Severe OSAHS was associated with 1 case of anaesthetic management of the jaw bone in patients with severe jaw deformities.

. During sleep, apnea and hypoventilation due to blockage in the upper airways, accompanied by snoring, sleep structure disorders, frequent pulse oxygen saturation (SpO2) decline, daytime drowsiness, and other symptoms, known as obstructive sleep apa hypopnea syndrome or OSAS. In recent years, the incidence of OSAHS is growing rapidly, osaHS patients in addition to the risk of upper respiratory tract obstruction, may also be combined with pulmonary hypertension,
hypertension
, cerebral infarction,
diabetes
, heart disease and other systemic diseases, is the independent risk factor of all fatal complications, anesthesiologists in OSAHS patients anesthesia should be treated as a high-risk population.

. 1. Patient information

patient, female, 26 years old, height 151 cm, body mass 40 kg. The main cause of "sleep snoring breath for more than 20 years" was admitted to the hospital. The patient was born around September left of the left jaw joint area of the overflow, after diagnosis and treatment at the local clinic, the symptoms did not significantly improve. Subsequently, the patient's jaw bone stopped developing, at the same time the appearance of sleep snoring, accompanied by night-time symptoms gradually aggravated, daytime drowsiness, dizziness, attention, memory loss, sleep. Recently due to the sharp increase in the symptoms of night-time argon, it was in the Fourth Military Medical University Oral Hospital, outpatient to "severe OSAHS with small jaw deformity" admitted to the hospital.

in good health. Specialist examination: front-facing jaw face asymmetry, left partial and abnormal development of the armpit, left skew of the middle line; The root of the tongue is thicker and the soft palate of the pharynx is not visible. Auxiliary examination: The airway sacroon (Figure 2A) on the skull CT shows: after the armpit shrinks; the airway 3D CT reconstruction shows: small jaw deformity, the narrowest part of the airway is 0.7mm (Figure 2B), the most narrow cross-sectional data of the corresponding airway is 10.5mm x 0.7mm; The remaining biochemical and laboratory examinations did not show significant anomalies.

Figure 1 Face Appearance. A: Face Side View; B: Face CT Side View.
Figure 2 on Air Channel CT. A: CT sambular airway structure; B: CT reconstruction diagram of the airway.

preoperative
diagnosis
for small jaw malformation accompanied by severe OSAHS, to be used in the whole hemp down the "two-sided jaw jaw puller implant, double-sided jaw joint fixation." Preoperative assessment: The patient has small jaw deformity since infancy, and the symptoms of nocturnal argon and wake-up are aggravated with age. Preoperative Mallampati grading, head craniofacial lateral film, airway CT reconstruction, and PSG results all indicated difficult airways. The patient is young women and is thin (40kg) and has not been accompanied by other diseases that OSAHS is easily combined. The difficulties of the management
of the
of perioperative period of anaesthetic
mainly lie in the
of airway
management, bleeding control and emergency treatment of unforeseen emergencies.

anaesthetic induction and intubation: atomized inhalation surface anesthesia (Lidocain 100mg and dexamethasone 10mg) before entering the room, connected electrocardiogram monitoring: blood pressure (BP) 110/70mmHg, heart rate (HR) 80 times/min, SpO295%, body temperature (T) 36.3oC. After opening the lower limb veins, the intravenous pump is given a fixed load dose of right metorium (1?g/kg), while using surface anesthesia in the nose and throat of the throat line (2% Lidocain 60mg), and the surface anesthesia of the cyclometamembrane puncture (2% Lidocain 40mg).

in the right nasal cavity with relatively good ventilation drips into the furphrine nasal fluid, the fiber bronchoscopy and trachea tube peripheral applied to the surface anesthesigel. After the completion of the hemp improvement and the right-hand metamine fixed-load dose pump injection, the patient takes the shoulder pad height, the head back elevation position began to implement the fiber bronchoscopy guide under the nasal wakeo tube intubation. Fiber bronchoscopy in the process of searching for the sound door, observed that the pharynx space is small, the larynx structure peeping difficult, will be tired and sagging, through repeated adjustment of the patient's head position and change the insertion direction of the end of the fiber bronchoscopy, the duration of 2min will be the fiber bronchoscopy successfully placed in the trachea, fiber bronchoscopy observed tracheal protrusion, and then completed the fiber bronchoscopy guide tube operation. Anesthetic maintenance: the heptafluoreine and rifenite conjugation complex anesthesia maintenance program, the operation closely monitors the patient's vital signs and bleeding conditions.

event 1: The surgeon in the display of the tibia bow, the HR suddenly dropped and gradually recovered, then pay close attention to the operation of the operation and HR changes. When the surgeon uses personalized titanium plate to fix the shinburst at the root of the bow, HR again suddenly dropped to 30 times / min, and there is a continuous downward trend, told the surgeon to immediately stop the operation, and the vein to give 0.5 mg of atropine, HR gradually recovered to 95 times / min, HR stability 1min, the surgeon tried the operation did not trigger the HR drop, surgery normal.

event 2: surgery is ready to transfer patients, the roving nurse found a small amount of brown fluid under the hips, accompanied by odor, anesthesiologists infer that patients may be stress
digestive
bleeding, immediate intravenous injection with blood coagulase 2U, intravenous drip Lansoola 30 mg, the implementation of anti-blood and acid suppression treatment, every 15min to observe the patient

he
morrhage
.

postoperative management: anesthesiologistand and surgeons to communicate on airway problems: it is expected that patients may have a long time after surgery airway obstruction problems, in order to ensure the safety of the patient's airways after surgery,
prevention
tracheotomy to ensure the smooth flow of the airways after surgery. After the patient wakes up well, connect the intravenous analgesic pump: Shufentani 50 sg s.toane stelor 10mg plus 0.9% physiological saline s. 100mL, background dose: 2mL/h single self-controlled dose 0.5mL/time, and transfer the patient to the ward ICU for intensive care. Close attention to the patient's airways, surgical area and gastrointestinal bleeding, anesthesia follow-up. The patient recovered well after surgery and was discharged on the 14th day.

. 2. Discussion of thethe challenges brought by the patient to the anesthesiologist mainly include: (1) the anesthesia management of patients with severe OSAHS with severe jaw deformities;
. 2.1 Anaesthetic management

oral pharynx anatomical factors and upper airway collapse are the most basic pathogenesis of OSAHS patients, compared with normal people, have narrow upper airways, belong to the high-risk population of difficult airways. In this case, in addition to the presence of obvious OSAHS symptoms, signs, but also accompanied by serious small jaw deformity, but because the patient is a young woman, body thin, has not been accompanied by OSAHS patients often concurrent heart, brain, lung, kidney and other important organs related diseases, so the focus of anesthesia management is mainly on the establishment of artificial airways. Difficult airway patients, if not adequate preoperative airway assessment, may lead to serious airway complications and even cause the patient's asphyxiation death, therefore, for OSAHS combined with severe jaw deformity patients, adequate preoperative airway assessment is particularly important.

. OSAHS is related to the narrowness of the upper airway anatomy plane, 3D CT reconstruction technology, which has obvious advantages in analyzing the airway blocking plane and the cause of blockage in OSAHS patients, and the technology can perform all-round, all-level upper airway scanning imaging in order to visually measure and analyze the specific obstruction of the upper airway. Therefore, the patient increased the upper airway 3D CT reconstruction examination, from the airway 3D CT reconstruction map can be seen, the patient's blocking plane is mainly in the back of the tongue root, serious small jaw deformity caused by the tongue body after the fall to reduce the effective area of the airway, the end of the tongue blockised is the patient's night sleep on the airway blockage is an important reason.

the small jaw deformity patient's pharynx space is relatively small, taking into account the lower jaw forward movement can appropriately increase the pharynx space, improve the vision of mask ventilation and fiber-optic trachea tube and find and sound door ability, before the operation also focused on the upper lip test to judge the patient's jaw joint activity and jaw forward transfer ability, but the operation to bite the upper lip test, found that the patient's jaw before the severe Therefore, it is predicted that the patient may have both severe mask ventilation difficulties and trachea intubation difficulties. A more comprehensive airway management plan is required when it is difficult to predict both the trachea intubation and the mask ventilation. The awake trachea intubation that retains autonomous breathing is the safest intubation option for patients with difficult tracts who had anticipated preoperative surgery.

the patient's opening is limited and there is a serious small jaw, inthemen in case of emergency airways, sound gate airway management tools will also be limited, therefore, the emergency tracheotomy as a wake-up tube process in the emergency airway management plan. OSAHS patients are sensitive to sedative drugs, the amount of sedative effect also exists individual differences, in order to avoid the use of midazolam, fentanyl, propofol and other sedative analgesic drugs due to poor dose control caused by respiratory inhibition, we chose to respiratory, circulatory inhibition of the less light right metoric tube pre-tube medication.

full surface anesthesia is an important factor in the success of fiber bronchoscoscopy sobriety tube intubation, in order to create good awake trachea intubation conditions, the use of atomized inhalation surface anesthesia, the spraying of the nasal cavity of the bureau's drug spray, the hematomy to the nasal and throat anaesthetic injection and other airway saes, in order to minimize the airway stress reaction when the awake trachea intubation. In this case, the patient in the actual intubation process, sedation and surface anesthesia effect is good, the process of exploring the sound door, airway stress response is light, there is an expected voyscosie difficulties, assistant assisted jaw is also limited, although the time is relatively long, but did not appear low oxygenation state, relatively smooth completion of the establishment of artificial airways.
monitoring and bleeding control during the
perioperative period are also two aspects that need to be focused on in the anaesthetic management of OSAHS patients. After the patient entered the chamber, the patient's vital signs were routinely monitored, and after the establishment of the airway, the change of coin oxide pressure at the end of the exhalation was monitored throughout, the location of the trachea catheter in the timely verification procedure was checked and the bleeding condition was closely monitored. In order to reduce intraoperative bleeding and ensure a good field of vision, the patient implemented controlled blood pressure under the continuous monitoring of invasive arterial blood pressure. Postoperative airway management in OSAHS patients is also an important part of anesthesia management, and its postoperative airway management scheme is related to the type of surgery that has been performed, and different types of surgery may have different management schemes.

the main implementation of this patient is the jaw jaw stylus implant implant and double-sided jaw joint fixation, although the trauma of the mouth and throat relative to the pharynx muscle transverse, dangling pharynx forming, jaw pre-removal surgery and other surgical procedures small, However, due to the existence of severe jaw deformity and long-term lead to bone, there is still a potential risk of long-term airway obstruction after surgery, and in addition, the surgeon has concerns about the safety of the airwayafter after surgery, after comprehensive consideration, selected the
prevention of
tracheopathy after the postoperative airway management program.

2.2 emergency treatment

2.2.1 adverse neuroreflection

patient, the surgeon exposed the tibia bow and used a personalized titanium plate to fix the shins at the arch root, the hr suddenly dropped, and the operation caused by the adverse nerve reflex is closely related. Trigeminino-cardiac reflex (TCR) is a common adverse neuroreflection in oral maxillofacial surgery, which has been reported in domestic and foreign literature. The trigeminal nerve sits forward from the trident nerve section, from the inside out in turn: the eye nerve branch, the upper jaw nerve branch and the jaw nerve branch.

the patient's adverse neuroreflection is caused by the surgeon's exploration and fixation of the tibia bow, and here is the distribution area of the upper jaw in the three branches emitted by the trigeminal nerve, so the TCR that occurs in this patient should be the upper jaw nerve-heart reflex. Its occurrence mechanism is: distributed in the tibia tibia region of the tibia nerve ends are stimulated by excitement, the signal is uploaded through the trigeminal nerve section to the sensory main core of the trigeminal nerve, and then the joint nucleocortex nerve fibers will direct the signal to the vagus nerve core, and then by the vagus nerve out of the heart muscle tissue, and thus lead to severe heart palpitations and even cardiac arrest.

for the whole hemp surgery appeared in the TCR, must do early detection, early treatment: general immediate lifting of the operation area pull or compression stimulation, heart rate can be restored, if not, can be partially given nerve block, immersion anesthesia or veins to give atropine and other drugs to intervene to deal with, for severe hypercardia or cardiac arrest, then immediately start cardiopulmonary resuscitation emergency plans.
. 2.2.2 Gastrointestinal bleeding

the patient in this case developed stressed gastrointestinal bleeding, which was indeed unexpected before surgery. When the body is in a state of stress such as severe trauma, critical illness or severe mental illness, it can induce
stomach
intestines
acute mucosal decay, ulcers and other lesions, and even the occurrence of gastrointestinal bleeding, perforation, called stress ulcers (stress ulcer, SU). OSAHS patients are prone to associated mental illness, the risk of potential psychological stress, and OSAHS surgery for patients, is a strong trauma stimulation, although the patient did not state before surgery has digestive-related diseases, but in view of the patient's wasting body type and flat skin irregular eating habits, its preoperative may have been accompanied by different degrees of digestive disease.

the traumatic stress of the surgery, which may further aggravate the damage to the
's stomach
intestinal
, which in turn causes bleeding in the digestive tract. Therefore, for those expected to be traumatic, long surgery or preoperative already associated with the hair.