90%.
However, the patient still had dilated pupils, cyanosis, and arrhythmia (premature ventricular contraction R on T).
), rescue immediately, give lidocaine, atropine, epinephrine, etc.
, and defibrillator for backup.
The patient’s cardiac arrest 15 minutes later, intravenous injection of epinephrine 1 mg, three defibrillation was ineffective, and 30 minutes after cardiac compression, both pupils were dilated and fixed, the electrocardiogram showed equipotential lines, and rescue was given up.
.
.
the patient’s family filed a lawsuit over the death of the patient And claim.
Discuss why the patient's SpO2 decreased? Why is the blood purple and black when cutting the skin? Why does the patient have arrhythmia and even cardiac arrest? The intubator claimed that he intubated under his eyesight and saw the tip of the catheter enter the trachea with his own eyes.
It is impossible to accidentally enter the esophagus.
However, after intubation, he did not have a careful auscultation and no end-expiratory carbon dioxide (PETCO2) monitoring.
He was directly connected to an anesthesia machine to control breathing , And then hand over.
At that time, the monitor did not find any abnormality, and there was no alarm signal.
The successor anesthesiologist said that the surgeon said the blood was purple and black.
I suspected that the catheter was not in the trachea.
At that time, the situation was urgent, the monitor alarmed, SpO2 suddenly dropped, and the patient looked cyanotic, so he had to pull out the tracheal catheter and re-intubate.
But then it still declined, vital signs were abnormal, a malignant arrhythmia appeared, the patient's cardiac arrest, and rescue was ineffective.
During the discussion in the whole hospital, 72% of the participants agreed that the tracheal tube was mistakenly inserted into the esophagus, and the patient was hypoxic for too long (10 min), which caused the patient to develop malignant arrhythmia, cardiac arrest and death.
21% of the participants believed that mistakes in selecting appropriate methods of epidural anesthesia plus general anesthesia for intubation led to a series of subsequent consequences for the patient.
The reason is: since the epidural is only for postoperative analgesia, there is no need to give the first dose.
What's more, immediately after the rapid induction of anesthesia, the anesthetic was not reduced.
In short, the effect of epidural circulatory inhibition is followed by anesthesia induction of a large amount of anesthetic drugs into the vein, resulting in severe circulatory collapse and insufficient perfusion leading to a series of subsequent consequences.
7% of the participants thought it was due to other reasons, such as occult heart disease, and the patient’s ECG showed left ventricular hypertrophy with abnormal repolarization.
Left ventricular hypertrophy can be a physiological manifestation, or it may be a pathological change caused by some diseases, and abnormal repolarization is generally seen in myocardial ischemia.
Considering diseases such as hypertensive heart disease and hypertrophic heart disease, the cause of death may be caused by severe myocardial ischemia or myocardial infarction after anesthesia.
However, there is a lack of laboratory data or pathological diagnosis supporting evidence.
While analyzing the patient's peri-anaesthesia performance throughout the whole process, the author agrees with the first possibility, because the patient has been given oxygen with a mask during epidural anesthesia, the oxygen reserve is sufficient, the anesthesia level is appropriate (T4-L1), does not affect breathing, and during intubation Denitrifying oxygen for a few minutes will make the oxygen reserve more sufficient, which is why SpO2 stays “normal” for 10 minutes.
After intubation, the patient was mistakenly entered into the esophagus.
Due to the effects of general anesthetics and muscle relaxants, the patient did not have any abnormalities.
After the procedure, the flatulence and abdominal bulging of the stomach could not be observed and found, which caused the patient to lose the best time for rescue.
Next, let's take a look at something like the tracheal tube strayed into the esophagus.
Preventive measures for the tracheal tube accidentally entering the esophagus.
Confirm that the tube is in the trachea.
The common method is auscultation.
Observe the normal undulation of the thorax and clear breathing sounds in both lungs.
The depth of the tracheal tube can be adjusted through auscultation.
The auscultation method has certain errors.
PETCO2 monitoring has a higher auxiliary diagnostic value for the tracheal tube strayed into the esophagus.
Compared with the gold standard of fiberoptic broncholaryngoscopy, PETCO2 monitoring is more convenient, rapid and intuitive.
After the blind intubation is completed, the ventilation of both lungs must be checked and the catheter insertion depth must be adjusted.
When changing positions, especially head and neck surgery, thoracotomy, lateral prone surgery, etc.
, the position and ventilation of the tracheal tube should be reviewed.
Clinical signs of the tracheal tube erroneously entering the esophagus.
During auscultation, the xiphoid process was overwhelming with water (grunting noise), gastric flatulence, no fluctuations in the chest with breathing, and even abnormal movements.
Gastric juice or gas overflowed from the catheter, and the patient gradually developed cyanosis, arrhythmia, and his blood pressure increased initially and then decreased.
If it is not corrected in time, cardiac arrest may occur.
SpO decreased within 210 min.
Emergency treatment of the tracheal tube erroneously entering the esophagus.
Insert the tube into the gastric tube to expel gas from the stomach, extubate the tube, and re-mask the positive pressure to give oxygen.
When the hypoxemia is relieved, SpO2 rises to more than 98% and is stable, and then the tracheal tube is accurately inserted.
Complications of tracheal tube mistakenly inserted into the esophagus are hypoxemia and hypercapnia.
Hypertension, tachycardia, arrhythmia.
Mechanical damage to the throat.
Aspiration reflux.
Myocardium is damaged.
Cardiac arrest.
In short, for one of the critical events during the peri-anaesthesia period-the tracheal tube strayed into the esophagus, it must be detected as soon as possible, otherwise the consequences will be severe.
References: [1] The second edition of the clinical guide for anesthesia [2] the second edition of the Concord Medical Manual
.
.
If the tracheal tube strayed into the esophagus, if it was not detected, it would be the most dangerous event in anesthesia.
It is often due to difficult airway or inexperience of the intubator or intraoperative posture changes.
The catheter inserted into the airway slips out into the esophagus.
A recent case in a department where a tracheal tube was mistakenly inserted into the esophagus without being found to cause death is as follows.
Case data: Male, 65 years old, farmer, hospitalized with intermittent upper abdominal pain for more than ten years, had a history of gallbladder stones, cholecystitis, and pancreatitis for many years; had a history of right inguinal hernia surgery, denied diabetes, hypertension, and heart disease , No history of drug sensitivity and family history of genetic diseases.
Vital signs: body temperature 36.
8℃, pulse 69 beats/min, breathing 18 beats/min, blood pressure 124/89 mmHg.
Physical examination: normal development, good nutrition, entered the ward, cooperated with physical examination, clear, no yellowing of the skin and sclera all over the body, no swelling of superficial lymph nodes, no liver palms and spider moles, soft neck; breathing in both lungs The sound is clear, there is no obvious dry and wet rales; the heart rhythm is uniform, no murmur; there is no percussive pain in the kidney area, and no obvious deformities of the limbs and spine are seen.
Specialty status: flat abdomen, soft abdominal muscles, no tenderness, no rebound pain, Murphy's sign (-), liver and spleen not reach under the ribs, liver dullness, no moving dullness, unheard and qi and water sounds, intestines The beeping sound is OK.
The initial diagnosis was gallbladder stones and cholecystitis.
Auxiliary test: Novel coronavirus pneumonia nucleic acid RNA negative (nasopharyngeal swab), new coronavirus pneumonia antibody test: new coronavirus antibody IgM negative, new coronavirus antibody IgG negative.
Three infections: hypersensitive C-reactive protein 0.
90 mg/L, C-reactive protein <5 mg/L, procalcitonin 0.
08 ng/mL, B-type natriuretic peptide precursor (BNP) 285.
00 pg/mL.
Blood amylase: blood amylase 82 U/L.
Liver function: total bilirubin 10.
8 μmol/L, direct bilirubin 4.
9 μmol/L, aspartate aminotransferase 17 U/L, and alanine aminotransferase 8 U/L.
Blood routine: white blood cells 5.
4×109/L, red blood cells 4.
80×1012/L, hemoglobin 164 g/L, platelets 188×109/L.
Chest CT showed lobular emphysema and gallbladder stones in both lungs.
The electrocardiogram showed sinus rhythm, left ventricular hypertrophy and abnormal repolarization.
Cardiac color Doppler ultrasound showed reduced left ventricular diastolic function and 52% EF.
Pre-anaesthesia visit: Elderly patients are in general condition, ASA 2-3 level, and plan to undergo laparoscopic cholecystectomy (LC) under general anesthesia.
The patient asked a well-known professor at the provincial hospital to perform the operation.
After the preoperative preparation is completed, the patient enters the room to open the vein, and routinely monitor the non-invasive blood pressure (NIBP), blood oxygen saturation (SpO2), heart rate, respiration, etc.
, take the T8-9 epidural puncture in the right decubitus position, and place the head after success Tube 3.
5 cm, withdraw blood and cerebrospinal fluid, and fix it properly for use.
After supine, the patient was given 5 mL of 2% lidocaine epidurally, and T4-L1 was measured 5 minutes later, that is, the first dose of 0.
5% levobupika was given Because of 8 mL.
At this time, the professor arrived in the operating room, the anesthesiologist gave oxygen and denitrification with a mask, and immediately induced intravenously: midazolam 2 mg, penehyclidine hydrochloride injection 0.
2 mg, etomidate emulsion 20 mg, sufentanil 25 μg, vitamin After intravenous injection of Curonium 8 mg, an ID7.
5 endotracheal tube was inserted through a clear vision intubation, and an anesthesia machine was connected to control breathing.
The monitor was all normal, and the anesthetist was handed over.
After 10 minutes, the surgeon spread the skin and cut the skin, and found that the blood was purple-black.
At this time, the monitor alarmed, SpO2 dropped rapidly, as low as 69%, blood pressure was 164/99 mmHg high, heart rate increased 120 beats/min, and lips were cyanotic.
The pupils on both sides are slightly larger with a diameter of 5 mm. The succeeding anesthesiologist immediately pulled out the tracheal tube and reintubated it.
After auscultation was correct, the SpO2 slowly rose to 90%.
However, the patient still had dilated pupils, cyanosis, and arrhythmia (premature ventricular contraction R on T).
), rescue immediately, give lidocaine, atropine, epinephrine, etc.
, and defibrillator for backup.
The patient’s cardiac arrest 15 minutes later, intravenous injection of epinephrine 1 mg, three defibrillation was ineffective, and 30 minutes after cardiac compression, both pupils were dilated and fixed, the electrocardiogram showed equipotential lines, and rescue was given up.
.
.
the patient’s family filed a lawsuit over the death of the patient And claim.
Discuss why the patient's SpO2 decreased? Why is the blood purple and black when cutting the skin? Why does the patient have arrhythmia and even cardiac arrest? The intubator claimed that he intubated under his eyesight and saw the tip of the catheter enter the trachea with his own eyes.
It is impossible to accidentally enter the esophagus.
However, after intubation, he did not have a careful auscultation and no end-expiratory carbon dioxide (PETCO2) monitoring.
He was directly connected to an anesthesia machine to control breathing , And then hand over.
At that time, the monitor did not find any abnormality, and there was no alarm signal.
The successor anesthesiologist said that the surgeon said the blood was purple and black.
I suspected that the catheter was not in the trachea.
At that time, the situation was urgent, the monitor alarmed, SpO2 suddenly dropped, and the patient looked cyanotic, so he had to pull out the tracheal catheter and re-intubate.
But then it still declined, vital signs were abnormal, a malignant arrhythmia appeared, the patient's cardiac arrest, and rescue was ineffective.
During the discussion in the whole hospital, 72% of the participants agreed that the tracheal tube was mistakenly inserted into the esophagus, and the patient was hypoxic for too long (10 min), which caused the patient to develop malignant arrhythmia, cardiac arrest and death.
21% of the participants believed that mistakes in selecting appropriate methods of epidural anesthesia plus general anesthesia for intubation led to a series of subsequent consequences for the patient.
The reason is: since the epidural is only for postoperative analgesia, there is no need to give the first dose.
What's more, immediately after the rapid induction of anesthesia, the anesthetic was not reduced.
In short, the effect of epidural circulatory inhibition is followed by anesthesia induction of a large amount of anesthetic drugs into the vein, resulting in severe circulatory collapse and insufficient perfusion leading to a series of subsequent consequences.
7% of the participants thought it was due to other reasons, such as occult heart disease, and the patient’s ECG showed left ventricular hypertrophy with abnormal repolarization.
Left ventricular hypertrophy can be a physiological manifestation, or it may be a pathological change caused by some diseases, and abnormal repolarization is generally seen in myocardial ischemia.
Considering diseases such as hypertensive heart disease and hypertrophic heart disease, the cause of death may be caused by severe myocardial ischemia or myocardial infarction after anesthesia.
However, there is a lack of laboratory data or pathological diagnosis supporting evidence.
While analyzing the patient's peri-anaesthesia performance throughout the whole process, the author agrees with the first possibility, because the patient has been given oxygen with a mask during epidural anesthesia, the oxygen reserve is sufficient, the anesthesia level is appropriate (T4-L1), does not affect breathing, and during intubation Denitrifying oxygen for a few minutes will make the oxygen reserve more sufficient, which is why SpO2 stays “normal” for 10 minutes.
After intubation, the patient was mistakenly entered into the esophagus.
Due to the effects of general anesthetics and muscle relaxants, the patient did not have any abnormalities.
After the procedure, the flatulence and abdominal bulging of the stomach could not be observed and found, which caused the patient to lose the best time for rescue.
Next, let's take a look at something like the tracheal tube strayed into the esophagus.
Preventive measures for the tracheal tube accidentally entering the esophagus.
Confirm that the tube is in the trachea.
The common method is auscultation.
Observe the normal undulation of the thorax and clear breathing sounds in both lungs.
The depth of the tracheal tube can be adjusted through auscultation.
The auscultation method has certain errors.
PETCO2 monitoring has a higher auxiliary diagnostic value for the tracheal tube strayed into the esophagus.
Compared with the gold standard of fiberoptic broncholaryngoscopy, PETCO2 monitoring is more convenient, rapid and intuitive.
After the blind intubation is completed, the ventilation of both lungs must be checked and the catheter insertion depth must be adjusted.
When changing positions, especially head and neck surgery, thoracotomy, lateral prone surgery, etc.
, the position and ventilation of the tracheal tube should be reviewed.
Clinical signs of the tracheal tube erroneously entering the esophagus.
During auscultation, the xiphoid process was overwhelming with water (grunting noise), gastric flatulence, no fluctuations in the chest with breathing, and even abnormal movements.
Gastric juice or gas overflowed from the catheter, and the patient gradually developed cyanosis, arrhythmia, and his blood pressure increased initially and then decreased.
If it is not corrected in time, cardiac arrest may occur.
SpO decreased within 210 min.
Emergency treatment of the tracheal tube erroneously entering the esophagus.
Insert the tube into the gastric tube to expel gas from the stomach, extubate the tube, and re-mask the positive pressure to give oxygen.
When the hypoxemia is relieved, SpO2 rises to more than 98% and is stable, and then the tracheal tube is accurately inserted.
Complications of tracheal tube mistakenly inserted into the esophagus are hypoxemia and hypercapnia.
Hypertension, tachycardia, arrhythmia.
Mechanical damage to the throat.
Aspiration reflux.
Myocardium is damaged.
Cardiac arrest.
In short, for one of the critical events during the peri-anaesthesia period-the tracheal tube strayed into the esophagus, it must be detected as soon as possible, otherwise the consequences will be severe.
References: [1] The second edition of the clinical guide for anesthesia [2] the second edition of the Concord Medical Manual
