A case in the past few days has become the focus of discussion in the anesthesia department.
The patient was a middle-aged man in his 50s whose biopsy diagnosed an esophageal tumor.
The tricky thing is that this person's lesion area is relatively large. From the cardia to the middle of the esophagus, obvious lesions can be seen. This means that the scope of the removal is large.
For this case, the surgery is nothing, and the chest and abdomen joint incision is done. However, for anesthesiologists, this means that the patient has greater trauma. It is necessary not only to suppress the pain during the patient's surgery, but also to control the patient's stress response. Because, once the stress is reacted, it may fall short.
The first is the first level, the intraoperative control problem of the thoracic and abdominal joint incision: intraspinal anesthesia, which obviously cannot meet the operation; general anesthesia, for such a large trauma may not be able to completely inhibit pain transmission.
Obviously, general anesthesia is definitely the first choice. The key is how to control the problem. Blindly pursuing deep anesthesia is a test for patients to stabilize intraoperative circulation. At the same time, related studies have shown that deep anesthesia may affect the long-term survival rate of patients.
Although the long-term survival rate may no longer be related to the anesthesiology department, as long as there is an impact, it will try to be considered as well as possible, which is also the professional quality of anesthesiologists.
Some people say that now that there are good means of monitoring, there are also good drugs, and it is completely safe to boldly take general anesthesia.
But there is a special thing about this patient: the patient is very obese. Excessive obesity keeps his body running at full capacity. Predictably, his cardiopulmonary function is on the margins.
In addition, a large amount of fat is bound to become a "hotbed" for the accumulation of anesthetic drugs. Even if intraoperative control is fine, postoperative anesthetics can be redistributed from fat, potentially endangering the patient's breathing.
Secondly, there is the problem of postoperative analgesia. Such a large incision, especially involving part of the chest wall, must be very painful after surgery. This means that a large dose of analgesia is required after surgery. However, such a fat, but also involving open chest surgery, no one dares to easily take such a large dose of anesthetic.
At this time, it was proposed that general anesthesia composite epidural anesthesia could be used.
However, here's the problem: the spinal segments of the thoracic and abdominal joint incision are designed from thoracic 5 all the way to thoracic 10. However, a stage of puncture can only satisfy two or three segments at most. This means that playing a little is simply not enough.
Since one point is not enough, is it okay to hit two points?
As soon as this design came out, it was immediately approved by everyone.
Although the two-point puncture is not often performed in the spinal canal, it is not difficult for everyone.
The next day, a senior anesthesiologist personally performed the puncture, followed by general anesthesia.
In the general anesthesia stage, everyone is also very careful. Especially for the difficult intubation problems that may be involved, everyone has prepared the visual intubation equipment early.
However, the surgery is not as easy as everyone thinks. This patient looks very heavy, but in fact he is very weak. After anesthesia, the blood pressure can not be carried at all. Therefore, it can only be held with a vasopressor.
In order to allow the two-point puncture epidural to work, the anesthesiologist reduced the concentration of local anesthetics and deliberately chose anesthesias that had a longer effect. As for blood pressure, it has also been maintained by vasoactive drugs.
When the incision was closed, the anesthesiologist put down the stone in his heart.
At this time, it is not the time to celebrate, only the patient's vital signs are stable and conscious.
After half an hour of fine adjustment, the patient's auxiliary vasopressor drug is gradually withdrawn. Asked if the knife edge hurt, the answer was "a little bit".
Hearing this answer, everyone is like hearing the "trumpet of victory." Decisively cleaned up the "scene" and quickly sent the patient back.
On the surface, the surgeon did not thank you, but in his heart he should say "this anesthesia is very reliable"!
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