1 case of anaesthetic treatment in patients with dilated cardiomyopathy whole heart failure combined with severe sleep apnea syndrome

The patient, male, aged 57, was admitted to hospital in April 2015 after more than half a year of discontinuation and shortness of breath for more than 4 yearsFour years ago,diagnosedas dilated cardiomyopathy, heart failure, this admissiondiagnosedsevere sleep apnea syndrome (OSAHS)Physical examination: to listen to the double lung breathing sound clear, the heart boundary to the left expansion, rhythm is not uniform, the heart sound is low blunt, the heart tip area can be heard and 2/6 degree contraction period noiseelectrocardiogram diagnosis: heart rate 74 times/min, heart room conduction block, QT inter-period extension (0.45s), ST-T segment abnormality, QRS .12sChest show: heart shadow increased, two-sided lung texture thickenedHeart color super: cardiomyopathy (left chamber lower wall, back wall, side wall and heart tip heart thinning no movement); Patients have varying degrees of elevated preoperative Cr, Urea and ALT, considering liver and kidney damage caused by heart failureThe patient had previously tried resynchronization of the intrapous cardiac syncandle and implanted in a cardiac resynration defibrillator (CRTD)the operation ended at the start of 40min due to a heart failure attackAfter the multi-medical consultation, the proposed re-surgery, taking into account that the patient's sobriety state is difficult to tolerate a long period of surgical stimulation, then decided to complete the second CRTD surgery under full mahjongPatients after this room regular line oxygen saturation, electrocardiogram, non-invasive blood pressure monitoring, and quickly establishaed invasive blood pressure monitoringBlood pressure 112/70mmHg, heart rate 81 times/min, breath14/min, SpO2 97%Give the mask oxygen absorption and the head of the bed is 15 degrees low Relying on miede 0.15mg/kg, Shufentani 0.15 ?g/kg, medapyrifen 3mg, Roco bromide ammonium 0.6mg/kg induction the patient to sleep and place it in a 4-year-old laryngeal Mask Ltd (Laryngeal Mask S Ltd., Malaysia) After the induction of the patient's blood pressure slightly decreased, to the deoxyrepinecent 0.38 sg / (kg .min) speed pumping in, during surgery blood pressure fluctuations in 80 to 100 / 50 to 60 mmHg, heart rate fluctuations in 50 to 60 times / min In-operative target infusion propofol, set the plasma effect chamber concentration of 0.5 sg/mL, while giving the smooth aquel almon ammonium 5mg/h pumping in, Shufen 5 sg intermittent intravenous injection The operation duration of 160min, into the crystal fluid 700mL, after the operation ended 5min autonomous breathing fullrecovery after the removal of the larynx, after 15min patient vital signs smoothly returned to the ward Discharged from hospital on the 4th day after surgery discuss one of the important treatments for moderate chronic heart failure is cardiac resynchronization therapy (CRT) or CRTD surgery based on optimal medication In the 45-90 age group, the incidence of heart failure increased by a corresponding lying rate by a twofold increase for every 10 years of age In elderly patients with chronic heart failure, the incidence of OSAHS was as high as 60.3% However, there are few reports of anesthesia in patients with heart failure combined with OSAHS dilated cardiomyopathy heart failure the risk of anesthesia in patients with OSAHS combined Patients with heart function loss, is the heart's extremely high-risk state, not only to avoid the use of sedation, analgesics when the heart muscle inhibition caused by low blood pressure, but also to avoid sympathetic nerve arousal, cardiomyopathy increase led to acute heart failure Patients with poor compensation capacity should avoid hypoxemia and hypercarbonemia However, the patient has a clear severe SEVERE OSAHS, anaesthetic induction and recovery process is very prone to hypoxia and induced heart failure In addition to the patient's own factors, CRTD itself is very high risk, prone to a variety of serious complications, such as coronary sinus mezzanine, perforation, heart-packed blood, severe arrhythmia and so on Therefore, anesthesia should take full account of the various risks faced by patients, strengthen monitoring, and good communication with the surgeon the principle of the management of of anaesthetic in patients with all-heart failure of -expanded cardiomyopathy is to maintain the balance between cardiomyocardial oxygen supply and oxygen demand Specific measures are as follows: (1) patients in the room, avoid all kinds of stimulation, before operation to do a good job of explanation work, in the prevention of blood pressure fluctuations, to avoid capacity overload; (2) boost medicine preferred deoxypine, high blood pressure at the same time reflexive exfoliation of the nerve, so that the heart rate slows down, so that the reduction of the heart rate, Cardiomyocardial oxygen consumption; (3) Induced drug selection has a slight effect on cardio vascular function, avoiding violent fluctuations in hemodynamics during the induction period; (4) choose sufffentanib, which has a fast,strong algemostatosphine effect and has little effect on hemodynamics to improve analgesics The main risk of perisination in OSAHS patients is severe hypoxia and carbon dioxide accumulation caused by respiratory obstruction, which can cause damage to important organs such as the heart and brain, and even death the of the treatment of the patient's perioperative period the following: (1) the use of non-invasive positive pressure ventilation treatment before surgery, the correction of hypoxemia to improve the oxygen supply of important organs, improve the safety of anesthesia; Prepare airway management tools and develop alternatives before you do, (3) avoid excessive use of opioids and sedatives to avoid excessive sedation and respiratory obstruction; (4) strictly grasp the extraction signs after surgery, fully intake myosines before extraction, and routinely prepare for re-intubation review, CRTD is usually done under the line or sedation, with less need for full hemp In this case, patients are prone to tension and have acute heart failure during the first intra-bureau surgery Therefore, this anesthesia should avoid simple hemp, but give appropriate sedation However, the patient has a clear severe OSAHS, sedative anaesthetic state of patients sleepiness easy to induce airway obstruction, lack of ventilation As a result, the patient in this case chose whole hemp Full hemp not only provides the patient with perfect sedation, analgesic, reduce the patient's stress during surgery, but also the whole hemp under the throat cover line mechanical ventilation can ensure the smooth airway, to avoid OSAHS patients simply sedating the tongue after falling the upper airway obstruction, for surgery to create a good condition the patient chose the larynx cover instead of trachea catheter for ventilation during full hemp surgery, the reason is that compared to the latter to maintain the stability of the laryngeal cover required by the shallower depth of anesthesia, the amount of anesthesia is less, and the laryngoscant tube can significantly reduce the trachea catheter insertion, tube-pulling period caused by the blood vessel reaction, reduce the incidence of patient awakening restlessness, is conducive to stable and comfortable awakening, more suitable for this case In addition, maintaining proper anaesthetic depth and perfect muscle steam is also critical to the patient's duringoperative management Too deep anaesthetic can easily reduce blood pressure, affecting myocardial perfusion Too shallow anaesthetic or insufficient muscle weakness may lead to poor tolerance of the laryngeal mask and the potential risk of laryngeal spasms In this case, due to the combination of liver and kidney insufficiency, intraoperative muscle pine maintenance selected the main hofmann removal and degradation of the smooth aquukanamtoum, to avoid the surgical myosone residue caused by the drainage difficulties In summary, heart failure combined OSAHS patients if hemp can not meet CRTD surgery, can try general anesthesia, but this kind of patient anesthesia management is a challenge for anesthesiologists, especially should pay attention to anesthesia individualization In addition, the condition allows for the condition of feasible anaesthetic depth and muscle loose monitoring, critical patients need more precision anesthesia