[Challenge] How do you deal with sudden intractable hypotension under general anesthesia during peri-anesthesia?

Sudden refractory hypotension during peri-anesthesia period Hang Bo typesetting Luo Na 1.
Occurrence and harm of sudden refractory hypotension during peri-anesthesia period Clinical symptoms in which blood pressure cannot be restored to normal after symptomatic treatment such as blood transfusion, fluid replacement, and vasopressors in patients with up to 80 mmHg
.

It is most common in shock, trauma, and major surgery.
It is a serious perioperative complication, with an incidence of 9% to 44%, and a mortality rate as high as 25%
.

Intractable hypotension during the peri-anesthesia period is due to the long-term low intravascular pressure, resulting in slow blood circulation and distal capillary ischemia, which affects the supply of oxygen and nutrients to tissue cells, and the excretion of carbon dioxide and metabolic waste
.

Since the drop in blood pressure affects the blood supply to the brain and heart, the function of the body is greatly reduced
.

It also increases perioperative complications and mortality
.

Refractory hypotension in the perioperative period, due to the prolonged period of hypotension, will present: ① cerebral embolism and cerebral hypoxia; ② coronary insufficiency, myocardial infarction, heart failure and even cardiac arrest; ③ renal insufficiency, anuria , oliguria; ④ Vascular embolism, which can be seen in various parts of the blood vessel
;
Once intractable hypotension occurs in the perioperative period, medical staff not only have to increase the cost of drug treatment, but also supplement certain inspection items, which will inevitably directly increase the economic burden of patients
.

2.
Analysis of the causes of sudden refractory hypotension during peri-anesthesia Endogenous catecholamine inactivation and adrenergic receptor desensitization, accumulation of metabolites, increased vascular permeability, arteriolar smooth muscle cell membrane hyperpolarization and changes in ion channels, cell membrane hyperpolarization, cytokine (NO, etc.
) effects, Oxygen free radicals, superoxide, etc.
, are mainly manifested in septic shock, anaphylactic shock, neurogenic shock, and other intractable hypotension due to adrenal crisis, mucous coma, and toxic shock
.

(2) Obstructive hypotension: caused by obstruction of blood flow in the cardiovascular circuit, characterized by abnormal diastolic filling or excessive afterload.
Common causes of such intractable hypotension are cardiac tamponade, tension pneumothorax, Pulmonary embolism, aortic dissection,
etc.

(3) Hypovolemia: such as massive intraoperative bleeding
.

(4) Cardiogenic hypotension: for example, patients with right-sided heart failure, left-sided heart failure and total heart failure, heart failure caused by severe arrhythmia,
etc.

2.
Specific reasons (1) Anesthesia factors: myocardial inhibition and vasodilation of various anesthetics and auxiliary anesthetics, hypoCO2 caused by hyperventilation, hypovolemia and hypokalemia caused by excessive urination, Acidosis caused by hypoxia, as well as effects such as hypothermia, can cause different degrees of hypotension
.

(2) Surgical factors: excessive intraoperative blood loss could not be replenished in time, parasympathetic reflexes caused by surgical operations in areas with rich parasympathetic nerve distribution, surgical operation compressing the heart and great blood vessels, open heart surgery, and TURP in urethral resection of the prostate Syndromes (dilutional hyponatremia) can cause varying degrees of hypotension
.

Electrovascular paralysis syndrome occurs during cardiac surgery, resulting in refractory hypotension, which requires clinical attention
.

(3) Patient factors: obvious hypovolemia before surgery without correction, adrenal cortical failure, severe hypoglycemia, sharp decrease in plasma catecholamines (after pheochromocytoma resection), arrhythmia or acute myocardial infarction, etc.
With varying degrees of hypotension
.

Patients with preoperative cardiac insufficiency, such as mitral stenosis, aortic regurgitation, recent myocardial infarction (myocardial infarction within 6 months), third-degree atrioventricular block and sick sinus syndrome, severe Arrhythmias (frequent premature ventricular contractions, multifocal premature ventricular contractions)
.

The patient had severe hypokalemia before surgery
.

The patient received long-term corticosteroid therapy before surgery
.

In patients with long-term hypertension, the cardiovascular system is less sensitive to adrenal receptors, and the vasoconstriction and diastolic functions are in a "paralyzed state", resulting in endocrine disorders and hypothyroid crisis
.

(4) Other factors: The drugs and fluids used in the perioperative period may cause allergic reactions in some patients with special constitutions
.

For example, patients who are allergic to soy products may have allergic reactions to propofol; polygelatin injection can also cause allergic reactions in some patients, and even severe allergic reactions (such as nausea, vomiting, hypotension, respiratory difficulty, shock, etc.
) refractory hypotension
.

(5) Comprehensive factors: such as severe vascular anesthesia syndrome in cardiac surgery, refractory shock with high cardiac output and low vascular resistance, no improvement in symptoms or insignificant improvement after fluid supplementation, requiring a large number of patients.
vasoactive drugs, but hypotension may still occur
.

3.
Coping strategies for sudden refractory hypotension during the peri-anesthesia period In order to prevent the occurrence of refractory hypotension during the peri-anesthesia period, the following principles can be followed
.

(1) Preoperative treatment measures 1.
For patients with fluid deficiency, they should be fully supplemented according to the deficiency, and the electrolyte and acid-base status should be restored to normal
.

2.
For patients with severe anemia, the hemoglobin should be raised to normal
.

3.
For patients with severe mitral stenosis, avoid using anesthetics and auxiliary anesthetics that have a significant inhibitory effect on the cardiovascular system
.

4.
For patients with coronary heart disease who have myocardial ischemia, the blood pressure should be maintained at a level that does not cause further ischemia in ST segment and T wave
.

5.
For patients with myocardial infarction, unless emergency surgery, elective surgery should be performed after 6 months
.

6.
Patients with heart failure should be operated again after 2 weeks of heart failure control
.

7.
For patients with third-degree atrioventricular block and sick sinus syndrome, a pacemaker should be placed to ensure a normal heart rate
.

8.
For patients with arrhythmia caused by hypokalemia, efforts should be made to raise serum potassium to normal levels
.

9.
For patients with atrial fibrillation, maintain the ventricular rate at 80 to 120 beats/min
.

10.
For patients who have received glucocorticoid therapy for a long time, the dosage of corticosteroids should be increased before and during the operation, so as to prevent the blood pressure from being difficult to recover after the reduction
.

11.
Patients who take Beijing Jiangyaling antihypertensive drugs for a long time will deplete the storage of sympathetic nerve conduction mediator norepinephrine in the postganglionic terminals of sympathetic nerves, which may lead to intractable hypotension due to depletion of norepinephrine and enhanced parasympathetic activity.
Sympathetic activity inhibition
.

Therefore, it is necessary to stop the drug for 2 to 6 days before surgery
.

12.
For patients with endocrine disorders, if there are symptoms of hypothyroidism, thyroid function should be adjusted before surgery to avoid intractable hypotension caused by hypothyroid crisis
.

(2) Intraoperative treatment measures 1.
In case of severe hypotension during the peri-anesthesia period, the anesthesia should be reduced immediately, and attention should be paid to the changes of SpO2 and PETCO2
.

At this time, if the central venous pressure is not high, the infusion should be accelerated, and the input of plasma preparations is more conducive to blood pressure recovery
.

2.
For patients with severe coronary heart disease, if hypotension occurs repeatedly during the operation, it indicates that myocardial infarction is about to occur, and monitoring should be strengthened, and all measures should be taken to support the heart pump function
.

3.
For the hypotension caused by the operation of the internal organs, the operation should be suspended and the vasopressor should be injected intravenously
.

4.
For hypotension with adrenal insufficiency, high-dose glucocorticoids should be given in time, and vasopressors should be given at the same time
.

5.
Once the blood pressure cannot be measured during the operation, regardless of the cause, external cardiac compression should be performed immediately and cardiac resuscitation should be performed
.

6.
During surgery, especially during general anesthesia, some allergic symptoms of patients are covered up due to the use of anesthesia, and are easily confused with complications of anesthesia and surgery.
Note, closely observe vital signs and skin and mucous membranes, and make timely judgments.
Once allergic, stop the drug immediately, and at the same time give epinephrine hydrochloride injection, glucocorticoid drugs, vasopressors, volume expansion, antihistamines to maintain hemodynamics Smooth while correcting electrolyte balance
.

7.
When intractable hypotension caused by acid-base and electrolyte imbalance, actively correct acid-base balance and electrolyte imbalance, and give continuous renal replacement therapy (CRRT) in time if necessary
.

8.
For patients with sudden severe arrhythmia, anti-arrhythmic drugs should be actively used according to the patient's cardiac function, and a defibrillator should be used if necessary to maintain stable hemodynamics
.

9.
For surgical patients with pheocytoma, intractable hypotension after tumor resection should be actively given catecholamine vasoconstrictor drugs such as phenylephrine, norepinephrine, α- Adrenoceptor agonists,
etc.

10.
For patients with major intraoperative hemorrhage, the need for early fluid resuscitation is determined according to the degree of blood loss and body condition.
For patients with uncontrolled bleeding, restrictive fluid resuscitation can be used to maintain the patient's blood pressure at a low level that can barely maintain tissue perfusion.
Permissive hypotension, the so-called delayed resuscitation, after the blood volume is controlled, fluid resuscitation should be performed actively, blood products should be given in time according to blood gas analysis and coagulation indicators, and vasoactive drugs should be used flexibly to maintain relatively stable hemodynamics , protect the function of important organs
.

11.
For refractory hypotension due to thromboembolism during operation, end-tidal carbon dioxide partial pressure, coagulation function should be monitored in time, lung signs should be checked, chest X-ray film during operation, and thrombolytic therapy should be timely after diagnosis
.

12.
For refractory hypotension due to pneumothorax during operation, closed drainage should be performed immediately
.

13.
For severe vascular anesthesia syndrome that may occur in cardiac surgery, a Swan-ganz catheter should be placed before surgery to obtain right heart preload, afterload and pulmonary artery wedge pressure for monitoring.
After diagnosis, add fluid to increase myocardial contractility.
Drugs and other catecholamines (preferred norepinephrine) combined with vasopressin to treat hypotension
.

14.
For patients with septic shock, under the condition of monitoring indicators such as lactate level, mean arterial pressure and vascular resistance index, actively administer catecholamines represented by norepinephrine, and appropriately use vasopressin, posterior pituitary vasoactive drugs such as hormone, glucocorticoid therapy and active anti-infective therapy if the hemodynamics is still unstable after treatment
.

15.
Sudden bone cement implantation syndrome in elderly patients undergoing total hip replacement, leading to intractable hypotension, hypoxia, arrhythmia, diffuse pulmonary microvascular embolism, shock, and even cardiac arrest, should be reminded during the operation Surgeons, to prevent massive bleeding, prophylactic expansion before prosthesis implantation, prepare vasoactive drugs, and gentle movements during prosthesis implantation to prevent excessive intracavitary weakness and pulmonary embolism
.

In case of sudden intractable hypotension during operation, medical staff should do it.
During preoperative anesthesia follow-up, the anesthesiologist should fully communicate with patients and their families under the premise of fully understanding the patient's condition, and explain perioperative anesthesia.
Risks.
At present, the strong medical team in hospitals and departments, especially anesthesia experts who are good at various operations, emphasize that if such a situation occurs, medical staff will actively rescue them, but success is not guaranteed.
Let patients and their families understand the risks of surgery and anesthesia.
, Have sufficient psychological preparation, gain the trust of patients and their families, and report to the medical office if necessary
.

If this happens unfortunately during the operation, it should be intervened early and timely, which has a significant effect on improving the prognosis.
At the same time, the prognosis should be judged and communicated to the patient's family in a timely manner, explaining the cause and treatment measures, and in line with the purpose of "patient-centered, saving the dying".
, to obtain the understanding and support of the patient's family to reduce medical disputes
.

At the same time, in accordance with the medical rescue procedures, the records of the rescue process will be improved in detail
.

4.
Thinking of sudden intractable hypotension in peri-anesthesia period Faced with possible sudden intractable hypotension in peri-anesthesia period, we should think carefully, actively prevent, and do the following aspects
.

1.
Strengthen the awareness of prevention, do a good job in preoperative visits, and fully understand the patient's condition, past history, and allergy history
.

Detailed assessment of the patient's cardiopulmonary function and the reserve function of other vital organs
.

If necessary, please consult a specialist, deal with complications in a timely manner, and comprehensively assess the risks of surgery and anesthesia
.

2.
Improve the system and strengthen the quality.
First of all, the hospital and the anesthesiology department should have drugs and a well-equipped first-aid kit, and check them regularly to prevent omissions.
At the same time, there should be a corresponding first-aid team.
In the process of active rescue, doctors should seek help from them in time and strengthen teamwork; secondly, improve the medical ethics and professional skills of medical staff, and conduct regular medical ethics education and professional skills assessment to improve the overall "combat readiness" of medical staff.
Make the medical care work take the patient's life as its own responsibility, and continuously strengthen and improve the first aid work in the perioperative period
.

3.
Make preparations For the possible causes of refractory hypotension during the perioperative period, under the premise of fully understanding the patient's condition, you should actively prepare for rescue before surgery, prepare first-aid supplies and medicines, and prepare them at any time
.

4.
Strengthen observation During the peri-anesthesia period, strengthen monitoring of vital signs and skin and mucous membranes, early detection and active treatment of related complications, and improvement of blood perfusion of important organs.
During surgery, especially during general anesthesia, patients are in an unconscious state, and In emergencies, some important symptoms and signs can only be found by medical staff in the operating room, so intraoperative monitoring should be strengthened, such as monitoring of hemodynamics, mainly including monitoring of circulatory volume, arterial blood pressure, and tissue perfusion.
Monitoring of pulmonary artery catheter (PAC) and pulse indicating continuous cardiac output (PiCCO) can help reduce the uncertainty of clinical assessment
.

5.
Improve diagnosis and treatment management and timely grasp the causes of intractable hypotension
.

In the event of sudden refractory hypotension during surgery, while closely observing the patient, we should grasp the causes of the occurrence and the mechanisms of various causes in time, and use the latest guidelines to guide the treatment methods, so as to be targeted
.

For example, for patients with severe infection and relative adrenal insufficiency that are prone to occur after radiotherapy and chemotherapy for malignant tumors, cortisol and adrenocorticotropic hormone levels should be checked when active resuscitation and symptomatic treatment fails to respond, and glucocorticoids should be administered experimentally.
treatment
.

For patients taking long-term antihypertensive drugs, a low-dose, slow-induction strategy should be used during anesthesia induction
.

In the event of intractable hypotension during the operation, there should be first-class equipment, complete drugs, a strong medical team, and perfect operation procedures.
While trying to rescue the patient, learn to protect yourself
.

5.
Typical case sharing of sudden intractable hypotension during perianesthesia incision
.

Past medical history: There was a history of hypertension in the past, and the blood pressure was controlled at about 140/80 mmHg by taking nifedipine sustained-release tablets
.

Preoperative liver and kidney functions were normal, and chest X-ray examination showed no abnormality; hemoglobin was 119 g/L, hematocrit was 35%; electrocardiogram showed sinus rhythm, pulmonary type P wave, and left ventricular hypertrophy; pulmonary function indicated: small airway disease, the largest The ventilation volume (MW) was 66L/min, which was 77% of the predicted value, and the ventilation reserve was 89%
.

Entering the operating room: After entering the operating room, peripheral venous access is established and routine monitoring is performed
.

Heart rate 90 beats/min, blood pressure 130/80mmHg, respiration 16 beats/min, SpO293%, SpO2 can reach 98% after mask oxygen inhalation
.

Anesthesia method: Combined spinal-epidural anesthesia was used
.

L3-4 space puncture through the subarachnoid space to inject mixed drugs (0.
75% ropivacaine hydrochloride 2ml and 10% glucose 1ml)
.

The epidural puncture space was L1-2, and a 3cm tube was placed at the head end.
The puncture and cannulation were smooth, and the block plane was at the T10 level
.

Surgical procedure: Bilateral orchiectomy was performed before the supine position, and the operation time was 1h
.

The patient underwent transurethral resection of the prostate (TURP) after changing the lithotomy position.
After 20 minutes, the patient began to experience a progressive decrease in blood pressure, with a blood pressure of 88 to 66/58 to 45 mmHg and a heart rate of 75 to 90 beats/min.
The patient had no special complaints and was given rapid fluid replacement.
(1500ml of compound sodium lactate, 1000ml of hydroxyethyl starch, 500ml of sodium-potassium-magnesium-calcium glucose solution) and intermittent intravenous injection of vasopressors (a total of 30mg of ephedrine, a total of 120ug of phenylephrine), the therapeutic effect is not obvious, and the systolic blood pressure is still low at 85mmHg
.

Dopamine was changed to 5~10/(kg.
min) by continuous intravenous infusion, and the right internal jugular vein was punctured and catheterized.
The central venous pressure was 3 cmH2O.
The invasive blood pressure was measured by left radial artery puncture.
Arterial blood gas analysis showed: pH 7.
46, BE 0.
5 , Hematocrit 26%, Hemoglobin 89g/L, K+3.
9mmol/L, Na+137mmol/L, the rest of the indicators are in the normal range
.

Dilutional hyponatremia was excluded and hypovolemic shock was considered
.

The surgical field and incision were examined, and a huge raised mass was found under the incision in the left groin area, and active bleeding in the incision was considered
.

That is, general anesthesia was changed, and anesthesia induction was completed with fentanyl 0.
15 mg, etomidate 15 mg, and vecuronium bromide 6 mg.
After tracheal intubation, sevoflurane inhalation and intermittent intravenous atracurium were used to maintain an appropriate depth of anesthesia
.

Exploration of the surgical incision in the left groin area, it was found that the internal spermatic artery ligation line fell off and caused active bleeding, and the bleeding artery was re-ligated and sutured, and the cumulative blood loss was about 2000ml
.

During the period, 500ml of succinyl gelatin, 1000ml of compound sodium lactate, 6U of red blood cell suspension and 200ml of plasma were infused through the right internal jugular vein
.

The systolic blood pressure gradually rose and maintained above 110mmHg, the heart rate was 70~80 beats/min, the central venous pressure was 6~8cmH2O, the dose of dopamine was gradually reduced to stop, and the hemodynamics were stable
.

Arterial blood gas analysis was performed again 10 minutes before the end of the operation: K+3.
5mmol/L, hematocrit 30%, hemoglobin 102g/L, BE-2
.

The whole operation lasted about 4 hours.
After the operation, the patient recovered spontaneously and was sent to the intensive care unit for respiratory support treatment
.

Two days after the operation, the patient's hemodynamics was stable, his consciousness was clear, his muscle strength and various reflexes recovered well, and the tracheal tube was removed
.

The patient recovered well and was discharged 10 days after the operation
.

Case 2, the patient, male, 73 years old, 170cm tall, weighs 50kg, was admitted to the hospital due to "dizziness with transient loss of consciousness and fell on the right hip for half a day", the diagnosis was: right femoral neck fracture, transient ischemic attack, old-fashioned Cerebral infarction (right lentiform nucleus), planned right total hip replacement surgery
.

Past medical history: gastric ulcer for more than 30 years, Meniere's disease for more than 30 years, no recent attack
.

Stage I coal worker pneumoconiosis for 3 years
.

The chief complaint is a history of penicillin allergy (shock due to use 50 years ago, and experience in first aid resuscitation, the details are unclear), and a history of multiple drug and food allergies (such as leeks, etc.
), the details are unclear
.

I usually do not dare to take western medicine but take traditional Chinese medicine for treatment
.

Physical examination: blood pressure 130/70mmHg, heart rate 80 beats/min, body temperature 36.
8C, respiration 21 beats/min
.

The patient was clearly conscious, answered the question to the point, the lips were slightly cyanotic, the jugular vein was full, the breathing was even, the breath sounds of both lungs were thick on auscultation, the heart sound was strong, P2>A2, and no murmur was heard
.

Laboratory tests: blood routine white blood cells 7.
91 X 109/L, red blood cells 4.
47 X 109/L, hemoglobin 135g/L, platelets 203 X 109/L, no abnormal liver and kidney function, blood sugar, and potassium, sodium, chloride plasma series No abnormality was found; coagulation international normalized ratio (INR) 1.
0, fibrinogen (Fib) 2.
91g/L; electrocardiogram showed sinus rhythm; ST changes, chest X-ray showed thickening and disorder of lung markings
.

Entering the operating room: The patient did not use preoperative drugs.
After entering the room, the blood pressure was routinely monitored at 130/60 mmHg, heart rate at 90 beats/min, and SpO at 96%
.

Mask oxygen inhalation, intravenous injection of fentanyl 0.
05mg, dexamethasone 10mg
.

Anesthesia method: First, under the guidance of nerve stimulator, inject 10ml of 2% lidocaine, 5ml of 1% ropivacaine, and 5ml of normal saline for right femoral nerve block
.

After 15 minutes of drug injection, the pain of the hip joint was relieved from acupuncture to the knee joint, and there was no anesthesia complication
.

After radial artery puncture and catheterization to establish invasive monitoring, general anesthesia was induced with propofol 60 mg, fentanyl 0.
2 mg, and rocuronium bromide 30 mg, and the tracheal catheter was successfully inserted, and the intubation process was stable in hemodynamics
.

Propofol 2-3 mg/(kg·h) and ramifentanyl 0.
05-0.
08 Ug/(kg·min) were infused by pump, and 10 mg rocuronium bromide was added to maintain general anesthesia at 1 hour intervals
.

A small incision was used for the operation.
It took 3 hours from the beginning of anesthesia to the completion of reaming, 900ml of blood oozing, 1500ml of crystalloid, 1000ml of colloid, and 300ml of urine, and the hemodynamics was stable
.

Prophylactic application of 5mg ephedrine before implantation of bone cement appropriately raised blood pressure to 140/70mmHg, bone cement implantation was successful, and blood pressure was stable
.

When the femoral stem is pressed, the blood pressure suddenly drops to 30/20mmHg, the SpO2 cannot be measured, the heart rate drops from 100 beats/min to 80 beats/min, and the PETCO2 drops from 35mmHg to 20mmHg.
Consider the "bone cement reaction and the possibility of pulmonary embolism", immediately Surgery was suspended and rescue started
.

Intravenous injection of epinephrine 1.
0mg, dexamethasone 20mg, blood pressure gradually increased to 180~240/100~130mmHg
.

After 5 minutes of maintenance, the blood pressure dropped sharply again.
After intravenous injection of epinephrine 1.
0mg, the blood pressure rose to 120/40mmHg and the heart rate was 140 beats/min.
After 1 minute, it dropped to 30/20mmHg again.
Intravenous injection of epinephrine 1.
0mg, blood pressure rose to 140/70mmHg, but it was difficult to maintain blood pressure, and it dropped sharply within 1min.
After that, dopamine, epinephrine, and norepinephrine were given repeatedly to increase blood pressure
.

And given calcium gluconate, hydrocortisone, dexamethasone, promethazine and other anti-allergic measures, epinephrine, dobutamine, sodium bicarbonate and other measures such as cardiotonic and acid correction to restore circulatory function, but with little effect
.

Blood pressure can not be effectively raised, and heart rate is kept at 80~125 beats/min, SpO287%-100%, PetCO2 20~37mmHg
.

After the rescue was maintained for 3 hours, the patient had cardiac arrest, and chest compressions were given to continue the rescue for 2 hours.
Eventually, the patient died
.

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