A case from a few days ago became the focus of discussion in the anesthesiology department.
The patient is a middle-aged man in his 50s with a biopsy diagnosis of an esophageal tumor.
What’s tricky is that this person has a relatively large lesion. From the cardia to the middle of the esophagus, obvious lesions can be seen. This means that the area that needs to be excised is very large.
For this case, the surgery was nothing, the combined thoracoabdominal incision was done. However, for anesthesiology, this means more trauma for the patient. It is not only necessary to suppress the pain of the patient during surgery, but also to control the patient’s stress response. Because once the stress responds, it may fall short.
The first is the first level, the problem of intraoperative control of the combined thoracoabdominal incision: spinal anesthesia obviously cannot satisfy the operation; general anesthesia may not be able to completely suppress the pain for such a large trauma Conduction.
Obviously, general anesthesia is definitely the first choice. The key is how to control the problem. Blindly pursuing deep anesthesia is a challenge to the stability of the patient’s 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 not be related to the anesthesiology department, as long as it has an impact, it will try to consider it carefully, which is also the professional quality of an anesthesiologist.
Some people say that now there are very good monitoring methods and good medicines, and it is completely safe to use general anesthesia.
But there was something special about this patient: the patient was very obese. Excessive obesity keeps his body working at full capacity all the time. Predictably, his cardiopulmonary function was in a marginal state.
In addition, a large amount of fat is bound to become a “hotbed” for the accumulation of narcotic drugs. Even if there is no problem with intraoperative control, the redistribution of the anesthetic drug from the fat after surgery may jeopardize the patient’s breathing.
Secondly, there is the issue of postoperative pain relief. Such a large incision, especially involving part of the chest wall, must be very painful after the operation. This means that a large dose of analgesia is required after surgery. However, being so fat and involving open-chest surgery, no one dared to take such a large dose of anesthesia easily.
At this time, it was suggested that general anesthesia combined with epidural anesthesia could be used.
However, here comes the problem: the spinal nerve segments designed by the combined thoracoabdominal incision, from thoracic 5 to thoracic 10. However, one stage of puncture can only satisfy two or three upper and lower segments at most. This means that hitting a little is simply not enough.
Since one point is not enough, can I hit two points?
As soon as this design came out, it was immediately approved by everyone.
Although two-point puncture is not often performed in the spinal canal, it should not be 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 problem that may be involved, everyone has prepared visual intubation equipment early.
However, surgery is not as easy as you might think. This patient looks very heavy, but in fact is very empty. After the anesthesia, the blood pressure can’t stand at all. Therefore, it can only be used with booster medicine.
In order for the two-point puncture epidural to work, the anesthesiologist lowered the concentration of local anesthetic and deliberately chose a longer-acting anesthetic. As for blood pressure, it has also been maintained by vasoactive drugs.
When the incision is closed, the anesthesiologist puts down the stone in his heart.
This is not the time to celebrate, only the patient’s vital signs are stable and consciousness is awake.
After half an hour of fine adjustment, the patient’s adjunctive vasopressor medication was gradually withdrawn. When asked if the incision hurts, the answer is “a little bit”.
Hearing this answer, everyone heard the “trumpet of victory”. He resolutely cleaned up the “site” and quickly sent the patient back.
On the surface, the surgeon did not thank him, but he should have said in his heart, “This anesthesia is very reliable”!