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    Home > Active Ingredient News > Study of Nervous System > 【Anesthesia Hotspot】Neuropathy after cardiac surgery

    【Anesthesia Hotspot】Neuropathy after cardiac surgery

    • Last Update: 2022-02-20
    • Source: Internet
    • Author: User
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    Postoperative Cardiac Neuropathy HAPPY NEW YEAR Cases Form: Retrospective case analysis The patient, male, 56 years old, 170 cm tall and 112 kg in weight, planned to undergo coronary artery bypass grafting due to three-vessel coronary artery disease combined with hypertension and type 2 diabetes
    .

    The patient complained of chest pain after activity, which was relieved by rest
    .

    Currently taking metformin, lisinopril and metoprolol
    .

    The patient worked as a data analyst, had no history of smoking, and consumed alcohol when socially necessary
    .

    Vital signs: body temperature 37.
    2°C; blood pressure 142/86mmHg; heart rate 64 beats/min; respiration 14 beats/min
    .

    Physical examination: Obese, clear breath sounds in both lungs, consistent heart rhythm, no murmurs, and no carotid murmurs
    .

    Preoperative laboratory tests showed normal biochemical parameters, cholesterol, and blood cell counts
    .

    The preoperative electrocardiogram showed left ventricular hypertrophy, and the others were normal
    .

    Exercise stress testing revealed significant ST-segment depression in the lateral leads, and subsequent coronary angiography showed 80% stenosis in the left anterior descending artery and 90% stenosis in the circumflex and right coronary arteries
    .

    Ventricular function, valve structure and function were normal
    .

    Anesthesia was induced with etomidate, fentanyl, midazolam, and rocuronium, and endotracheal intubation was performed
    .

    The left radial artery was punctured with a 20G puncture needle
    .

    Under ultrasound guidance, the right internal jugular vein was punctured, and a pulmonary artery catheter was inserted into the pulmonary artery through a 9F guide sheath
    .

    The patient's arms are placed naturally at the sides of the body in a neutral position, and foam pads are placed on the elbows, forearms, and hands
    .

    Anesthesia was maintained with isoflurane, fentanyl, rocuronium, and midazolam balanced anesthesia techniques
    .

    The thoracotomy was performed through the median of the sternum, and a sternal retractor was placed to facilitate the separation of the left internal thoracic artery, and the rest were grafted with the great saphenous vein
    .

    The total cardiopulmonary bypass time was 2 hours
    .

    The patient's cardiac function recovered without inotropic support and was successfully released from cardiopulmonary bypass
    .

    Intraoperative fluid infusion: 5% albumin 1L, lactated Ringer's solution 3L
    .

    The operation time was 6 hours
    .

    After the operation, the patient was sent to the ICU, where nitroglycerin was pumped at a constant rate of 0.
    5 μg/(kg·min), and mechanical ventilation was continued
    .

    No intraoperative complications were found, and the tracheal tube was removed after 4 hours of observation in the ICU
    .

    On the first postoperative day, the patient complained of numbness in his right hand and weakness in his grip
    .

    Progressive observation showed that the skin on the ulnar side of the wrist and the dorsal and volar surfaces of the ulnar half of the little and ring fingers was lost, and the hand was claw-shaped at rest
    .

    Motor function tests showed decreased index-to-little flexion and normal elbow tests
    .

    A diagnosis of ulnar neuropathy was made, and a physical therapist was consulted
    .

    On the third postoperative day, the patient had regained about 50% of his hand strength, but still had numbness
    .

    On the fifth postoperative day, a neurological examination was performed on the patient to further evaluate the patient's condition
    .

    Electromyography (electromyography, EMG) examination showed continuous compression of the carpal tunnel
    .

    On further questioning, the patient reported occasional numbness in his hands after working on the computer for several hours
    .

    Three months later, the patient's symptoms returned to preoperative levels, and hand motor function was fully restored; his recovery was attributed to the treatment of carpal tunnel disease by a hand surgeon
    .

    Case Discussion Perioperative Peripheral Nerve Injury Although peripheral nerve injury (PNI) is not life-threatening, PNI can cause serious distress to patients and anesthesiologists, resulting in short-term and rarely long-term dysfunction or residual
    .

    Therefore, PNI increases the risk of medical liability
    .

    Peripheral nerve injury (16%) is the second most significant injury after death (32%), according to non-public compensation data from the American Society of Anesthesiologists
    .

    Ulnar neuropathy had the highest incidence among nerve injuries (28%), followed by brachial plexus (20%), lumbosacral plexus (16%), and spinal cord (13%) neuropathy
    .

    The mechanisms of perioperative neuropathy are not fully understood
    .

    Although nerve compression, traction, ischemia, direct trauma, or metabolic disorders caused by inappropriate posture can all lead to nerve injury, in most of the reported cases, the injury has nothing to do with the patient's posture, and the mechanism remains unclear
    .

    PNI can manifest as sensory, motor, or mixed disturbances in areas of damaged innervation
    .

    Sensory disturbances alone are often temporary, recovering in days or weeks without any intervention
    .

    The movement disorder is relatively severe and requires further evaluation and management of the patient by the neurology department
    .

    Sensory disturbances lasting longer than 5 days also require neurological management
    .

    Nerve conduction testing and EMG can help determine the type (axonal, demyelinating, or mixed) and distribution (proximal, distal, symmetric, asymmetric) of nerve injury, as well as the degree of motor and sensory involvement
    .

    Peripheral Nerve Injury After Cardiac Surgery Various PNIs can occur after cardiac surgery
    .

    Brachial plexus neuropathy, phrenic nerve injury, saphenous neuropathy, recurrent laryngeal nerve injury, sympathetic trunk disorder with Horner syndrome, and optic neuropathy have been reported
    .

    Brachial plexus The incidence of brachial plexus injury is 2% to 18%
    .

    Ulnar neuropathy is usually caused by stretching and injury to the lower nerve root (C8-T1)
    .

    Brachial plexus compression and stretch can be caused by excessive sternum and cranial placement of a sternal retractor, as well as asymmetric stretching of the internal thoracic artery resulting in a fracture of the first rib
    .

    The plexus is more susceptible to stretch between the fixed fascial attachment and the fixed proximal origin
    .

    Prolonged stretch of the plexus interferes with axonal transmission, resulting in transient neuropraxia
    .

    The amplitude of somatosensory evoked potentials in the brachial plexus was reduced by more than 50% after placement of the sternum retractor
    .

    Risk factors that make the injury worse or cause permanent symptoms include pre-existing neuropathy, such as elbow or carpal tunnel compression, and advanced age
    .

    This situation is known as a "double squeeze" phenomenon, where two injuries to any one nerve will produce severe symptoms, whereas a single injury may be asymptomatic by itself
    .

    Smoking, diabetes, height and weight were not associated with this risk
    .

    Male patients appear to be at slightly higher risk of developing permanent symptoms than female patients
    .

    Symptoms vary depending on the location and severity of the injury
    .

    Phrenic and recurrent laryngeal nerves Complications of phrenic and recurrent laryngeal nerve injury are known to occur after cardiac surgery
    .

    The main reason for its occurrence is believed to be local hypothermia caused by ice slush and/or asystole fluid
    .

    Sternal distraction, separation of the internal thoracic artery, and placement of a central venous catheter are also associated with neurological dysfunction
    .

    Improper placement of the transesophageal echocardiography probe can also lead to recurrent laryngeal nerve dysfunction
    .

    Diaphragmatic dysfunction due to phrenic neuropathy should be considered in patients who cannot be weaned off the ventilator after cardiac surgery
    .

    Similarly, vocal cord dysfunction due to recurrent laryngeal nerve injury may lead to postoperative respiratory failure
    .

    Diagnostic techniques currently used include X-ray, ultrasound and EMG
    .

    Saphenous nerve separation of the saphenous nerve can lead to saphenous neuralgia
    .

    Although endoscopic vein dissection may reduce wound pain, whether it can reduce saphenous neuralgia requires further investigation
    .

    Optic nerve optic nerve ischemia resulting in visual impairment is an uncommon but serious complication of cardiac surgery
    .

    Chronic hypotension, blood clots, hemorrhage, and anemia can reduce blood perfusion anywhere along the visual pathway from the retina to the occipital lobe
    .

    Central venous catheterization and nerve injury Central venous replacement has a low incidence (1%) of nerve injury, which can be caused by direct nerve puncture or hematoma compression
    .

    Numerous cases of brachial plexus palsy, phrenic nerve, and recurrent laryngeal nerve injury due to repeated intrajugular or subclavian venipuncture have been reported
    .

    Ultrasound-guided venipuncture reduces the number of punctures, thereby reducing the incidence of nerve injury
    .

    Compared with traditional methods, ultrasound-guided catheter puncture has a higher success rate, lower repetition rate, and lower complication rate (mainly arterial puncture)
    .

    Ultrasound guidance should be considered in patients with difficult access, such as anatomical variation, obesity, and scarring at the access site
    .

    Ulnar neuropathy in non-cardiac surgery The American Society of Anesthesiologists (ASA) Non-Public Compensation Database reports that the most common type of nerve injury is ulnar neuropathy (UN)
    .

    Ulnar nerve crush injuries are immediately symptomatic; however, UN usually occurs within 24 hours after surgery, suggesting that direct nerve crush injury is not the primary mechanism in these cases
    .

    The most common site of injury is the brachial plexus at or above the elbow
    .

    UN may still occur even with careful padding of the upper extremities
    .

    Risk factors associated with UN were male sex, excessive body mass index, and length of hospital stay
    .

    Symptoms of UN include loss of sensation in the ulnar half of the little and ring fingers, decreased grip strength, and claw-like shape of the little and ring fingers due to muscle imbalance in the hand
    .

    Preexisting underlying neuropathy may predispose patients to perioperative UN
    .

    The study found that the vast majority of patients had abnormal nerve conduction not only on the affected side but also on the contralateral side, which supports the above findings
    .

    Prognosis of Peripheral Neuropathy After Cardiac Surgery The prognosis of peripheral neuropathy depends on the type and severity of the injury
    .

    Most common deficits are transient, with complete recovery within 6 to 8 weeks, with very few symptoms lasting more than 4 months and improving slowly over time
    .

    Prevention and Management of Peripheral Neuropathy Prevention of peripheral neuropathy is a very important component of perioperative care for all surgical patients
    .

    Appropriate patient positioning and bedding to avoid direct compression or pulling of peripheral nerves is especially important for patients undergoing long-term surgery
    .

    For the upper extremities, avoid compression of the ulnar sulcus of the elbow and the humeroradial sulcus, and do not abduct the arm more than 90° in the supine position
    .

    For the lower extremities, avoid tendon hyperextension and avoid compression of the peroneal nerve at the fibular head
    .

    When the patient is in the lateral decubitus position, a protective pad and a chest pillow are placed over the nerve compression site
    .

    Postoperative identification of peripheral nerve injury requires prompt and comprehensive evaluation, complete documentation, and close observation
    .

    If symptoms worsen or persist beyond 1 week after surgery, a neurologist should be consulted
    .

    EMG may help determine the type and location of nerve damage, as well as identify pre-existing conditions
    .

    Key information 1 .
    Brachial plexus injury often occurs during cardiac surgery2.
    All patients with PNI should be followed closely and further appropriate evaluations should be considered as appropriate
    .

    3.
    Most patients with PNI have a good prognosis, with complete resolution of symptoms within weeks or months of injury
    .

    4.
    Pre-existing neuropathy can be identified if EMG is performed preoperatively
    .

    Question 1.
    What neuropathies are most commonly encountered in the perioperative period? Answer: Nerve injury UN had the highest incidence (28%), followed by brachial plexus injury (20%), lumbosacral neuropathy (16%), and spinal neuropathy (13%)
    .

    2.
    Which PNI is associated with heart surgery? Answer: Brachial plexus neuropathy, phrenic nerve injury, saphenous neuropathy, recurrent laryngeal nerve injury, sympathetic trunk disorder with Horner syndrome, and optic neuropathy have been reported after cardiac surgery
    .

    3.
    Which peripheral neuropathy is associated with central venous catheterization? Answer: There have been reported cases of brachial plexus palsy, phrenic and recurrent laryngeal nerve injury caused by repeated internal jugular or subclavian vein punctures
    .

    Notes/Review by Guan Yong/Wandering Cloud Typesetting/Dingdang Maruko Ma together to the future TOGETHER FOR A SHARED FUTURE
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