Laparoscopic gastric reduction surgery placed in The Bogie gastric support tube leading to an abnormality in the blood pressure of the artery

The patient, 26 years old, is in good healthDue to weight aggravation in the full hemp down
laparoscopicsleevestomachexcision, height 170 cm, weight 100 kg, BMI 34.60kg/m2, Mallampti III classPatients havethe history of hypertensionanddiabetes, conscious, self-subjectNormal development, neck fat build-up, overnutritionAccompanied by sleep apnea syndromeFastbefore before surgerypatients into the operating room, open the peripheral venous pathway, the right side of the hemp down the tibia punctured tube and monitored the invasive artery pressureFull hemp induction: The dose of the anaesthetic is calculated according to thin weight, i.e thin weight , actual weight x (1-body fat rate) Full yin denitrogen intravenous injection of midazolam 2mg, propofol 200mg, fentanyl 0.2mg, shun aquor ammonium 25mg, inserted under the visual laryngoscope 7.5 , fiber bronchoscopy confirmed patients 81 times/min, BP 134/86mmHg, SpO2 97% Induced HR 64 times/min, BP 121/77mmHg, SpO2 100% Anesthetic machine maintains breathing, VT600ml, RR 12 times/min, Ppeak 30 to 34 cmH2O, FiO2 50% In surgery to give propofol 4 mg kg-1 h-1, riffentanil 0.2 sg.kg-1-min-1, intermittently pushed shun-type aquku ammonium maintenance anesthesia Separation gastric big bend, through the mouth inserted into the Bougie gastric support tube, clear Bougie gastric support tube placed in the stomach after the arterial blood pressure indicates the disappearance of arterial waveform, HR 73 times / minute, BP 62/33mmHg, right SpO2 99%, suspended surgery left upper limb cuff test BP 128/85mmHg, heparin water punch arterial catheter, back pumping artery blood flow, touch the right arterial no throbbing, touch the left artery and artery prompt the beating normal, the two-sided neck movement pulse is normal Replacement of arterial conductors, arterial waveforms are not restored, considering The Bougie gastric support tube caused, so pull out the Bogie gastric support tube, there is arterial blood pressure and waveform recovery, re-inserted Bougie gastric support tube, right artery blood pressure and waveform disappear, during the operation ultrasound indicates normal double-sided cervical artery filling normal, HR 75 times/min, BP 129 /82mmHg, SpO2 99%, patient vital signs stable, consider Bougie gastric support tube local compression vascular , continue surgery, the operation process is smooth, surgery time 150min, surgical natural awakening, give Xins Ming and Atropine antagony, pull the tube smoothly, the patient did not complain of obvious special discomfort 3d discharged after surgery discussion
gastric sleeve excision is 70% of the stomach tissue sleeve removal, including the stomach bottom, the general step is to use laparoscopic , separation of gastric bends, placed in the Bogie gastric support tube to guide the role, the use of cutting closure along the direction of the long gastric axis to remove most of the stomach wall, the remaining gastric cavity is "banana-like." The lost right clavian artery (ARSA) is also known as the transpositional right clavian artery, a congenital malformation in the arch of the main artery that occurs during the of the embryo, and the artery under the right clavicle passes through the back of the esophagus Natsis et al are 0.16% to 4.40% high eras in the 2017 latest statistics, and indicates that it is most common in aortic bow abnormalities Only 10% of the lesions show clinical symptoms due to ARSA's compression of the esophagus Wang Willen and others in the esophageal smooth fibroid surgery found that the aortic arch has a diameter of 0.8 cm of avariant artery, the autonomic artery arch left back wall, through the esophagus rear oblique upward walk, consider for the loss of the right clavicle artery, blocking the artery after the right tibia pulse disappeared, BP from 120/80mmHg to 55/40mm The symptoms of this patient during surgery are consistent with them Suzuki et al described in 2012 a case of ARSA patient esophagus ultrasound on the second day of the digestive endoscopy showed a large amount of fresh blood in the stomach, indicating that the esophagus ultrasound probe placed in patients with arteries under the right collarbone is potentially dangerous the patient in the Bougie gastric support tube, the right arterial blood pressure disappeared, the right tibia pulse disappeared, pullout the Bogie gastric support tube after the artery blood pressure recovery, the pulse movement of the tibia also resumed, and the left artery and the pulse movement of the tibia, the two-sided neck movement of the pulse consistent The Bougie gastric support tube is the same diameter as the 7.5-degree trachea duct, but compared with the trachea catheter, the hardness is strong and the diameter is much larger than that of the normal gastric tube compared to the normal gastric tube comprehensive literature reports and patients in this case are likely to have ARSA, which compresses the ARSA after placing Bougie's gastric support tube, causing the right tibia to disappear Therefore, before surgery should be more detailed understanding of the patient's medical history, whether to combine dysphagia, breathing difficulties and other symptoms in surgery encountered an unknown side of blood pressure drop, pulse disappear, in the exclusion of the cause of surgical anesthesia should be measured on the side blood pressure and pulse, the elimination of variation vascular factors caused by the appearance of blood pressure drop, and should not blindly give the rise of drugs, resulting in adverse consequences At the same time, we should closely monitor the blood supply of the affected limbs, communicate with surgeons, shorten the operation time, prevent the occurrence of ischemia caused by prolonged compression of blood vessels , although the incidence of the patient's lost right collarbone artery is low, most patients do not have clinical symptoms, but when placed in the Bougie gastric support tube, due to its location variation, it is likely to compress the surrounding organizational structure, resulting in the appearance of blood pressure drop Clinically, when experiencing symptoms such as the disappearance of one side pulse, it is necessary to be alert to the possibility of an offside collarbone artery