1 case of caesarean section anesthesia in patients with myocardial hypertrophic incompleteness

Patient, female, 26 years old, body mass 74kgThe main cause of intrauterine pregnancy 30 plus 6 weeks of the first child, intermittent heart palpitations 10d, aggravated with chest tightness, short ness 4d admissionPatients due to 10d before the activity of heart palpitations, accompanied by sweating, lasting 3 to 5min, after rest reliefYou can lie down flat at night and wake up occasionallyNo chest tightness, shortness of breath, no cough, sputum, not paid attention to4d before no obvious cause to appear the above symptoms aggravated, with chest tightness, shortness of breath, accompanied by coughing, sputum, white, easy to cough outYou can't sleep flat at nightMenopause for more than 30 weeksbody: God Qing, nutrition canBP100/64mmHg, HR158/min, R20/minDouble lung breathing sound clear, unheard and wet tone, the sharpest point of heart throb is located on the left side of the Vrib icy collarbone outside the line 0.5 cm, the diagnosis of the heart boundary expands to the left, the hearing rhythm is irregular, the two-tip and three-tip lobe hearing area can hear and contraction period noise, S1, S2 normal, smellable and third heart toneElectrocardiogram: ventricular rate 196 times/minHeart color super see: left heart, right room expansion, EF23%, the remaining chamber size is normalThe chamber interval and the thickness of the left chamber wall are normal, and the movement is reducedThe left ventricle and strip-like muscle bundles, non-dense myocardial thick about 19 cm, dense myocardial heart muscle thickness of about 6 cm, the valve form did not see abnormal CDFI: The two-tip flap of the shrinkage period is visible medium-heavy reflux, the three-tip flap in the contraction period is visible in moderate reflux, and the blood flow is visible in the left chamber muscle gap The preliminary diagnosis is: (1) left ventricle myocardial tightness is incomplete, left heart enlargement is accompanied by severe closure of the two-tip flap, left chamber contraction function is reduced; (2) Intrauterine pregnancy 30 plus 6 weeks of the first baby LOA After internal medicine actively absorb oxygen, deacetyl hair flower strong heart, diuretic reduces the pre-heart load, nitrate-type amplified blood vessels, angiotensin conversion enzyme inhibitor and beta blocker meitamate inhibits left ventricle cardiomyopathy reconstruction, reduces heart rate to reduce cardiomyopathy oxygen consumption Heart function has improved and pregnancy continues to be maintained recent intrauterine pregnancy 34 to 3 weeks when nausea and vomiting symptoms increased, do not think about diet, poor mental health, obstetrics consider the patient's serious illness, should terminate the pregnancy as soon as possible Oxygen absorption after entering the operating room, monitor show: HR158/min, BP92/52mmHg, SpO2 90%, R20 times/min Cha arterial blood gas, PaCO2 24.9mmHg, PaO2 92.8mmHg, SpO2 97.5%, K-3.7mmol/L, HCO3-17.3mmol/L, Na-132m/L, Ca2 1.79m/L, CO2 19mmol/L, Lacmol/L Since the pH is normal, the compensation is complete and not specially treated Take the head high foot low, reduce the front of the heart load, intravenously push the Westland 0.2mg, the heart rate slows down According to the condition and surgical methods of continuous epidural anesthesia, epidural puncture after the success of the 2% Lidoca in the test volume of 3 ml, and then given 5 ml and 5 ml, 10min after the anaesthetic effect is satisfactory, the caesarean section was carried out after the delivery of the fetus BP dropped to 70/40mmHg, again intravenously pushed to The west orchid 0.2 mg, take the head low foot high, proper rehydration, blood pressure rose to 96/50mmHg The anaesthetic effect was satisfactory and the drug was not assisted Monitoring of other vital signs during surgery is relatively smooth No contractionins are used During the operation, the amount of infusion was controlled by 500 ml of lactic acid ringer fluid The anaesthetic is smooth, the operation is smooth, the surgery is completed with the epidural pain pump, sent to the ward discussion heart muscle dense insufficiency (noncompaction of the ventrified myocardium, NVM) is a rare congenital cardiomyopathy Left ventricular noncompam, LVNC is more common, also known as spongy heart muscle, persistent cardiomyopathy sinus gap, is a special type of ventricular dysplasia In the early stages of embryonic development the heart is a loose structure interwoven with numerous muscle fibers, and LVNC is caused by the failure of the embryonic heart muscle density process early in the embryo, the heart muscle is spongy, and the blood in the heart cavity supplies the heart muscle through the hidden nest between the heart muscles In the 5th to 8th week of embryonic development, ventricular muscle gradually becomes denser, and the cryptine develops into capillaries and coronary artery circulation Failure of this process caused the development of the endocardial membrane to stop and the heart muscle dense process failed, the intracardial sinus-like hidden nest of the heart muscle persisted, the muscle beam was abnormally large, and the corresponding area dense myocardial formation decreased Because the process of denseness is from the outer membrane of the heart to the inner membrane, from the bottom of the heart to the tip of the heart, so the denseness often occurs in the left ventricle, the inner membrane of the heart, the right ventricle can be affected at the same time, but the separate right chamber heart muscle denseising is not all rare The clinical manifestations of NVM, e-e-cardiogram, etc are not specific The echocardiogram is a reliable way to diagnose the disease General clinical manifestations are progressive heart failure, arrhythmia, thrombosis circulation embolism, common symptoms and signs such as palpitations, chest tightness, breathing difficulties, dizziness, fainting, edema, chest pain, heart murmurs and embolism caused by speech confusion, physical activity disorders or gangrene patients diagnosed as heart failure, arrhythmia, there is no physical circulation embolism performance, but the operation appeared atrial fibrillation, the heart muscle beam deep in the hidden nest of the blood flow is slow, at any time there is a risk of body circulation embolism Heart failure, arrhythmia and thrombosis are the main pathophysiological characteristics of NVM Heart failure is a slow progression process, heart failure is caused by ventricular contraction and disparageous function, mostly progressive, which is also the main cause of hospitalization of patients, manifested in chest tightness, palpitations, shortness of breath, breathing difficulties and so on The decrease of diastolic function is due to the active flacing barrier of the ventrline and the increase of chamber wall stiffness caused by the large muscle beam, and the decrease of compliance causes the increase of ventricle diastolic pressure The main cause of the contraction dysfunction is the ischemia under the chronic endomethum, and the lack of microcirculation perfusion increased demand for blood from several abnormally protruding muscle beams and mismatches in cardiac blood supply are important causes of myocardial ischemia If the nipple muscles are affected, it can cause the nipple muscles to be insufficiency, resulting in poor valve closure In this case, the patient's two-tip valve, three-tip valve closed incomplete, arrhythmia is mostly fatal ventricular arrhythmia, but also room arrhythmia, a few can occur conduction block The mechanism of arrhythmia is not very clear, may be related to the dense incomplete myocardial muscle small beam is irregularly branched, the chamber wall tension increases when the isoconity shrinks, causing low perfusion, microcirculation disorders and other induced electrical conduction delays and tissue damage There have been reports of heart-conducting beam slobiny fibers found in the hypertrophy beams of the disease, similar to the false tendon strain, which may be one of the anatomical bases for arrhythmia heart thrombosis and thromboembolism events are caused by slow blood flow and concurrent atrial fibrillation in the hidden den of the heart muscle girders, which can easily form intrawall thrombosis and embolism At present, mainly for heart failure, arrhythmia and thromboembolism and other complications to prevent and control The drug can be used to resist heart failure such as diuretics, beta blockers and angiotensin conversion enzyme inhibitors, and can also be used to improve cardiomyocardial energy metabolism, such as coenzyme Q10, vitamin B and qumetrin, and severe refractory heart failure requires heart transplantation When arrhythmia can be selected for the type of arrhythmia anti-arrhythmia drugs, amine iodone is a safe and effective anti-ventricular rapid arrhythmia drug, left ventricular dysfunction oral anticoagulant drugs to prevent thromboembolism, can be used aspirin or warfarin as anti-embolism treatment, to prevent thrombosis embolism events In accordance with the patient's situation in accordance with the above-mentioned treatment principles to choose the appropriate treatment patienthr158/min, BP92/52mmHg, atrial fibrillation, ventricular rate 140 to 150 times/min Low blood pressure, heart rate fast indicates poor cardiac contraction function, so intravenous injection of Sedilands 0.2 mg strong heart, high blood pressure, reduce heart rate, resistance to heart failure and increase the important organ blood supply Take the head high foot low, reduce the lower limb back heart and blood, reduce the front of the heart load Although the patient has a trial fibrillation, but can maintain blood pressure BP92/52mmHg, hemodynamic changeist is not much, can not be treated However, concurrent atrial fibrillation coupled with slow blood flow in the hidden nest of myocardial beams is easy to form intrawall blood clots, embolism is prone to heart thrombosis and thromboembolism events, can be oral anticoagulant prevention the birth of the fetus after the drop in blood pressure, fetal body on the abdominal aorta pressure lifted, lower abdomen and lower limbvascular volume increased, the amount of blood back blood decreased Again intravenously push the Westland 0.2mg strong heart, increase the heart output Take the head low foot high, appropriate rehydration, increase the amount of blood, so as to raise high blood pressure The protection of heart function reduces the front and rear load of the heart and maintains a certain amount of backheart work, and ensures a relative balance between the blood perfusion of important organs When applying strong heart medicine, we should pay attention to: the increase of blood-thinning blood capacity of pregnant women and the increase in the rate of glomerular filtration, the same dose of drugs in pregnant women's blood concentration is relatively low, but pregnant women's tolerance of artichoke drugs is poor, need to pay attention to toxic reactions Can be given the effect and excretion of faster preparations, to prevent the accumulation of drugs in the tissue and in the inhemital period with the tissue moisture into the body cycle caused by toxic reactions the maternal metabolic rate increased during pregnancy, the increase in blood volume caused the increase of heart excretion and heart rate, the heart workload increased The change of hemodynamics during pregnancy aggravates the heart load in patients with heart disease and induces heart failure After the birth of the fetal placenta during the operation, the uterus suddenly shrinks, the placenta cycle stops, about 500 ml of blood in the uterine sinuses suddenly enters the body circulation, the body blood capacity increases In addition, the intracavity pressure sudden reduction, a large amount of blood into the internal organs, resulting in rapid changes in hemodynamics, plus center of gravity failure In this case, patients choose epidural anesthesia as a good one, because it has the effect of dilating blood vessels and reducing the load before and after the heart Compared with lumbar hemp, it has less effect on patients' hemodynamics, and this case uses a small amount of sub-administered drugs to minimize the effects on hemodynamics, to ensure the smooth anaesthetic, and to ensure the safety of mother and child compared with whole hemp, almost all narcotic drugs have myocardial inhibition, try to choose as few anesthetics as possible, reduce the patient's already failed heart muscle inhibition Anestheticshould should not be added to epinephrine, anesthesia plane should not be too high, can take the left side lying 15 degrees, to prevent reclining low blood pressure syndrome Unused mycosin is also used to maintain hemodynamic stability In view of the characteristics of pregnancy combined heart disease in this patient, anesthesia effect is better, otherwise pain greatly increases the heart load Based on the characteristics of poor heart function in patients, in order to prevent pain after postoperative anesthesia effect to increase the burden of the heart, after surgery, the application of epidural pain pump PCEA: 0.125% resistance products , 0.2 mg fentanyl , physiological saline with 250ml Reduces pain stress, dilates blood vessels in the lower extremities, and prevents vascular embolism and pulmonary artery embolism patients due to the reduction of NVM contraction function, blood score (EF) only 23%, the blood supply of all important organs insufficient, oxygen supply is insufficient, SpO 290%, so the entire operation to absorb oxygen in order to slow down Shrinking and diastolic function is reduced, will inevitably cause pulmonary circulation bruising and so pulmonary edema, although the hearing double lung no wet sound, but the patient into the operating room cough, indicating signs of pulmonary edema Therefore, it is required to strictly control the amount of infusion in surgery Intraoperative blood gas: pH7.35, PaO2 92.8mmHg, PaCO2 24.9mmHg, SpO2 97.5%, K-3.7mmol/L, HCO3-17.3mmol/L, Na-152mmol /L, Ca2 1.79mmol/L, CO2 19mmol/L, Lac 1.6mmol/L, ABEe-4.4mmol/L, SBEc-5.9mmol/L, consider metabolic acidosis combined with respiratory alkali poisoning compensation HCO3-down, Lac rise, ABEe-4.4mmol/L, SBEc-5.9mmol/L, indicating metabolic acidosis Due to compensation, coupled with the patient's own heart muscle tightness incomplete oral circulation bruising, before there is chest tightness, shortness of breath, coughing sputum, night can not sleep flat symptoms, resulting in PaCO2 decline, CO2 decline Since the compensation is complete, the pH is normal and no special treatment is required The anesthesia and intraoperative management of NVM patients should be based on their clinical manifestations and the pathophysiological characteristics of NVM to ensure maximum safety in patient anesthesia and surgery