For a long time, it has been believed that anesthesia work is as simple as "taking a shot". Not only do patients think this way, a few surgeons think this way, but even some anesthesiologists let their guard down.
Seeing the following case, I believe that everyone will once again tighten the nerves of medical safety.
The patient is male, 17 years old. Because of "trauma caused by the right buttock for more than 5 hours", he was rushed to the hospital by 120 for treatment. The clinical diagnosis is "open trauma to the buttocks with a foreign body of the buttocks, and it is proposed to undergo emergency debridement of the right buttocks under lumbar anesthesia." After the operation, antibiotics, dressing changes, etc. are routinely used prophylactically.
I thought it was a very simple operation. However, 24 hours after surgery, patients feel headache, nausea, vomiting, and gradually worsen.
After consultation with the department of anesthesiology, the cause of intracranial hypotension after lumbar anesthesia is first considered. Intravenous sodium chloride injection was given for rehydration, analgesia, and antiemetic therapy. However, the effect is not obvious. 36 hours after surgery, the patient developed a high fever of 39 degrees. Therefore, a physical cooling treatment is given, but the effect is not obvious. 48 hours after the operation, the patient complained of severe headache with nausea and vomiting, high fever did not go away, and the maximum body temperature was close to 40 degrees.
In view of the complexity and criticality of the patient's condition, urgent consultation was made again. At this time, the blood culture results also came out. To everyone's surprise, blood cultures did not produce bacteria. So, where does such a strong manifestation of infection come from?
The condition was critical, not the time to shirk, and everyone once again carried out the disease analysis and corresponding examination. Physical examination shows a rigid neck and a positive Kernig sign, considering intracranial infection.
For the sake of rigor, the patient was immediately given a lumbar puncture. The results showed that intracranial pressure was as high as 450 mmH2O. Combined with opacification of cerebrospinal fluid and severe abnormal elevation of white blood cells, intracranial infection is confirmed.
After treatment with antibiotics, hormones and glycosyl dehydration, the headache, nausea and vomiting of the patient were alleviated the next day. After 10 days of treatment, the patient's headache, nausea, and vomiting disappeared. The results of the review showed that the body temperature, blood routine, cerebrospinal fluid routine and biochemistry and other indicators returned to normal.
Although the patients ended up leaving no sequelae, the incident was shocking: where did the infection come from? With this question in mind, the case discussion was once again launched.
Available evidence suggests that there are four routes of intracranial infection in adults:
1. Direct infection: The bacteria enter the skull directly through the wound of an open head injury or craniotomy. After admission, the patient is clearly conscious and has no head trauma on examination. Obviously, this patient can basically rule out this aspect.
2. Lesion infection: Bacteria invade the skull from the lesions of infection adjacent to the brain such as skull osteomyelitis, paranasal sinusitis, otitis media or mastoiditis. This can be ruled out from preoperative cranial CT.
3. Hematogenous infection: if secondary to sepsis, bacteremia or purulent lesions in other parts of the body, the bacteria spread to the brain through hematogenesis. At the first consultation, blood cultures without cultured bacteria can rule this out.
4. Infections caused by cerebrospinal fluid pathways: infections caused by operations such as lumbar puncture, lateral ventricular puncture, or intrathecal injection of drugs. In this case, there is no lateral ventricular puncture or intrathecal injection of drugs, so there is a high suspicion of lumbar puncture.
Case discussions are not when accountability is held and the anesthesiology department agrees to cause lumbar anesthesia.
But what went wrong? Anesthesiologists who work in the operating room all year round have a very strong concept of sterility. So, everyone sorted out the possible reasons:
There are three main ways of infection caused by lumbar anesthesia:
1. There is an infection at the site of the puncture.
2. Aseptic operation is not strict.
3. Waist anesthetic liquid is contaminated.
Analysis summary: Puncture site infection refers to obvious skin breakage, subcutaneous abscess, or boils and carbuncles near the puncture point. Buttock trauma does not belong to the presence of infection at the puncture site, and the first can be ruled out; because the current puncture packages are disposable, and the anesthesiologist's own sterility concept is very strong, the second point can be basically excluded; the local anesthetics used in the lumbar anesthesia puncture process or the normal saline used for dispensing medicine are glass bottles, that is, ampoules. When the ampoule is broken, broken glass may fall into the bottle, resulting in contamination of the liquid medicine.
The truth is clear, or the phrase "not the time to hold accountable." The only way to avoid recurrence is to avoid recurrence.
After discussion, it was agreed that stricter operating practices should be implemented: after sawing the ampoule with a grinding wheel, then using medical alcohol to sterilize the ampoule and then break the ampoule, once it is found that there is broken glass slag falling into the bottle, it is stopped.
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