Throat cover intermittent autonomous breathing line McKeown esophageal cancer cure anaesthetic management one case

Patient, male, 54 years old, 173 cm, 71kgDue to "difficulty of sexual swallowing more than 5 months" hospital,diagnosisfor esophageal cancer, previous history of hypertension, good controlECG show: sinus heart thym is too slow, I degree chamber conduction blockThere were no obvious abnormalities in the heart color superAirway evaluation: normal opening degree, Mallampati II grade, a xlas spacing of 6.5 cm, cervical vertebral activity is not limitedThe gastroscopy indicates a ring narrow at 32 cm from the door teeth, with the mucous membrane bulgingBiopsy pathology is squamous cell carcinomaIt is proposed to take the throat cover intermittently to retain the autonomous breathing row chest laparoscopic joint three-incision McKeown esophagus cancer treatmentroutine monitoring after entering the room, the establishment of venous pathways, the bureau hemp down the left artery puncturetube and pressure measurementAfter giving oxygen denitrogen, anaesthetic induction to szefentani 10 sg, right metormia at0After taking 10min of intravenous medicine, the 10min, again static propofol 2mg/kg, waiting for the patient's consciousness to disappear, placed in the No4 double-tube larynx cover, choose SIMV modeInhalation 0.8% to 10% heptafluoroether, right metorciin 0.5 sg kg-1 h-1, Riffentani 0.01 to 0.05 sg-kg-1-min-1, proppheic 3 to 5mg kg-1-h-1 pump injection to maintain BIS40 to 60 After placed in the larynx cover, B super-guide downwards to the right side of the neck venous puncture tube 0.4% Ropixca in 20 ml abdominal abdominal plane (transversus abdominal plane, TAP) block, and the left side of the back line lying, ultrasonic guidance down the right side of the vertebral nerve block (T5-T6, T7-T8) total 0.4% Ropixcain 20ml At the beginning of the operation, the patient gradually resumed autobreathing, and tend to stabilize, its right lung under the action of atmospheric pressure gradually collapsed (equivalent to artificial gas chest), and then the surgeon in the chest mirror directly looked at the surface of the lower plurico 1% Lidocain and 0.5% ropone spray, vagus nerve stem and serium nerve block a total of 15 ml thoracic laparoscopic joint three-incision McKeown esophageal cancer treatment phase 1 retains autobreath anesthesia, replenishes the patient's capacity, and maintains cycle stability with norepinephrine In the process of physician separation, the dose of rifentenini was adjusted appropriately to maintain RR10 to 15 times/min and VT200 to 300 ml, reducing the vertical and swinging This stage can adjust the amount of rifen, reduce RR and VT, and even stop breathing, so that the lungs "silent" for a few minutes, to provide surgeons with a good surgical vision, to avoid accidental injury
blood vessels and reduce bleeding This can lead to carbon dioxide accumulation, resulting in a sexually permissible hypercarbon-coccuatedemia, intermittent hand-controlled assisted breathing, after the completion of the critical steps, re-use of Riffentini to adjust RR and VT, PaO2 gradually return to normal levels Chest esophagus free (Figure 1), sweep ingress of the lymph nodes of each station, attract, drum lung, chest section surgery is over Stage 2 abdominal surgery anesthesia, chest surgery after the appropriate deepening of anesthesia and use the muscle relaxant shun aquku ammonium 2mg/kg to interrupt the self-breathing, converted to mechanical ventilation This stage ensures that CO2 abdominal pressure is controlled below 12mmHg and PETCO2 is maintained at 42 to 49mmHg Stage 3 neck surgery anesthesia, neck surgery to select the left neck chest lock mastual prostrusion frontal incision, free neck section esophagus, parallel tube-like stomach-esophagus left neck match Timely adjustment of the position of the larynx, the appropriate small dose of the muscle loose medicine shun-type aquukammonium 3mg maintenance muscle loose, is conducive to reducing the larynx shift or leakage PETCO2 is maintained at 41 to 48mmHg In the process of neck and abdominal surgery incision, the patient's autorespiratory recovery, no CO2 accumulation, 10min after consciousness recovery, remove the larynx after muscle strength recovery, self-transition to the surgical push bed, safely into the PACU the total anaesthetic time of 334 min, during the operation bleeding about 150 ml In the operation input colloid 1000 ml, balance fluid 2500ml, 20% human haemoglobin 200ml, bleeding volume 200 ml, urine volume of 1200 ml Patients after surgery to the intestinal nutritional support, the second day of ventilation, review of the chest tablets show good double lung resuscitation, no obvious chest cavity gas build-up fluid No sore throat, cough, sputum, breathing difficulties, nausea, vomiting, bloating and other symptoms On the 6th day of iodine water imaging normal after the removal of chest tube, gastric tube, gradually resume eating, the 8th day discharged from the hospital discussion conventional thoracic anesthesia support requires double cavity trachea intubation, ventilator positive pressure ventilation and the use of muscle loose medicine to provide a relatively quiet, fixed field of vision of surgical operation and appropriate oxygenation, but the complications of the double cavity tracheal intubation and discomfort affect the patient's rapid recovery after surgery In 2015, scholars have put forward the concept of non-tracheal intubation to support thoracic surgery, and at present, in cooperation with the department of anesthesiology, the natural airway support anaesthetic method of non-intubation thoracic surgery has been applied to the operation of pulmonary large foam removal, pulmonary leaf removal, bronchial forming, angioplasty, and even trachea/protrusion non-tracheal intubation chest laparoscopy joint McKeown tricheresophageal cancer theme theme key points are: (1) chest surgery for the establishment and maintenance of autonomous breathing; The difference between non-intubation esophageal surgery and conventional non-intubation thoracic surgery is that the surgeon's requirements for vision are greater, the swing range needs to be smaller, so as not to hinder the operation, the accidental injury of large blood vessels caused by hemorrhage need stoic intubation and open chest Flexible use of the short-acting analgesic rifentani, reducing the breathing range is beneficial for surgery operations, while at the same time leading to carbon dioxide retention, so an anesthesiologist needs to find the right dose intra-thoracic esophageal free requires ananesthesios to adjust the use of narcotic drugs in a timely manner, so that the field is clear and relatively quiet, but also requires the surgeon to have a good anatomical foundation and the ability to perform operations on co-breathing, the key site separation immediately after the adjustment of breathing, so that carbon dioxide accumulation conditions are timely and effective improvement, shorten the allowed hypercarbonemia time During abdominal surgery, laparoscopic abdominal gas requires relaxation of the abdominal muscles secondly, there is no tube intubation positive pressure ventilation protection, esophagus fissure opened after the gas belly and chest cavity to the effect of double lung ventilation is fatal This treatment group was able to take the lead in applying non-tracheal intubation anesthesia to esophageal cancer surgery, mainly on the use of double cavity larynx In the case of double cavity larynx and well-closed conditions, it is able to isolate and attract oral secretions, and ensure the safety of patients switching in the state of autonomous respiration and mechanical ventilation Therefore, autonomous respiration free esophagus and cleaning of lymph nodes can be retained when operating under the chest mirror When operating under the laparoscopic mirror, the broken esophagus completely avoids the risk of reflux and misabsorption, making up for the short plate used in the throat cover Neck surgery by the influence of the larynx, Raman and so on have been verified in the pig model, esophagus after esophagus matching mouth can tolerate the pressure is completely higher than the throat cover no trauma ventilation pressure, will not cause leakage and other complications, suggesting that in the operation neck cut-off when the throat cover ventilation should be feasible, this has also been confirmed in this case non-tracheal intubation anesthesia chest laparoscopic joint McKeown three-cut esophageal cancer treatment of the adaptation and contraindications must be strictly controlled, for cardiovascular comorbidity, poor lung function, obesity (BMI s 30kg/m2), patients with predictable difficulties in the airways, surgery duration, team strength is weak, or should choose trachea intubation general anesthesia In the whole anaesthetic process to prepare trachea intubation items, such as: single tube and double cavity tube catheter, laryngos, fiber glasses and other intubation tools, strictgrasp the signs of transit, such as: haemorrhage, carbon dioxide accumulation, chest section of autonomous breathing serious suppression, surgery difficult to complete, etc , at any time to complete trachea intubation, to ensure the safety of patients compared to conventional double-cavity tube tube tube cocince co-surgery joint McKeown triincoral esophageal cancer treatment, non-tracheal intubation anesthesia when less anaesthetic drugs, the use of throat cover can avoid duct damage caused by trachea intubation, reduce mechanical ventilation brought about by the respiratory tract Complications, reduce adverse reactions to myosindrugs, while providing more stable hemodynamics and good postoperative analgesics, avoid inglisal catheterization back to ward and sedative analgesic drug use, reduce inflammatory factors and other indicators, patients can move early and get out of bed, help quickly recover after surgery However, the disadvantage is that the after-the-inducing nerve block part can be implemented in the patient's left neck neck shallow plexus block, thus covering the analgesic area of the entire surgical area, so as to achieve a similar to non-intubation chest surgery to optimize the analgesic management Through the attempt of this example, intermittently retaintheed the autonomous breathing laryngoscope downstream thoracic laparoscopic joint three-mouth esophageal cancer treatment is clinically feasible, thus expanding the treatment scope involved in non-tracheal intubation thoracic surgery anesthesia