As an important endocrine organ of the human body, the thyroid gland is often treated with surgery when there are pathological conditions such as thyroid mass, thyroid adenoma and hyperthyroidism. With the rapid development of today's anesthesia technology, general anesthesia with endotracheal intubation is mostly used in clinical thyroid surgery. This not only increases the comfort of the patient, but also provides greater convenience for the surgeon. However, sometimes we will encounter some special patients who are not suitable for tracheal intubation and general anesthesia for various reasons, so we need to weigh the pros and cons and develop an individualized anesthesia plan to reduce the occurrence of related complications. Recently, the author's hospital received a patient with a goiter and damaged lungs.
The patient, a 61-year-old female, was admitted to surgery for a goiter and was scheduled for surgery. The patient complained of bronchiectasis, old tuberculosis for more than 30 years, long-term lung infection, cough and sputum hemoptysis, and left lung damage. Complete preoperative examinations: the patient's trachea was centered without deviation, the chest was symmetrical, and no breath sounds were heard in the left lung.
Chest CT showed that: 1. Lung damage was considered, 2. Right lung cord, 3. Left pleural thickening with calcification, 4. Hypodense opacity of the right thyroid lobe. Pulmonary function tests show hypospirometry, very severe mixed ventilatory dysfunction, impaired small airway function, severely elevated residual lung volume, and increased pulmonary elastic obstruction. The blood gas results in calm state showed that PH 7.410, PCO2 41.0mmHg, PO2 98.0mmHg, and the other laboratory tests showed no obvious abnormalities. Preoperative diagnosis: 1. Bilateral goiter 2. Old tuberculosis 3. Left damaged lung, "most of the right lobe of the thyroid gland + left lobe mass resection" is planned.
This case is a patient with damaged lungs secondary to tuberculosis, and is often accompanied by symptoms such as cough and sputum production, hemoptysis, and dyspnea. Due to the long course of the disease, cavitation, fibrosis, and calcification of the lung on the affected side are formed, resulting in obstruction, stenosis, and deformation of the bronchi on the affected side. Long-term recurrent infections and increased secretions lead to irreversible destruction of the affected lobe. For such patients who require surgical treatment, they face difficulties in managing the intraoperative airway, so the choice of anesthesia and anesthetic drug is particularly important. After a detailed preoperative evaluation of the patient, and after multidisciplinary consultation and communication with the patient and his family, we decided to abandon the conventional endotracheal intubation general anesthesia and choose cervical plexus block anesthesia plus MAC (monitory anesthesia), which is more conducive to the patient's rapid postoperative recovery.
The cervical plexus is composed of the intertwined anterior branches of the C1-C4 cervical nerve, located lateral to the apex of the transverse process, deep to the sternocleidomastoid muscle, and gives rise to cortical and muscular branches (i.e., superficial and deep branches). The four cutaneous branches of the cervical plexus (the lesser occipital nerve, the greater auricular nerve, the transverse cervical nerve, and the supraclavicular nerve) penetrate the cervical fascia at the midpoint of the posterior border of the sternocleidomastoid muscle, and mainly innervate the skin sensation of the occipital, auricle, neck, shoulder, and upper part of the chest, and belong to the pure sensory nerve. The deep branches of the cervical plexus generally innervate the levator scapulae, subhyoid muscles, diaphragm, and deep cervical muscles. Cervical plexus block is the injection of local anesthetic into the nerve to produce a corresponding anesthetic effect in the area it innervates. It is important to note that because the phrenic nerve is inevitably blocked during deep cervical plexus block, this reminds us that bilateral deep cervical plexus block cannot be performed even with bilateral thyroid surgery, in order to avoid dyspnea when both phrenic nerves are blocked at the same time.
After the patient was admitted to the room, he first injected 2mg of midazolam intravenously, and after his mood stabilized, he underwent a nerve block of the deep right cervical plexus plus bilateral superficial cervical plexus under ultrasound guidance, and about 15 minutes after the block, the skin on the surface of the patient's neck was weakened by warmth, touch and pain. At the same time, we applied sufentanil intravenous injection and dexmedetomidine hydrochloride intravenous pumping during the operation, so that the patient was in a relatively ideal state of sedation: the patient closed his eyes and was quiet, without obvious discomfort, and at the same time retained spontaneous breathing, the circulation was basically stable, and he could be awakened at any time to cooperate with the surgeon. At the end of the operation, the patient woke up well and did not complain of significant discomfort. At the 4-hour postoperative follow-up, the patient was completely awake, the wound was painless, and there was a slight pulling pain when swallowing, with a VAS score of 2 points; at the 24-hour follow-up after the operation, the patient had no pain in the wound, and the swallowing and pulling sensation was also reduced, and he could eat normally; on the third day after the operation, the patient complained that there was no discomfort, and was discharged from the hospital 5 days after the operation.
Although conventional endotracheal intubation and general anesthesia can ensure the comfort and safety of the patient during the operation, it is very likely that the tracheal extubation will be difficult after surgery, which will inevitably prolong the postoperative recovery period of the patient. The visual manipulation under ultrasound greatly improves the success rate of cervical plexus block and can provide good analgesia to the surgical area. However, the stretching discomfort caused by the special position of the operation (extreme tilt of the head), the stuffiness of the surgical towel and the patient's nervousness and fear also require us to add an appropriate amount of sedation and analgesics to alleviate it, that is, MAC (Guardian Anesthesia).
Through a series of optimization measures, the anesthesia program is formulated to ensure the safety of patients, to achieve the greatest degree of painlessness and comfort, multidisciplinary cooperation, reduce the physical and psychological traumatic stress of surgical patients, and achieve the purpose of rapid recovery.
Li Yehua, Department of Anesthesiology, Shijiazhuang Ping'an Hospital
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