A case of emergency caesarean section anesthesia in patients with new coronavirus infections.

The patient, female, 23 years old, pregnant 2 birth 0, due to "pregnancy 37 plus 3 weeks, fever 4d, irregular abdominal tightening feeling 3h more" transferred to Wuhan Concord Hospital.
after hospitalization: body temperature 38.7 degrees C, HR122 times/min, RR20 times/min, BP130/87mmHg.
double lung stethoscope breathing sound thick, abdominal puffing, fetal heart rate 156 times / minute, can touch irregular contractions, internal diagnosis is not available.
a healthy past, denied genetic history, no history of hypertension, diabetes, 2018 due to grape fetal surgery, no history of drug-free food allergies, no history of blood transfusions.
given that it is currently in the 2019-nCoV outbreak, initial screening of mothers is carried out immediately.
to take the pharynx swab specimen line nucleic acid test.
ct in the lungs suggests viral pneumonia, a small amount of heart fluid.
the emergency outbreak, no influenza A, influenza B and other viruses were detected.
obstetrics B super-show: pregnancy 37 weeks plus, front placenta, placental lower edge reached the inner mouth of the cervix, amniotic water is too little.
blood routine after hospitalization: white blood cell 8.28 x 109/L, hemoglobin 124g/L, plate plate plate 114g/L, neutral granulocyte count 7.07 x 109/L, lymphocyte count 0.84 x 109/L, lymphocyte percentage 10.1%, C-reactive protein (CRP) 63.3mg/L, normal blood clotting function.
initial diagnosis was: (1) pregnancy 2 birth 0, pregnancy 37 plus 3 weeks precursor birth; (2) pre-placental; (3) viral pneumonia? All medical personnel take three levels of protection.
, routine electrocution monitoring, open intravenous access, BP135/80mmHg, HR138 times/min, SpO292%.
the mother after lying flat cough, panic and discomfort, give the mask oxygen absorption.
the anaesthetic consent, the mother sleeps on the left side and tells the mother to try not to cough during the anaesthetic operation.
routine disinfection towel, take L2-3 clearance line single cobweb subcab block, the use of heavy gravity bureau hemp liquid anaesthetic, the vertebral tube is not left in the catheter.
the puncture, tell the mother to lie flat and measure the anaesthetic plane at T6 level.
the results of the anaesthetic, a live baby boy was successfully delivered, with 1 and 5min Apgar scores of 9 and 10, respectively.
the operation of the mother non-stop cough, the operation has a certain impact.
hypotension in hypotension, and was given a static injection of 2 mg of methicilton and 2 mg of dopamine after smooth.
the entire operation lasted 150min, in-patient rehydration 1500ml, bleeding about 300ml, urine volume about 400ml, stable vital signs, smooth surgery and anaesthetic process, the operation of the maternal return to the isolation ward.
medical staff after surgery no symptoms of infection.
review CRP117.52mg/L on the first day after the operation, CRP87.93mg/L on the 3rd day, clotting function APTT54s, FIB4.91g/L.
postoperative maternal vertebral anesthesia-related complications, after the operation of the second world of activity.
tested positive for 2019-nCoV nucleic acid after surgery.
the neonatal unit and tested positive for 2019-nCoV nucleic acid with a postoperative pharynx swab.
discussed the outbreak of unexplained pneumonia in Wuhan at the end of 2019, the pathogen was quickly identified as a new type of coronavirus (2019-nCoV), 2019-nCoV infection was included in Class B infectious diseases, the use of Class A infectious disease prevention and control measures.
The National Health Care Commission issued the "new coronavirus infection of pneumonia diagnosis and treatment program (trial fifth edition)" pointed out that the current 2019-nCoV infection is the main source of infection is the new coronavirus pneumonia patients, the main transmission channels include respiratory droplets transmission, contact transmission, aerosol transmission, there is the possibility of digestive tract transmission and vertical transmission of mother and child.
general susceptible to 2019-nCoV, with an incubation period of about 1 to 14d after infection, mostly 3 to 7d.
2019-nCoV infection is mainly manifested as fever, dry cough, fatigue, shortness of breath, the total number of exothermal white blood cells normal or reduced, lymphocyte count decreased, the lung CT presents a virus-like pneumonia change.
since the outbreak, maternal mothers have become one of the susceptible populations in 2019-nCoV.
maternal is a special high-risk group, pregnant women on the viral respiratory infection of inflammatory emergency response significantly increased, at any time to face the rapid progress of lung disease, fetal intraconsural distress and other risks.
In the 2019-nCoV infection epidemic, for the highly suspected or confirmed maternal emergency caesarean section anesthesia, anesthesiologists how to protect themselves under the premise of helping the mother to smoothly and safely through the perinatal period, is one of the current clinical work must be paid attention to, worthy of every anesthesiologist's attention and discussion.
(1) preoperative assessment and preparation.
This case has a history of living in Wuhan epidemic area, fever, dry cough and other symptoms, lung CT prompt viral pneumonia, blood regular lymphocyte count decreased, and the current 2019-nCoV infection clinical symptoms are highly similar, although the 2019-nCoV nucleic acid test results did not come out, but before surgery has been treated as 2019-nCoV highly suspected cases of infection management.
Preoperative assessment: (1) maternal lung infection is serious, shortness of breath, poor oxygenation, oxygen absorption, poor lung function, fetal preoperative distress may be;
decision-making throughout the process was decisive, and medical personnel assembled quickly, saving valuable time for mothers.
(2) options for anesthesia programmes.
for the maternal anaesthetic selection, the conventional selection of vertebral anesthesia, if necessary, the choice of general anaesthetic.
is it possible to have intravertebral anaesthetic or general anaesthetic for women who are infected with 2019-nCoV infection after a caesarean section? Compared with general anesthesia, intravertebral anesthesia does not require direct face-to-face contact with the patient's gas channel, anesthesiologist's risk of infection exposure is relatively reduced, but requires the patient's high degree of cooperation, and the blood clotting function is normal, there is a risk of imperfect anesthesia effect or puncture failure.
compared with intravertebral anesthesia, general anesthesia can control the patient's air, to a certain extent, improve the patient and fetal oxygenation, patient comfort is high.
the risk of infection by an anesthesiologist is extremely high, patients may have difficulty removing the tube after surgery, respiratory failure.
studies have shown that prolonged coagulation enzymes are one of the symptoms that may occur in patients with 2019-nCoV infection.
the technical requirements and preoperative evaluation of anesthesiologists are greater because of the possible abnormality of blood clotting in patients with 2019-nCoV and the fact that patients should not cooperate with anaesthetic puncture operations.
to ensure that the mother can safely and comfortably complete the operation, but also to ensure the safety of the mother and newborn after surgery, reduce the possibility of adverse prognostication.
so the anaesthetic options of this type of patient are even more important.
Based on the experience of similar patients in our hospital and the summary of the maternal anesthesia in this case, it is recommended that in patients with combined severe obstetric complications, it is recommended that, in the case of normal clotting function, the priority line of single lumbar hemp is relatively safer and more effective, if necessary, general anesthesia.
case, the maternal lungs were in poor condition, but oxygenation remained stable under the oxygen absorption of the mask.
Maternal preoperative clotting function is normal, but with the progression of pneumonia, clotting function has the risk of abnormality, so decided to give priority to the use of the smallest impact on the fetus intravertebral anesthesia, the use of fine single needle lumbar hemp, reduce the risk of hematoma formation within the vertebral tube.
all the drugs and articles of the general anaesthetic tracheal tube are prepared at the same time, in case the puncture fails or the effect is not good, change to general anaesthetic at any time, mechanical air.
(3) Neonatal Management.
case, preoperative consideration of the possibility of fetal in-house distress, in advance ready to rescue the newborn.
after the birth of a newborn baby, the general condition is good, vital signs are stable.
because of the pregnancy combined with 2019-nCov infection of the maternal symptoms of high fever and hypoxemia, fetal distress, premature birth risk greatly increased, should be closely monitored and rescue newborns.
during the outbreak, cases of in-house fetal infection 2019-nCov have been reported, and there may be vertical transmission between mother and child.
in this case, there were no obvious abnormalities in the postoperative review of the coagulation function of the mother, and the postoperative review of the child was positive for nucleic acid, indicating from the side that the virus may have vertical transmission.
, the 2019-nCov infection of the mother of the newborn, in the process of handling and referral of newborns, anesthesiologists also need to do a good job of isolation protection.
recommends isolation of 10 to 14d, collection of pharynx swab samples, confirmed tests.
should not be breastfed until the 2019-nCov infection has not healed.
(4) anesthesiologist protection.
2019-nCov is highly contagious and is transmitted mainly through droplets, contact transmission and aerosol transmission, which is extremely high risk of exposure and infection for frontline medical workers working clinically.
The World Health Organization (WHO) reported that the outbreak of SRAS in 2003 led to 1,706 infections among health care workers, with a high risk of infection mainly due to operations related to the air duce and breathing, inadequate or improper use of medical protective clothing, reuse of medical protective masks, fatigue and lack of training in infection control.
recommended that anesthesiologists should take three levels of medical protection when anaesthetic is used in patients with suspected or confirmed 2019-nCov.
wearing a hand wash, medical protective mask, disposable work cap, jacket disposable protective clothing, disposable latex gloves, disposable shoe covers, take-away eye protection type medical surgical mask or goggles and medical protective mask or positive pressure hood.
clinical practice, we should strictly follow the order and principle of wearing and dislodgging protective equipment, and ensure the tightness of masks, goggles and protective clothing when wearing protective equipment.
in the process of de-protective supplies, irregular operation is also easy to cause medical contamination and increase the risk of infection and exposure of medical personnel.
medical personnel from continuing to work in extreme fatigue situations.
this case, due to the shortage of protective equipment, there is no standard of protective clothing, so we wear two layers of isolation clothing, coat surgical clothing, shoe cover, instead of protective clothing for protection.
the end of the work, all the participating medical personnel at home isolation 14d, no signs of infection, also indicating that the protective measures were successful.
In short, 2019-nCov infection is a highly contagious acute respiratory infection, pregnancy combined with 2019-nCov infection of pregnant women is a special type of patients in clinical work, anesthesiologists in the process of anaesthetic of such maternal, should strictly do a three-level protective measures, pre-anesthesia fully assess the patient's cardiopulmonary function, blood clotting function, reasonable choice of anaesthetic methods, in order to ensure the safety of the mother and child, as far as possible to reduce the risk of infection and exposure of medical personnel.
actively monitor staff in contact with patients for fever and other symptoms, it is best to isolate 14d at home to avoid cross-infection.
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