"Big surgery, small anesthesia" is a common saying in the industry. Even for minor operations, anesthesiologists should make a mountain out of a molehill and be meticulous! Because the occurrence of anesthesia crisis events is often extremely sudden, even without warning, it is necessary to closely monitor the patient's vital indicators in order to find the problems in time and deal with them quickly.

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Back to the dock

Recently, a 49-year-old female patient planned to undergo hysteroscopy under general anesthesia because of "cervical polyp". The patient's previous health and cardiopulmonary function were normal, and there was no obvious abnormality in preoperative examination.

In the past, cesarean section was performed under spinal anesthesia, and ectopic pregnancy was performed under general anesthesia, and the anesthesia operation process was smooth. (Well, this is general anesthesia: Assessing ASA I level before anesthesia, surgery and anesthesia are low-risk, and the probability of cardiovascular events during perioperative period.

After the patient entered the room, routine vital signs monitoring was established, venous access was opened, and conventional anesthetic drugs sufentanil, etomidate and cis-atracurium were used for anesthesia induction, and then laryngeal mask was placed for mechanical ventilation.

All the procedures are in good order. However, three minutes after induction, the patient's blood pressure dropped rapidly from 120/80 to 60/40mmHg (noninvasive cuff pressure), and the heart rate gradually increased to 1 10 beats/min. The waveform of blood oxygen saturation was not displayed, and Petco _ 2 decreased. After taking norepinephrine 4 and 8 micrograms, the blood pressure did not increase, but increased further.

Allergic reaction is simply a series of "cascade" systemic reactions caused by the sharp increase of capillary permeability after human contact with a certain substance.

We know about food allergy and pollen allergy, but many people don't know that allergies can also occur during anesthesia. According to reports, the incidence of allergic reactions during perioperative period is one in ten thousand to one in ten thousand. About half of the patients developed symptoms within 5 minutes after exposure to allergens, and only 65,438+00% patients developed symptoms after half an hour.

Mild symptoms are only redness and maculopapules; More seriously, in addition to skin manifestations, there will be accelerated heartbeat, dyspnea and gastrointestinal symptoms; More seriously, the patient's cardiovascular function is seriously disordered (blood pressure can not be measured, heart rate is accelerated), and bronchospasm appears, which is life-threatening; What's more, the heart stopped immediately.

No matter what substance and how much dose you are exposed to, allergic reaction is an all-or-nothing thing, only the severity is different. Once the circulatory system is harmed, it is severe anaphylactic shock.

02

storm wind

The patient's blood pressure continues to drop, and cardiac arrest may occur at any time! Dr. Wang immediately gave epinephrine 100ug, intravenous injection of 200ug, and started the emergency call system of anesthesiology department!

Director Chu received a phone call (13 20 meters away from the operating room) while examining patients in PACU, and immediately ran to the operating room with Dr. Qi Hailong. After a brief communication with Dr. Wang, Director Chu issued the rescue instruction of anaphylactic shock level IV (the highest level) and continued to evaluate the ABCDEF process!

Further deployment of three anesthesia attending physicians and nurses arrived at the scene, and at the same time clear division of labor instructions:

1 person established invasive arterial pressure monitoring.

1 person established central venous access.

1 person Continue to establish peripheral venous access.

1 person changed to tracheal intubation for mechanical ventilation.

1 person was monitored intermittently by TTE, and changed to TEE monitoring after intubation. A person can't bear the rescue, and calling for help in time is king. )

Give accessory kidney 200ug\500ug\ 1mg intermittently until accessory kidney 3mg is given intravenously, accessory kidney 2mg is given by pump, hypothyroidism 2mg is given by pump, and fluid replacement is 2000ml. The blood pressure barely maintained at 80/50 mhg, and TEE showed obvious kissing sign, suggesting insufficient capacity. Continue to rehydrate to 5000ml+ balanced salt solution (6000 ml).

In the first aid, give 20U to the pituitary gland, then pump 4U/h, and inject Meilan intravenously. During the period, blood gas analysis was carried out to actively correct electrolyte disorder and acid-base balance. In a series of rescue measures, the patient's eyelids, lips and arms gradually became edema, and the skin of chest and thighs showed wheal-like changes, which further confirmed the correctness of the diagnosis and rescue measures of anaphylactic shock.

After 3 hours+rescue, blood pressure increased, vasoactive drugs gradually decreased (6 accessory kidneys were used in the rescue), the patient recovered consciousness, and all vital signs were stable. The endotracheal tube was removed and sent to ICU after continuous observation for half an hour.

03

regain one's composure

Anesthesiology grew up late, but the work requirements were very high. We shouldn't be wise and stable at this age ...)

This is a typical perioperative allergic reaction caused by narcotic drugs, like an avalanche without warning. In just a few minutes, life actually collapsed in cascade. Fortunately, the rescue was timely. If the anesthesiologist's judgment and treatment are a little late, the consequences will be unimaginable.

Therefore, an anesthesiologist is a high-risk profession, and it is really not an "injection" thing. If the surgeon is a dancer on the tip of the knife, then the anesthesiologist is a dancer on the tip of the needle!

04

In v.

At the morning meeting, Director Chu made a simple summary of this case: the patient was a middle-aged woman who was in good health in the past and planned to have a short gynecological operation. Severe anaphylactic shock suddenly occurred during induction of general anesthesia. According to the perioperative allergy classification, the patient was classified as Grade III: hypotension and life-threatening skin and mucosa symptoms. The diagnosis is basically clear, the treatment is timely, and the prognosis of the patient is good!

Experience in successfully rescuing the patient:

The attending anesthesiologist should accurately predict (grade ⅲ allergy) and make decisive decisions (call the emergency system in time)-this is very important, similar to the scene of cardiopulmonary resuscitation, call 120 for help first, and then rescue! Win valuable time for the arrival of the emergency expert group! ;

Clear and orderly division of labor to organize rescue: quickly set up an emergency team headed by the director of the department, call the manpower and material resources of the department to start the first aid procedure, and divide the work according to the ABCDEF process to ensure the accuracy and effectiveness of all implementation operations, which greatly improved the rescue efficiency. (Members of emergency expert group: department director, chief resident, cardiac anesthesia group, nerve block group. The anesthesiologists who participated in the above are all department directors during their work. In case of emergency, the chief resident is responsible for mobilizing the members of the emergency expert group, who should arrive at the emergency site as soon as possible without delay, unconditionally obey the division of emergency roles arranged by the leaders and carry out rescue);

For grade Ⅲ-Ⅳ allergy, accessory kidney should be injected intravenously as soon as possible, sufficient venous access should be established as soon as possible, and crystal rehydration should be infused quickly, up to 2-3L, and other measures should be taken as auxiliary measures.

For life-threatening hypoxia and hypotension, bedside ultrasound should be used as soon as possible to implement the third process:

(In this case, timely TTE/TEE monitoring and guided fluid replacement can improve the success rate of treatment. )

For any situation that endangers the patient's life during the operation, it is necessary to communicate with family members and sign informed consent forms, and communicate with superiors (including department directors, medical departments and even hospital leaders) in time. (In this case, the patient communicated with the patient's family three times during the rescue, signed the informed consent form and reported it to the hospital administration department).

Allergic reaction classroom

◆ What are the manifestations of allergic reaction during perioperative period?

Allergy is the immune response of human body to foreign substances (drugs, food, bacteria, viruses, etc.). ), this is actually a protective effect on the body. Most allergic reactions during anesthesia have skin and mucosal symptoms, and in severe cases, symptoms such as cardiovascular system and bronchospasm may occur.

According to the severity of allergic reaction, its clinical manifestations are divided into four grades:

◆ Why is there an allergic phenomenon during surgical anesthesia?

General anesthesia is one of the most commonly used anesthesia methods at present, which requires at least three basic drugs: sedatives, analgesics and muscle relaxants;

Intraoperative infusion, antibiotics, plasma, albumin, etc. When necessary;

Surgery may also use anti-adhesion drugs, hemostatic drugs, implanted bone cement, prostheses, etc.

Perioperative patients are exposed to and infused with multiple potential allergic substances at the same time, which is more likely to cause allergies than single medication.

◆ What substances in anesthesia can cause allergies?

Strictly speaking, almost all drugs may cause allergic reactions, and even leucorrhea, film and other items have been reported as allergic reactions. It's just that some have higher incidence and some have lower incidence.

The main drugs or substances that cause allergic reaction in perioperative period are antibiotics, muscle relaxants, latex, gelatin, lipid local anesthetics, blood products, protamine and so on. The incidence of female is 2~2.5 times that of male.

Previous allergic history, asthma history, cross-reaction of muscle relaxants (patients who are allergic to one muscle relaxant may also be allergic to other muscle relaxants) and latex-fruit syndrome (patients with a history of allergic to tropical fruits have an increased risk of latex allergy) are the high-risk factors of perioperative allergic reactions.

◆ Is it terrible to have an operation?

Don't worry too much.

The incidence of severe allergic reaction in perioperative period is very low, and most patients do not need special examination. However, in view of the threat of severe allergic reactions to patients' safety, we must attach great importance to high-risk patients, such as:

If you don't have the above symptoms and medical history, you only occasionally have rashes and itching, so you don't have to be too nervous and you don't need routine preoperative examination.

◆ What can patients do?

◎ Make it clear to the anesthesiologist

Patients should record the previously diagnosed or highly suspicious allergic drugs or foods. When anesthesiologists visit before operation, they must describe the symptoms of allergies in as much detail as possible, so that doctors can identify whether it is a serious allergic reaction and decide the medication plan during operation.

◆ In case of allergy, how to rescue it?

Once typical symptoms appear, stop using suspicious drugs immediately and stabilize circulation:

Allergic reaction processing flow

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Rapid infusion of crystal solution can replenish the fluid lost by capillary leakage and maintain effective circulation ability.

The five main causes of cardiovascular anaphylactic shock are: increased chest pressure, pump failure, increased peripheral venous pressure, fluid entering the gap and decreased peripheral resistance.

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Intravenous injection of low dose epinephrine in time

When circulation is severely inhibited, phenylephrine, norepinephrine and vasopressin can also be continuously infused intravenously.

Methylene blue can block the expansion of vascular smooth muscle mediated by nitric oxide. Methylene blue is often effective when catecholamine and vasopressin resist. When methylene blue was used, the loading dose was 1mg/kg, and 0.25mg/kg was injected intravenously every 4 hours.

Guidelines for the management of suspected perioperative allergies in adults

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Relieve bronchospasm

four

Intravenous injection of adrenocortical hormone;

Dexamethasone has a strong anti-inflammatory effect, but it takes a long time to reach the peak (12~24h), so it is not the first choice in allergic reactions. It is advisable to choose hydrocortisone 1~2mg/kg which directly acts on its receptor without metabolism, and it can be administered repeatedly after 6 hours. 24h does not exceed 300mg.

You can also inject methylprednisolone 1mg/kg intravenously.

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Combined use of antihistamines: promethazine+ranitidine

At present, there are no drugs that can effectively prevent allergic reactions. Anaphylactic shock should be found in time and dealt with decisively; After 4~6 weeks of recovery, the patient should complete the skin test, determine the allergen, and inform the patient and his family, or issue an anaphylactic shock registration card for the doctor's reference.

Perioperative allergic reaction should be a clinical adverse event that most anesthesiologists will encounter, mostly sudden and unexpected. The more acute the onset, the more severe the symptoms, which requires the anesthesiologist to diagnose quickly and handle correctly, so that the patient's vital signs tend to be stable. However, even with timely treatment, the mortality rate of severe allergic reactions is still as high as 3%-6%.

Therefore, if there are no plans, measures and drugs in clinical work, the best opportunity for discovery and treatment will be missed.

I recommend

Regarding perioperative allergic reaction, BJA British Journal of Anesthesiology published a column in July 20 19, introducing the related topics of perioperative allergic reaction. Interested children's shoes can refer to the following resources:

Poke "read the original" to charge together!