Clinical anesthesia and analgesia diagnosis and treatment difficult and critical discussion essence gestation, gestation 2 0 weeks, rheumatic heart disease, mitral stenosis, pulmonary hypertension, cardiac function grade III.~IV., emergency cesarean section

2 weeks gestation, rheumatic heart disease, mitral stenosis, pulmonary hypertension,

Cardiac function grade III.
~IV.
, quasi-emergency cesarean section

Case introduction

Discuss analytical thinking questions

1.
How is the patient pre-operative evaluation?

2.
What are the principles of anesthesia management for pregnant patients with heart disease?

3.
What is the diagnosis of dyspnea after the delivery of the fetus? The reason? How to deal with it?

Clinical thinking essentials

1.
Patient-issued preoperative assessment: cardiac function grade III.
~IV.
, patient Goldman score of about 17 points, anesthesia risk is great
.

2.
Strictly grasp the anesthesia treatment principles of pregnant patients with heart disease to ensure the safety of
patients' surgical anesthesia.

3.
Acute pulmonary edema occurs after the delivery of the fetus.

There are many causes of acute pulmonary edema, and common factors include too much fluid production or too little elimination, or both
.
The treatment principle of acute pulmonary edema is to reduce the hydrostatic pressure of pulmonary vessels, increase the osmotic pressure of plasma colloid, improve the permeability of pulmonary capillaries, give sufficient oxygen, and correct hypoxemia
.

Refer to the answer

1.
The patient's preoperative evaluation focuses on the assessment of cardiac function

(1) According to the New York Heart Association (NYHA) Cardiac Function Classification:

Grade I.
, physical activity is not restricted, no excessive fatigue after general physical activity, no palpitations, dyspnea or angina;

Grade II.
, physical activity is slightly restricted, comfortable at rest, general physical activity can cause fatigue, palpitations, dyspnea or angina;

III.
, physical activity is obviously limited, rest fashion sense comfortable, but light physical activity causes fatigue, palpitations, dyspnea or angina;

Grade IV, has completely lost the ability to be physically active, heart failure symptoms or angina may still exist at rest, and any physical activity will aggravate
the symptoms.

In this case, the patient's cardiac function was
grade III.
~IV.
.

(2) The multifactorial cardiac risk index proposed by Goldman et al.
(Table 1-1) provides preoperative evaluation indicators for non-cardiac surgery in heart patients, and can be used to predict the risk, cardiac complications and mortality of perioperative patients (Table 1-2).

In this case, the Goldman score was about 17 points (heart failure manifestations, abdominal surgery, emergency surgery).

Table 1-1 Goldman Multifactorial Cardiac Risk Index

Table 1-2 Cardiac function classification and cardiac risk factor score pairs

Relationship between perioperative cardiac complications and cardiac mortality

*Nonfatal myocardial infarction, congestive heart failure, and ventricular tachycardia

2.
For patients with pregnancy complicated with heart disease, regardless of the choice of anesthesia method, it should achieve:

• Pain relief perfect
  .
  

• Does not significantly affect the compensatory capacity
  of the cardiovascular system.
  

• There is no significant inhibition
  of myocardial contractility.
  

• Maintain stable circulation and ensure blood supply
  to important organs.
  

• Does not promote arrhythmias and increase myocardial oxygen consumption
  .
  

• The level of
  anesthesia should be controlled when selecting neuraxial anesthesia.
  

• Prepare
  your newborn for first aid.
  

3.
Diagnosis, cause analysis and treatment of dyspnea in patients after delivery of the fetus

In this case, dyspnea after delivery of the fetus should be diagnosed as acute pulmonary edema
.

Clinically, acute pulmonary edema manifests as sudden dyspnea, cyanosis, jugular venous distention, cough, and pink foamy sputum
.
Auscultation reveals crackles and wheezing
, both lungs.
In the late stage, shock, confusion, arrhythmia, etc.

appear.

There are many causes of acute pulmonary edema, which can be summarized as either too much fluid produced or eliminated too little, or both
.
It is illustrated
from the following eight aspects.

1.
Increased hydrostatic pressure in pulmonary capillaries:

(1) Cardiogenic, such as mitral stenosis, left heart failure, cardiomyopathy, etc.
;

Non-cardiogenic, mostly related to pulmonary vein stenosis and occasive diseases, such as congenital pulmonary venous root stenosis, mediastinal granulomas, pulmonary vein stenosis caused by mediastinal tumors;

(3) Excessive
infusion.

2.
Increased permeability of the vascular wall:

Common causes include infection, circulating toxins, vasoactive substances, DIC, uraemia, aspiration pneumonia, radiation pneumonia, ARDS, acute hemorrhagic pancreatitis, diffuse capillary leak syndrome, etc
.
They cause increased
vascular wall permeability through humor, cellular, or neurological factors.

3.
Lymphatic system drainage disorders: seen in lung transplantation, silicosis, etc.
, increasing the fluid volume and protein content
of lung tissue space.

4.
Decreased colloidal osmotic pressure: seen in hypoproteinemia, nutritional deficiency and loss of intestinal protein.

5.
Increased negative pressure between the lungs: the common clinical conditions are pulmonary edema and remanating pulmonary edema
after upper respiratory tract obstruction.

6.
Unexplained pulmonary edema: such as after pneumonectomy, high-altitude pulmonary edema, pulmonary embolism, parenchymal lung lesions, eclampsia, cardiocardioversion, cardiopulmonary bypass, etc
.

Pulmonary edema
during anesthesia.

7.
Neurogenic pulmonary edema: after sympathetic overexcitation, blood is transferred from peripheral to central circulation, left atrial and left ventricular compliance decreases, pulmonary capillary wedge pressure increases, and then pulmonary edema
occurs.

Circulating blood volume during pregnancy increases by 30%-40%.

Increased
cardiac workload.
After the delivery of the fetus, the uterine blood sinus closes, the placental blood circulation stops, the blood in the uterus enters the circulation, the amount of blood returning to the heart increases after the sudden drop in abdominal pressure, and the afterload decreases sharply, which has a great
impact on cardiac function.

In this case, the heart load increases after the delivery of the fetus, resulting in left heart failure, resulting in acute pulmonary edema
.

    The treatment principle of acute pulmonary edema is to reduce the hydrostatic pressure of pulmonary vessels, increase the osmotic pressure of plasma colloid, improve the permeability of pulmonary capillaries, give sufficient oxygen, and correct hypoxemia
.

• Enhance myocardial contractility: cardiac glycosides can enhance myocardial contractility, prolong the diastolic filling interval, reduce the average pressure of pulmonary capillaries, aminophylline can increase myocardial contractility, reduce afterload, but also relax bronchial smooth muscle, increase renal blood flow and sodium excretion
  .
  

  
  

• Reduce cardiac afterload: nitropruna and nitroglycerin can reduce peripheral vascular resistance, improve left ventricular expulsion effect, and reduce left ventricular filling pressure
  .
  

  
  

• Reduce circulating blood volume and reduce preload: lower extremity tourniquets, injected morphine, diuretics, etc
  .
  can be used.
  

• Cortisol hormones: cortisol hormones suppress inflammation, prevent increased capillary permeability, and promote the resolution
  of swelling.
  

• Adequate oxygen and respiratory support: intermittent positive pressure ventilation (IPPV) should be used for severe hypoxaemia that cannot be corrected with high-flow oxygen.
  
  If there is no significant improvement in symptoms with IPPV, PEEP
  should be used.
  Oxygen blowing in by oxygen inhalation with a defoaming agent such as a 50% ethanol solution eliminates foamy sputum
  from the respiratory tract.