1 case of surgery treatment of chromosomal celloma in elderly patients

Patient male, 65 years old, weight 61kg, 4 months ago no obvious cause of dizziness, headache, chest tightness, palpitations, self-tested blood pressure up to "190/100mmHg"hypertension,diabetesdisease, multiple cavity cerebral infarctionHeart color: EF value of 58%, left chamber diastode function decreased, coronary CT: coronary atherosclerosisThe concentration of cortisol was normal, the three indicators of catecholamine were significantly higher than the reference value, and the cola test was not inhibitedPET-CT results: left adrenal lump, consider low-level malignant tumor probability is greatAfter the proposedlaparoscopyadrenal tumor excisionbefore surgery will be blood pressure control stable at 140/80mmHg below, no heart palpitations, sweating and other manifestations, heart rate in 80-90 times / minute, red blood cell pressure of 0.42, blood gas analysis ion concentration in the normal rangePreoperative routine fasting fasting, preoperative preoperative infusion source Snow An 500ml, physiological saline 500ml expansionPreoperative muscle injection benzene barbiturate 100mg, long Toin 0.5mg static note, 100mg hydrogenated can be pine noteAfter entering the chamber mask oxygen absorption, open venous channel, blood pressure 150-160/78-90mmHg (1mmHg-0.133kPa), heart rate 92 times / minuteThe electroencephalic double-frequency index (BIS) monitoring and local brain oxygen saturation (rSO2) monitoring were carried out Bureau hemp artery puncture tube, and connects the FloTrac/ Vigileo monitoring system (Ed-wards) to enter weight, height, gender, age Monitoring has traumatic blood pressure, heart output (CO), and per-fight variability (SVV) anaesthetic induction: intravenous Medaaazole 6mg, Shunakul ammonium 15mg, propofol 100mg, fentanyl 0.3mg, tracheostorial application lidocain cream, Diacco visual larynx tracheotorial intubation, set mechanical pass parameters for moisture volume 8-10 ml / kg, ventilation frequency 12-16 times / minute, pumping ratio 1.0pet Maintenance in surgery: Continuous pump injection propofol 4-8mg kg-1-h-1 Rifentanil 0.2-2?g-kg-1-min-1 and shun-aquku ammonium 0.2mg kg-1.h-1 The venous puncture tube in the right neck is detected by the central vein pressure Capacity-expanding therapy is guided by SVV 12%, and if SVV is 12%, 250 ml of long source snow injection seisis is entered in 5-15min The patient is too old, and the heart diastofunction function is weakened, choose to slow down the infusion speed, before the tumor removal long source Snow an 500 ml, so that SVV close to 12% when the patient is in a side lying, the tumor is compressed by the surrounding tissue, which causes blood pressure to rise, give nikadeflat 0.2mg a minute in advance for pretreatment, and the side lying process blood pressure is stable At the beginning of the operation, the pump began to pump 20 g/min nitrate, according to the blood pressure during surgery to adjust the infusion speed at any time During the separation of tissue around the tumor, blood pressure rose rapidly to 162/80mmHg due to surgical operation stouching the tumor, immediately resinned 0.2 mg of nikadiflat (Per), while increasing the speed of nitroglycerin pump injection, and the blood pressure slowed down to 120/65mmHg pay attention to observe the field situation, and timely communication with the operator, in the supply of tumor blood vessels a small dose of pump to remove norepinephrine 0.5mg/min for pretreatment, improve the concentration of norepinephrine in the blood, to prevent the tumor blood vessels completely disconnected blood pressure suddenly after the sudden drop During the operation to pay attention to the patient's brain oxygen saturation, tumor blood vessels completely broken, blood pressure drop, through pre-treatment of norepinephrine pre-pump injection, reduce the depth of light anaesthetic to high blood pressure , so that the brain oxygen saturation within 10% of the basic value, in order to reduce its brain damage many blood gas analysis, the concentration of ions is normal, blood sugar is normal Surgery, blood pressure is stable, heart rate 80 times / minute, urine volume of 500 ml, bleeding volume of about 50 ml, patients recover from independent breathing, all vital signs are stable Postoperative pathology results show: (left) chrome-oblastoma immunity grouping; CGA( Syn(plus), CD56 (plus) discussion the characteristics of this case are elderly patients, multiple cavity cerebral infarction history, diabetes history, coronary atherosclerosis The heart reserve function is weakened, the artery elasticity is reduced, and the hemodynamic stability is needed The diagnosis of the of cytomoblastoma in this case is clear and the hemodynamics are basically stable, and the key point of the anaesthetic scheme lies in pretreatment and monitoring and treatment of the pathophysiological characteristics of elderly patients pre-treatment: (1) preoperative sedatives, anti-choline application, reduce the patient's sympathetic neuroexcism, thereby controlling blood pressure, reduce the heart load (2) sufficient amount of opioid induction to reduce the stress reaction generated by intubation (3) the application of Ditvvisual laryngoscope, tracheostomy applied lidocain cream, can further reduce the intubation reaction, to ensure the stability of hemodynamics (4) Nitrate glycerin surgery began to pump injection, dilating blood vessels, so that the circulating blood volume is sufficient at the same time dilating the coronary veins, to prevent the operation of myocardial ischemia, arrhythmia occurred Whenever you communicate with the operator, start a small dose of the pump to remove noepinephrine at the beginning of the tumor blood vessel break, to prevent the blood pressure of the tumor blood vessel sharply plummeting after the blood vessel is completely broken (5) CVP, SVV monitoring under the full expansion of the hemodynamics more stable, in the tumor excision and after the excision of blood pressure did not increase and decrease excessively central venous pressure and perbo variation to monitor the long-term hypertension of patients with chromophilioma patients caused by insufficient circulatory blood volume, after anesthesia prone to severe hypotension, often need a large number of expansion of rehydration The elderly patients' heart pump function is weakened, and excessive rehydration can easily lead to heart failure 60% of patients with cytophilic celloma have preoperative catanosis heart toxicity, including electrocardiogram ST-T changes, acute myocardial infarction , acute pulmonary edema and cardiomyopathy Therefore, the monitoring of central venous pressure and perbo variation is particularly important, based on the monitoring of perbo variation of the target-oriented liquid therapy can effectively improve the heart front load of elderly patients with cranial brain surgery, while improving brain metabolism, that is, to ensure adequate circulating blood volume, without causing heart failure the monitoring of brain oxygen saturation in elderly patients is one of the factors of delirium restlessness after surgery, and the patient has a history of multiple cavity cerebral infarction, chromosomal tumor removal after the lack of catecholamine due to low blood pressure caused by the patient's postoperative delirium, wake-up delay, cerebral infarction and other complications greatly increased the probability The monitoring of oxygen saturation of the brain can detect the deficiency of oxygen supply in the brain, nitroglycerin nitrate, pre-treatment of norepinephrine, timely boost, dilating blood vessels to increase perfusion is very important Whether the central nerve damage is an important factor affecting the patient's prognosis, the brain oxygen saturation monitoring is applied to the perinatal tumor excision patients perinatal perination period brain oxygen supply and demand balance management can provide a sensitive and safe objective index for patients to safely pass through the perination period In summary, elderly patients with chromosomal celloblastoma often comorbidity, surgery risk is large, need to pay close attention to the surgical process, clear the key nodes in the surgical process, close monitoring, communication with the operator, pay close attention to the patient's vital signs, and give timely pre-treatment