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    Home > Active Ingredient News > Anesthesia Topics > Anaesthetic management of paracancerous herpes with thymus surgery

    Anaesthetic management of paracancerous herpes with thymus surgery

    • Last Update: 2020-07-16
    • Source: Internet
    • Author: User
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    !---- The patient, female, 26 years old, height 158 cm, weight 45 kg, due to "repeated rash 13 months, after the interval of 7 months, chest breathing breathing breathing more than 10 days" into my hospital chest surgery for treatment13 months ago, the patient because of repeated rash repeatedvisits in different hospitals, diagnosed as "systemic lupus", oral perisone and other drug treatment effect is not good, 7 months ago the hospital CT prompted right back column occupied, the size of 5.9 cm x 4.1 cm x 14 cm, because of repeated skin loss can not be treatedmore than 10 days of breathing difficulties to my hospital for surgeryadmission HR140 to 160 times / minute, shortness of breath, the whole body skin many disc-shaped erythema (Figure 1), many mouth ulcers, the patient continued to cough and cough white sputumauxiliary examination: immunoglobulin, individual complement (Ig-C3C4) IgG16.5g/L, IgM2.24g/L, blood sink 103mm/hthe total amount of 24h urine 1500 ml, 24h urine protein quantitative 269.69 mgcentopholipid antibody IgG negative, anti-neutrophil cytoplasmic antibody pANCA negative, ANA antibody negativecombined with the patient's skin loss and chest CT results, diagnosed as para-tumor herpes, hormones and other treatment at the same time actively prepare for surgeryon the 18th day of admission, the patient suddenly short of breath, confusion, unresponsiveness and other symptoms, HR145 times / minute, BP107/82mmHg, SpO2 70%, FiO 2 40%, PaO2 81mmHg, PaCO2 109mmHgconsidering severe co2 accumulation for para-tumor herpes and severe obstructive bronchitis, immediately transferred to the ICU line of mechanical ventilation, transfer to the time blood gas analysis show FiO2 100%, PEEP5 cmH2O, pH7.16, PaO2 273mmHg, PaCO2 97mmHg, HCO-334.6m/Lmoairway resistance of 40 to 45 cmH2O during mechanical ventilation, multiple fiber bronchoscopy detected a small amount of yellow-thick sputum in the double lung, bronchial mucosa mild edemasustained hypoxyandoxi and hypercarbonate, oxygenation index of about 200ct-review indicates double lung infection, right lung inthem is not open, right side a small amount of thoracic fluidinto the ICU on the 5th day, multidisciplinary consultation opinion: surgical removal of tumor is a necessary means of para-tumor herpesanaesthetic is the current treatment to strengthen the treatment of cnocystal protein shock, especially during perioperative surgeryafter active preparation, in the ICU 10days of surgerypreoperative 25g propylene globulin drips, single cavity tracheostosis mechanically ventilated into the operating room, in-room HR140 times/min, BP115/80mmHg, SpO2 100%, PaCO2 65mmHg intravenous lymics 3mg, relying on miede 14mg, Roco bromide ammonium 20mg, Shufentani 15 sg induction can be seen around the lips (Figure 2), after the removal of the trachea fixed can be seen the lips and the mucous membrane in the mouth of many festering, a small amount of blood oozing to avoid aggravating injury, give up replacing the double-cavity bronchial intubation, and place the sealer into the original trachea duct to seal the right main bronchial tube right open chest surgery, during which airway pressure 40 to 42 cmH2O, a small amount of gas overflowed into the right lung to the right lung collapse incomplete pure oxygen supply in surgery, multiple detection of blood gas, pH7.2 to 7.3, PaO2 150 to 273mmHg, PaCO2 59 to 75.4mmHg due to single lung ventilation can not maintain good oxygenation, surgery intermittent double lung ventilation lasted 3h, and the tumor was completely peeled out after surgery to pull out the blocker for repeated expansion of the lungs, the right lung in the middle lobe still can not re-open, consider the sputum blockage, to the fiber mirror gradually deeply attracted (Figure 3) after the lung again slowly re-opened the operation is still smooth, infusion 2900 ml, urine volume of 1200 ml returned to ICU, HR90 times/min, BP105/62mmHg, SpO2 100% the rash gradually improved after surgery and 15d was transferred back to the general ward, where he is continuing to recover discuss ediphyne herpes is a clinically rare autoimmune herpes disease that affects the skin and mucosa often associated with tumors of the origin of the lymphatic system, and 80% of PNP patients are associated with non-Hodgkin's lymphoma (NHL), chronic lymphocytic leukemia (CLL) and Castleman disease up to date, the domestic reported a total of more than 200 cases of para-tumor natural blisters, mainly with Castleman disease, accompanied by the NHL's side tumor herpes is rare The key to reducing the mortality rate of the disease is the timely detection and removal of associated lymphatic tumors, as well as the prevention and control of fatal obstructive bronchitis After diagnosis, strive to complete the tumor removal surgery within 1 to 2 weeks, does not require the control of skin mucosa symptoms after surgery the patient to the whole body rash as the first symptom, according to systemic lupus treatment effect is not good, found that the large tumor, due to the skin damage is more serious failure to operate, resulting in serious respiratory dysfunction studies have reported that the use of immunoglobulin during perioperative can effectively reduce the occurrence of obstructive bronchitis after surgery 20g of intravenous immunoglobulin drops before, during and after surgery, especially in patients with respiratory symptoms after surgery, help prevent or mitigate the occurrence of fatal obstructive bronchitis patients with severe plasma dialysis can try plasma dialysis to reduce autoantibody titer in the blood, thereby more effectively prevent and reduce the occurrence of obstructive bronchitis patients in this case were only used 25g of propylene globulin once before surgery 1h due to economic factors has not yet met the literature-recommended dosage the patient due to a long medical history, the tumor volume is large, airway blockage is serious, there has been a serious carbon dioxide accumulation, the emergence of consciousness disorders, mechanical ventilation is still poorly improved, anesthesia management is difficult for the surgery, the ideal airway management should be a double cavity tracheal duct intubation single lung ventilation, good double lung isolation at the same time easy to attract but consider the patient's oral mucosal ulcer bleeding, while the trachea mucosal edema, so give up anesthesia after changing the double cavity tube and choose to retain the original trachea catheter in the case of the placement of bronchial blocker, to avoid airway damage aggravated due to the patient's lung problems, the airway pressure is high during surgery, the blocking effect is not good, and the single lung ventilation can not maintain good oxygenation, so the intermittent double lung ventilation during surgery to maintain a relatively normal oxygen pressure and carbon dioxide pressure patients before surgery CT is found that the right middle loin lung is not open, in the course of surgery, even if the double lung is positive pressure ventilation, can not expand the right middle loiteral lung after the tumor was removed, the practitioner repeatedly massaged the aering lung lobe, while increasing the pressure of the puffed lung, still can not change the lung leaf condition consider possible due to concurrent occlusionbronitis, then the use of 2.8mm fiber mirror gradually deep into the bronchial tube and repeatedly attracted white mucus, the lung leaf can gradually re-open adhesty tumor herpes has a low incidence, high mortality rate and lack of clinical treatment experience preoperative need to fully consult the relevant information, and multidisciplinary discussion, the development of medical treatment programs and special circumstances of the plan, at the same time to explain to the family related risks to the family's understanding and support
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