Last weekend, I just attended a regional anesthesia conference. At the meeting, some of the case discussions were of great interest to everyone.
One of the cases shocked everyone present. Even, some people whispered at the bottom: How can this happen?
How can this happen? Hey, it really happened.
However, people dare to come up with cases that are still worthy of praise. The reported case is a hospital with good comprehensive strength in all aspects. Of course, it also has a clinical teaching job.
What does clinical tape teaching mean? That's to bring students. Leading medical students to enlightenment and laying solid basic skills is the main task of teaching.
However, it was such a hospital that had such a thing, which surprised everyone a little. But, on reflection, it seems likely that this could happen to our own hospital.
The patient was nothing special: men in their 30s, appendicitis, no serious underlying disease. Preparation for appendicitis surgery, anesthesia is done by epidural anesthesia.
No matter how you look at it, it's a simple little surgery. From the perspective of surgical grading, this is a procedure that can be completed by the attending doctor.
Anesthesia: In order not to let the young doctor's puncture technique be unfamiliar, the director specially arranged for Dr. Li, who is relatively young in Corey, to perform anesthesia.
After the patient entered the operating room, Dr. Li quickly connected various monitoring wires and checked various examinations again. He thought to himself: the epidural anesthesia waits for a long time, he should prepare faster, and don't let the surgeon urge.
After the tripartite verification, it quickly entered the disinfection, toweling and puncture links.
With the clear arrival of several layers of breakthroughs, Dr. Li was secretly happy in his heart: thanks, thanks, this patient is so good at puncturing!
Subsequently, he also successfully completed the operation of the "epidural" catheter.
In order to shorten the time of epidural waiting, before he could turn over, Dr. Li pushed a few milliliters of local anesthetics into the indwelling epidural catheter.
Hearing this, the people in the audience who listened to the case report were in an uproar. The faint voice was full of accusations.
What you don't know is that there are people in the audience who often do this. It's just that nothing happened to me. In principle, the drug must be administered after the patient lies flat. Once the patient has an emergency, it is convenient for rescue.
The case reporter continued to introduce that there was nothing abnormal after the patient lay flat, his head was not dizzy, and his ears were not ringing. Therefore, Dr. Li, who was in charge of anesthesia, pushed the epidural anesthetic "in full" in full.
Total amount, is a technical term in epidural anesthesia, which can be understood as "full dose". That is to say, by injecting the full amount, the process of epidural administration is completed. Usually, the full amount can already achieve the desired anesthesia effect, and the surgical procedure can be carried out smoothly.
However, as soon as the full dose of the drug was pushed in for about 10 minutes, the patient felt that breathing was very laborious.
The sudden situation made Dr. Li's brain "boom". He was thinking: Poisoned by local anesthetics? Impossible. If the local anesthetic is injected into the blood vessel, the patient's consciousness should change! Besides, the epidural catheter retraction is normal, it shouldn't be.
Here it needs to be corrected: the epidural catheter withdrawal without blood or cerebrospinal fluid does not completely rule out that the catheter is not in the blood vessel or in the blood vessel.
Although he was thinking about the reason at a high speed in his brain, the movement of his hands did not stop. Rapidly use a mask to assist the patient with breathing. At the same time, let people quickly call for help.
The director who heard the news rushed to the director, after careful examination, judged that this patient should have had a subdural block. The main evidence is that there is little noticeable anesthetic effect on the lower extremities (including the upper limbs). However, the labor of breathing and the marked decrease in blood pressure can basically confirm the presence of an abnormally extensive block.
Dr. Li anxiously waited for the director's instructions for intubation, but the director said: First assist in the look. We only used short-acting local anesthetics to see if we could recover.
At this time, everyone was talking about it. Some say the intubation is not necessary.
At this time, the case reporter continued to introduce: there was no rush to intubate at that time, mainly considering that after intubation, it may be because of general anesthesia drugs to aggravate the existing circulatory inhibition; in addition, it may also be because the patient is unconscious and cannot accurately grasp the progression of the disease.
After that, several well-known experts began to express their opinions.
The final opinion was also not agreed. Some say that this situation can be prevented, and some say that there is no way to prevent it.
The main means of prevention, in addition to standardizing puncture, is the "test volume" of epidural anesthesia.
The amount of test is to use a little local anesthetic in advance to test whether the epidural catheter is in the subarachnoid space or in the blood vessel. Note that it is not that the test is not in the epidural cavity, but that the test is not there.
If inside the vessels, there may be manifestations of local anesthetic intoxication.
Some people will question: patients who push a few milliliters of intravenous local anesthetic will not feel it, and epidural anesthesia will respond when pushed into the blood vessels?
This is because the blood vessels in the epidural space are different from those in other parts.
Of course, this refers to the vein. Because, the veins are refluxed.
The intradural intradural network is characterized by a communion with the intracranial venous network. Therefore, the drug may reach directly into the skull through this special anatomical route. Directly into the skull, a few milliliters of local anesthetic can cause a serious reaction.
What happens if the epidural catheter enters the subarachnoid space?
It is mainly manifested as the effect of simple waist anesthesia. Therefore, when the test volume has a similar effect to waist anesthesia, it is necessary to be vigilant.
The topic returns to this case, since the subdural space can lead to abnormally extensive blocking, it may be similar to lumbar anesthesia because of a few milliliters of local anesthetics, right?
No, it won't. The main reason is that the onset of the hypodural space is also very slow, generally 15-20 minutes.
The reason why this patient appeared in a relatively short period of time was mainly due to the preposition of the test volume. If you start from the sideways propulsion test volume, the time is just 15-20 minutes.
The meeting site is almost exclusively anesthesia professional, but there doesn't seem to be a good solution to this problem: even if the catheter is in the subdural gap, it is difficult to detect abnormalities before the full amount due to delayed symptoms.
Finally, a method of retesting the volume was proposed. This is done by testing the amount at the standard 3 ml for the first time. Second time, push 5 ml. Even if there is an abnormally extensive block this time, the recovery time will be greatly shortened due to the lack of medication.
There is also a consensus that once a subdural space block occurs, the intraspinal anesthesia should be terminated in time. If surgery is necessary, general anesthesia is performed with caution.
A case discussion is over, but we are left with many questions: how to technically ensure the safety of patients? How does anesthesia continue? In most cases, the anesthesiologist does not deliberately emphasize this complication, can the family understand?
【Warm tips】Point to pay attention, here is a lot of professional medical science, for you to reveal the secret of surgical anesthesia those things ~ ~