1 case of anaesthetic management of intracoabole removal combined with upper lobe removal of the right lung

1Medical history reviewpatient son, age 66 years old, height 163 cm, weight 55 kg, hospitaldiagnosistrachea swelling, right lung upper leaf occupancy lesions, intended in general anesthesia down the right lung upper lobe excision and intratubetalysis excisionPreoperative fiber bronchoscoscopy examination tips: 5.5 to 6.0 cm under the sound door in the trachea section visible polyps-like swelling, the diameter of the swelling is about 3/5 trachea diameter, the swollen substrate is wide in the front wall of the tracheaTrachea flat sweep 3D reconstruction CT prompt: main trachea visible noduility, size of about 0.7 cm x 0.7 cm, right lung upper leaf front visible noduum shadow, size of about 2.9 cm x 2.0 cm (Figure 1)Preoperative arterial blood gas analysis: 7.42 pH when not oxygen-absorbing, PaCO2 for 39mmHg (1mmHg - 0.133kPa), PaO2 for 102mmHg; The ASA, grade II, denies a history of high blood pressure, coronary atherosclerotic heart disease,diabetes, and patients who describe their right side of the liech with breathing difficulties2Anaesthetic inducedafter entering the room is clear, the vital signs are stableCardiac surgery is prepared for CPB in case of intubation failure and ventilation failure after anesthesiaBlood pressure 115mmHg/56mmHg, heart rate 72 times/min, SpO298%, mask oxygen absorption 5L/min, establishment of the right upper extremities peripheral venous pathway, intravenous injection of hydroxyethyl starch 130/0.4 electrolyte injection (production batch number: 81LF081, Beijing FessenYuskabi Pharmaceutical Co., Ltd.) 500mlLeft lycacross (no breathing difficulties), in the T6-T7 gap line epidural outer puncture tube, the process is smooth Local anaesthetic lower left artery puncture tube Prepare the inner diameter (inner diameter, ID) 6.5mm single cavity trachea duct duct and length enlongate the pipe by about 7 cm (Figure 2) to ensure that the length of the catheter can pass through the swelling Anesthesia induction to take rapid induction, intravenous give midazolam (production lot number: 20170414, Jiangsu Enhua Pharmaceutical Co., Ltd.) 2mg, Shufenteni (production lot number: 1171202, Yichang Manfu Pharmaceutical Co., Ltd.) 30 sg, relying on mistere (production lot number: 201 80305, Jiangsu Enhua Pharmaceutical Co., Ltd.) 14mg, amber choline (production lot number: AA170403, Shanghai Xudonghai Pu Pharmaceutical Co., Ltd.) 100mg, Lidocaine (production lot number: 1803J08, Shanghai Chaoyu Pharmaceutical Co., Ltd.) 60mg Visual throat mirror direct vision through the mouth line trachea intubation, trachea tube front into the sound door about 3 cm, remove the visual throat mirror, through the trachea tube inserted into the visual tube soft mirror, the lens is stopped above the swelling, confirm the position of the swelling (Figure 3), the trachea tip back to the swelling, gently into the trachea duct to ensure that the trachea through the swelling, with the tube tube soft mirror to confirm Located above the trachea (Figure 4), connecting the ventilator mechanical ventilation, moisture volume of 450ml, breathing rate 12 times / min, suction ratio 1:2, SpO2 100%, intravenous injection of psisochlorosulphate aquor ammonium (production batch number: 171004AK, Jiangsu Hengrui Pharmaceutical Co., Ltd.) 12mg 3 Anaesthetic maintenance anaesthetic maintenance adopt simulous compound epidural anaesthetic mode, heptafluoroetheration (production lot number: 65171001, Lunanbet Pharmaceutical Co., Ltd.) 1.5%, propofol (production batch: 16LD7377, Beijing Fessen Yuskabi Pharmaceutical Co., Ltd.) 5mg kg-1 h-1, intermittently assisted by the epidural 1% Lidoca 5ml 3.1 right lung upper lobe excision the left side of the patient lying, row right main bronchial blocking (Figure 5), through the trachea catheter insertion temporary sealer to the right main bronchial tube, because the trachea catheter is fine, the airduct pressure in the insertion process increased to 40 cm H2O (1 cmH2O - 0.098kPa), when the sealer is inserted about 50 cm, the airway pressure instantly drops to 22 cmH2O, at which point the retaining blocker, inflatable by the sealer sleeve about 5 ml The right breathing tone of the hearing patient disappears, the left breathing tone is normal, opens the vent switch of the sealer tube, and the left lung single lung ventilation After opening the chest confirmed that the right lung wilts better (Figure 6), the upper lobe of the right lung, surgery smoothly, pure oxygen ventilation in surgery, SpO2 fluctuations in 95% to 100% 3.2 tracheotomy removal after the right lung upper lobe removal, remove the sealer, under the guidance of the visual intubation soft mirror, the trachea catheter back to the trachea above the swelling The operator cuts the left main bronchial tube under the tracheotomy and inserts the ID6.0mm single-cavity trachea duct to establish a temporary airway to connect the ventilator At this time the vital signs are stable: blood pressure 113mmHg/68mmHg, heart rate 82 times/min, SpO2 100% After the main elishow emphysema removal and trachea break, the duct tube will be sent to the trachea protrusion, the temporary left main bronchial intubation is removed, and the double lung ventilation is restored 4 Postoperative conditions after the patient was completely awake, trachea tube extraction, the process is smooth, after surgery SpO2 99%, no other complications, after 6d removal of the drainage tube, 14d after discharge