Two-fetal pregnancy combined with 1 case of anesthesia management in patients with Stanford A aortic mezzanine

1Medical historypatients 35 years old, height 160 cm, weight 84 kg, pregnancy 36 to 3 weeks, due to sudden back pain 8 h emergency hospitalEmergency B super-suggests two-sided thoracic fluid, ascending aortic dilation, left room enlargement, double living tire, front placenta, emergency to "aortic mezzanine suspicious diagnosis, twin pregnancy 36-3 weeks pending delivery, front placenta" income obstetricsPreviously, there were two histories of tubal surgery, no other special medical history, no special physical examination, no signs of preterm birth, blood routine examination showed white blood cells 15.24x109/L centunocytes 89.90%, neutrophils absolute value 13.71x109/L, D dipolymer 963ug/L, other laboratory examination no specialchest CT prompts suspected diagnosis of aortic mezzanine, gallbladder stone, in-walking aortic imaging examination confirmed the main artery mezzanine Stanford A type, mezzanine hematoma extended from the aorta root to the double-sided tibia general artery level, abdominal stem and left kidney artery pressure, intestine The artery and right renal artery in the membrane were not affected; an echocardiogram indicated that the aortic valve was moderately stenosis open and restricted, left ventrvention blood score (left ventr ejection fraction, LVEF) was about 65%diagnosisis Stanford A aortic mezzanine, twin pregnancy 36 to 3 weeks, front placenta, gallbladder stonesIt is proposed that the caesarean section in the lower section of the lower uterus under general anesthesia, the aortic replacement and the aortic arch stent implantation2After thepatient sier edified into the operating room by ICU flat car, the human chamber was indifferent, mildly sedated, and immediately monitored blood pressure, heart rate, SpO2, body temperature, BISBlood pressure 150 mmHg/90 mmHg (1 mmHg-0.133 kPa), heart rate 110 times/min, SpO2 98%, body temperature 36.5 degrees C, BIS 69; immediate mask oxygen absorption 8 L/min, veins Pump injection of nitroglycerin nitrate injection (production batch number: 20160121, Beijing Yimin Pharmaceutical Co., Ltd.) 3-5ug kg-1.min-1 buck to 100 to 120 mmHg/60 to 80 mmHgB super-guided local anesthesia under the left cervical vein, the collarbone under the vein puncture respectively placed people 7 Fr double cavity central venous catheter (production lot number: 1605021)Henan Camel Medical Device Group Co., Ltdto establish a rapid rehydration channel and monitor CVP, local anesthesia under the left arterial puncture connection Flotrac (Model: MHD6, Edward (Shanghai) Medical Supplies Co., Ltd., United States) monitoring of direct arterial pressure, continuous heart blood volume (cardiac output, co) After the preparation of the disinfection pad began anaesthetic induction: 2% heptafluoreel (production batch number: N9826F, Shanghai Hengrui Pharmaceutical Co., Ltd.) mask sucker (oxygen flow 8 L/min), while intravenous propofol injections (production batch number: X151) 82B, AstraZeneca Pharmaceuticals (China) Co., Ltd 2 mg/kg, intravenous lymium-bromine (production lot number: 151028, Zhejiang Xianyu Pharmaceutical Co., Ltd.) 0.6 ms/ks, mask control breathing, FiO 2 100%, moisture volume 6 ml/kg, frequency 20 times/min, snorting ratio 1:1.5, local anesthesia to enhance caesarean section, regulation of nitrate glycerin dose 0.3-3.0 ug-kg-1 min-1 Maintain systolic pressure at 100-120 mmHg, heart rate 90 to 110 times/min, BIS 42-54, CVP 9-10 cmH2O (1 cmH2O-0.098 kPa) blood gas analysis: pH 7.28, PaO2 148 mmHg, PaCO2 42.9 mmHg, HCO3- 1 9.5 mmol/L After the operation starts 6 min, the fetus is born (weight 2 520 g, Apgar score: l min 6 points, 5 min 8 points); After fetal 2 umbilical cord ligation, the patient intravenously injected midazolam injection (production batch number: 1160910, Jiangsu Enhua Pharmaceutical Co., Ltd.) 0.05 mg/kg, Shufentani injection (production batch number: 161028, EuroCept BV, Netherlands) 1ug/Netherlands) kg, 1 min post-tracheal intubation Primus anaesthetic machine (Drager company, Germany), regulate breathing parameters (tide volume 6-8 ml/kg, breathing frequency 8 to 14 times/min, suction ratio 1:1.5, FiO2 60% to 100%) to maintain arterial blood gas in the normal range anaesthetic maintenance: heptifee ether 0.25% to 1.00% inhalation, intravenous pump with propofol injection 4-8 mg-kg-1 h-1, Riffenteni injection 0.05 to 1.00ug kg-1.min-1, saubezole aquorcoamol (production of ammonium Lot number: 20160901N, Jiangsu Hengrui Pharmaceutical Co., Ltd.) 1 to 2ug kg-1 min-1, adjust the depth of anesthesia to keep BIS at 40 to 56, blood pressure 100 to 120 mmHg/60 to 80 mmHg, heart rate 60-85 times / min The mouth is placed in an esophageal echocardiogram (transesophageal echoeardiography, TEE), and the near-infrared spectroradiometer (Model: NIR200, Hamamatsu, Japan) monitors local oxygen saturation of the bilateral forehead (regional cerebral oxygen, SCO2) 50 min after obstetric surgery ended, chest surgery began At the end of obstetric surgery, the amount of bleeding was 600 ml, isofting 500 ml and the urine volume was 100 ml Infusion volume: Sodium lactate fluid (production lot number: S1610038, Shanghai Baxter Medical Supplies Co., Ltd.) 300 ml, amber-styrgege injection (production lot number: 13 1758740l, Belon Medical Co., Ltd.) 100 ml Tee examination before the start of thoracic surgery show: left chamber contraction, diastolic function is good, LVEF about 60%, the aortic endoscosphonal vent is located in the right coronary artery opening about 12 mm, the aortic valve is not significantly closed incomplete, mild reflux, the valve does not expand, the ascending aorta expansion, the widest diameter of about 45 mm Conventional center open chest, systemic heparin, upper and lower cavity venous intubation and right upper pulmonary veins placed left heart decompression tube blood, right femoral artery intubation, two-sided cervical artery Y-shaped artificial vascular (Turemo Co., Ltd., Japan) bridging the filling tube, establishing CPB; Brain and body separate perfusion, ice pack cooling brain, CPB cooling, small dose sourcere glycerin 0.3ug-kg-1 min-1 and dopamine (production batch number: 120321, Jiangsu Yabang Pharmaceutical Co., Ltd.) 3ug kg-1 Min-1 to maintain blood vessel dilation, nasal temperature down to 24 degrees C to 26 degrees C, temperature down to 24 degrees C to 27 degrees C, stop the whole body cycle only maintain brain perfusion, regulate CPB irrigation flow, Hb concentration, PaCO2 and other maintenance of SCO2550% aortic arch mulch stent (China Minimally Invasive Medical Device Stent) Implanted, Artificial Vascular (Turemo Co., Ltd., Japan) end-to-end match restores full body circulation perfusion and begins re-irrhesis, regulates nitrate glycerin (0.3 to 5.0 ug-kg-1-min-1) and dopamine (1-3ug-kg-1-min-1) Maintain MAP 55 to 70 mmHg, resuming to nasal temperature of 36 degrees C, temperature 35 degrees C, heart recovery autonomic sinus rhythm, heart rate 82 to 93 times / min MAP, 63 to 95 mmHg, stopped dopamine, small dose scarlet nitrate (0.3ug kg-1 min-1) maintenance Again TEE examination: left ventricular contraction, diastolic function is good, aortic valve mild reflux, valve no stenosis and closure incomplete, valve ring no dilation, valve circumnavigation no obvious blood flow reflux signal, left and right coronary artery opening good adjust the internal environment, gradually reduce the CPB auxiliary flow until the shutdown, after the shutdown of the vital signs stable Nose temperature 36 degrees C, temperature 35 degrees C, blood pressure 107 to 126 mmHg/56 to 69 mmHg, deaf blue 68-90 times / min, CVP 9-12 cmH2O, CO 7.6 L/min, 104 ml per beat, 59 per fight index, 6% per fight variation rate, BIS 4246, S0255% Fish sulfate ethoprotein injection (Shanghai First Biochemical Pharmaceutical Co., Ltd.) neutralized heparin, stopped bleeding after closing the chest, surgical cessation anesthesia (total anesthesia time 540 min, CPB total time 196 min, ascending aortic blocking time 82 rain, Stop CPB time 27 min), after surgery transferred to the ICU for further treatment, 1 d after the ICU transferred to the general ward of cardiosurgery, after the 10th day of rehabilitation discharge, discharge 30 d after the telephone return visit, self-described mother and child recovery can, no obvious abnormalities