Text | Wang Yan ◆ Source | Drunken Magnolia
"Surgery is big or small, anesthesia is not big or small" is a common saying in the industry. Even for small surgeries, anesthesiologists have to make a big deal out of it! Because anesthesia crisis events are often extremely sudden, even without warning, you must closely monitor the patient's vital indicators, in order to detect the problem in a timely manner and quickly deal with it.
01
Wind and waves
Recently, a 49-year-old female patient, because of "cervical polyps" to be carried out under general anesthesia "hysteroscopy". The patient's previous physical health, cardiopulmonary function is normal, preoperative examination did not see obvious abnormalities.
She had previously undergone a cesarean section under intrathecal anesthesia and an ectopic pregnancy under general anesthesia, and the anesthesia procedure was uneventful. (Well, this is an ordinary case of anesthesia: preanesthesia assessment ASA I, surgery and anesthesia are low risk, the probability of perioperative cardiovascular events <1%)
The patient was admitted to the room, and the routine establishment of vital signs monitoring, the opening of venous access, tripartite checking and then use of conventional anesthesia medication sufentanil, etomidate, cisatracurium for induction of anesthesia, then A laryngeal mask was placed and mechanical ventilation was performed.
All procedures are in order, however, just 3min after induction, the patient's blood pressure dropped rapidly from 120/80 to 60/40mmHg (non-invasive cuff pressure), the heart rate gradually accelerated to 110 beats/min, the oxygen saturation waveform does not show that the PetCO2 decreased, after giving norepinephrine 4, 8ug, blood pressure did not rise but further decline, anesthesia second-line doctor Wang Diem immediately realized that this is not the case. Wang Yan immediately realized that this was by no means a general post-induction hypotension, and that the patient was most likely experiencing a severe allergic reaction!
Allergic reaction, simply put, is a series of "cascading" systemic reactions caused by a sharp increase in capillary permeability after exposure to a certain substance.
We know about food allergies, pollen allergies, and so on, but many people don't know that allergies can occur during anesthesia. The incidence of perioperative allergic reactions has been reported to be 1 in 20,000 to 1 in 10,000, with about half of the patients experiencing symptoms within 5 minutes of exposure to the sensitizer, and only 10% of patients experiencing symptoms after half an hour.
In mild cases, the only symptoms are redness and maculopapular rash; in severe cases, in addition to the skin symptoms, there is a rapid heartbeat, dyspnea, and gastrointestinal symptoms; and in more severe cases, there is a serious disturbance of the cardiovascular function of the patient (blood pressure is undetectable and the heart rate is increased), and the bronchial tubes go into spasm, which is life-threatening; and worse, the heart stops beating instantly.
Regardless of what the exposure is, how many doses of exposure, the allergic reaction is an "all or nothing" thing, only the severity is different, once the circulatory system is jeopardized, is a serious anaphylactic shock.
02
The storm
The patient's blood pressure continues to drop, and cardiac arrest is likely to occur at any time! Dr. Wang immediately gave 100ug and 200ug of epinephrine intravenously and started the emergency call system of the anesthesiology department at the same time!
Director Chu Qinjun received the call when he was checking the patient in the PACU (20 meters away from the 13th operating room where the incident occurred), and immediately rushed to the operating room with Dr. BING Hailong at a run. After briefly communicating with Dr. Wang, Director Chu issued an anaphylactic shock level IV (the highest level) resuscitation order and continued the ABCDEF process assessment!
Further deployment of three attending anesthesiologists and nurses urgently arrived at the scene, while the division of labor to clarify the instructions:
1 person to establish invasive arterial pressure monitoring
1 person to establish central venous access
1 person to continue to establish peripheral venous access
1 person to change the endotracheal tube intubation for mechanical ventilation
1 person to intermittently perform TTE monitoring, changed to TEE monitoring after intubation. (Resuscitation one person really can not afford to come, timely call for help is the king)
Intermittently given 200ug \500ug \1mg of paracrine, until the static paracrine 3mg, pumped paracrine 2mg, pumped 2mg of desogestrel, rehydration of 2000ml, the blood pressure is barely maintained 80/50mmHg, TEE shows obvious kiss sign, suggesting insufficient capacity, continue rehydration to 5000ml + balanced salt solution (crystal) (within 1.5h).
Pituitary 20U was given in the first aid, 4U/h was pumped in afterward, and melphalan was given intravenously, during which blood gas analysis was performed, and electrolyte disorders and acid-base balance were actively corrected. During a series of rescue measures, the patient's eyelids, lips, arms gradually appeared obvious edema, the chest and thigh skin appeared a rash change like a wind ball, more certain of the diagnosis of anaphylaxis and the correctness of the rescue measures.
After 3h+ resuscitation, blood pressure rebounded, vasoactive drugs were gradually reduced (in the resuscitation *** use of paracrine 6), the patient's consciousness was restored, and all vital signs were stabilized after the removal of the endotracheal tube, and continued observation for half an hour and then sent to the ICU.
03
Return to peace
(Anesthesia grows late, but the work is very demanding, and we have to bear the responsibility of this age shouldn't be wise, and we should be very careful, and we should be very careful. Fortunately, the rescue is timely, if the anesthesiologist's judgment and treatment a little later, the consequences are unimaginable.
So, the anesthesiologist is a high-risk occupation, it is not really a "shot" 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 summary
In the morning meeting, the storage director of the case of the rescue of the patient for a brief summary: the patient is a middle-aged woman, the past health, intended to carry out gynecological short surgery. Sudden severe anaphylactic shock during induction of general anesthesia, according to the perioperative allergy grading, the patient in this case is grade III: the emergence of life-threatening hypotension and skin and mucous membrane symptoms. The diagnosis is basically clear, the treatment is timely, and the patient has a good prognosis!
The experience of successful rescue of this patient:
The attending anesthesiologist's prediction is accurate (class III allergy), decisive decision-making (timely activation of the call emergency system) - this is very important, similar to the scene of the CPR, the first call for help 120, and then rescue! For the emergency expert team to arrive to win valuable time!
Organized rescue orderly and clear division of labor: quickly set up at the scene to the director of the department as the leader of the emergency team, call the department of human and material resources to start the first aid procedures, according to ABCDEF process of division of labor, to ensure that all the implementation of the operation of the exact and effective, and greatly improve the efficiency of the rescue and treatment. (Department of emergency expert team members: chief, chief of hospitalization, cardiac anesthesia team, nerve block team, all the attending anesthesiologists above the work period are the chief of the department, the emergence of emergency events when the chief of hospitalization is responsible for mobilizing the emergency team members, team members need to arrive at the scene of the emergency as soon as possible without delay, and unconditionally comply with the LEADER arrangement of first aid roles to implement the rescue);
To the Class III-IV allergy, give paracrine as early as possible intravenously, establish adequate venous access as soon as possible, and rapidly infuse crystalloid rehydration up to 2-3L, with other measures as auxiliary measures;
For life-threatening hypoxia and hypotension, use bedside ultrasound as early as possible, and implement the THIRD process:
(In this case, the patient underwent TTE/TEE monitoring in a timely manner, and was given guided fluid replacement (In this case, the patient's family communicated with the patient's family three times during the resuscitation process, and signed an informed consent, while reporting to the hospital administration).
Allergic reaction mini-class
◆What are the manifestations of perioperative allergic reactions?
Allergy is the body's immune response to foreign substances (drugs, food, bacteria, viruses, etc.), and is actually a protective effect on the body. Most allergic reactions occurring during anesthesia present with skin and mucosal symptoms, and in severe cases, cardiovascular manifestations, bronchospasm, and so on.
According to the severity of the allergic reaction, its clinical manifestations are classified into 4 levels:
◆Why do allergies occur during surgical anesthesia?
General anesthesia is one of the most commonly used forms of anesthesia today, and requires the use of at least three basic medications: sedatives, analgesics, and muscle relaxants;
Intraoperative infusion of fluids, antibiotics, and, if necessary, plasma, albumin, etc.
Surgical procedures may also involve the use of anti-adhesion medications, hemostatic medications, and the implantation of bone cements, prosthetics, and more.
Patients who are exposed to and infused with multiple potentially sensitizing substances at the same time during the perianesthesia period are more susceptible to allergy than a single medication.
◆What substances in anesthesia can cause allergies?
Strictly speaking, almost all medications can cause an allergic reaction, and even items such as white tape and patches have been reported to be allergic. It's just that some have a higher incidence and some have a lower incidence.
The main drugs or substances that cause perioperative allergic reactions are antimicrobials, myorelaxants, latex, gelatin, lipid-based local anesthetics, blood products, and fish protein; the incidence in women is 2-2.5 times higher than in men.
A history of previous allergies, asthma, muscarinic cross-reactivity (patients allergic to one muscarinic may be allergic to other muscarinic), and latex-fruit syndrome (patients with a history of allergy to tropical fruits are at increased risk for allergic reactions to latex) are high risk factors for perioperative allergic reactions.
◆ It's scary to have surgery, too, isn't it?
◎ There is no need to worry too much
The incidence of severe allergic reactions during the perianesthesia period is very low, and the vast majority of patients do not need any special tests, but in view of the threat that severe allergic reactions pose to the safety of the patient, it is important to pay great attention to high-risk patients, such as:
If you don't have any of the above symptoms and history, and you only have occasional disseminated skin rashes and itching, there is no need for undue stress or routine preoperative testing.
◆What can patients do?
◎ Talk to the anesthesiologist
The patient should keep a record of previous clear or highly suspicious allergies to medications or foods, and during the anesthesiologist's preoperative visit, be sure to describe in as much detail as possible the symptoms that occur when allergies occur, so that the doctor can identify whether it is a severe allergic reaction and decide on the intraoperative medication regimen.
◆How to resuscitate in case of allergy?
In the event of typical symptoms, stop the administration of the suspected drug and stabilize the circulation:
Allergic reaction management process
1
Rapidly infuse crystalloid solution to replenish fluid loss due to capillary leakage, and to maintain effective circulatory volume.
Five major causes of cardiovascular anaphylaxis: increased chest pressure, pump failure, increased peripheral venous pressure, entry of fluid into the interstitium, and decreased peripheral resistance
2
Promptly infuse a low-dose epinephrine
Continuous IV can also be used in cases of severe circulatory depression. phenylephrine, norepinephrine, and vasopressin.
Methylene blue blocks nitric oxide-mediated vasodilatation of vascular smooth muscle, and treatment with methylene blue is often effective when there is resistance to catecholamines and vasopressin, with a loading dose of 1 mg/kg of methylene blue administered as a drip of 0.25 mg/kg every 4 hours.
Guidelines for the management of suspected perioperative allergies in adults
3
Relief of bronchospasm
4
Intravenous adrenocorticotropic hormone:
Dexamethasone has a strong anti-inflammatory effect, but the onset of action is slow, the peak time is long (12-24h), allergic reactions is not the preferred choice, and it is preferable to use a hydrocortisone which does not need to be metabolized and works directly on its receptor. strong> Hydrocortisone 1~2mg/kg, can be repeated after 6h. 24h not more than 300mg.
Can also be injected with methylprednisolone 1mg/kg.
5
Combination of antihistamines: promethazine + ranitidine
At present, there is no drug that can prevent the occurrence of allergic reactions effectively. When anaphylaxis occurs, it should be detected in time and dealt with decisively; skin tests should be completed 4-6 weeks after the patient has recovered to determine the allergens and inform the patient and his family, or issue an anaphylaxis registry card, which should be held for the doctor's reference when visiting the doctor.
Perioperative anaphylaxis is a clinical adverse event encountered by most anesthesiologists, mostly sudden and episodic, and the more rapid the onset, the more severe the symptoms, the need for anesthesiologists to be able to quickly diagnose and correctly deal with in order to make the patient's vital signs tend to be stabilized, but even with timely treatment, the mortality rate of severe anaphylaxis is still as high as 3% -6%.
Therefore, if there is no plan, no measure, no medicine in clinical work, the best time for detection and treatment will be missed.
I recommend
Regarding perioperative anaphylaxis, BJA British Journal of Anaesthesiology (BJA) has launched a column on perioperative anaphylaxis in July 2019, and the following references are available for those who are interested:
Poke the "original article" to recharge! Recharge your batteries!
Allergic reactions in the perioperative setting.