老年女性患者全麻诱导致过敏性休克1例

2019-06-24 石宏宇 路畅 黄美佳 中国实验诊断学

患者女性73岁。现病史:绝经22年,22天前出现阴道间断流血时有时无鲜红色经妇科医生明确诊断为:子宫内膜癌。治疗方式:择期行广泛全子宫切除术。既往史:患者结肠癌术后30年,高血压病史10年,血压最高160/90mmHg,规律口服硝苯地平片控制,血压控制在130/70mmHg,糖尿病病史30年,近2年使用诺和灵30R早36U、晚34U皮下注射规律监测血糖FPG:9.3mmol/L,OGTT2h:10

1. 临床资料
 
患者女性73岁。现病史:绝经22年,22天前出现阴道间断流血时有时无鲜红色经妇科医生明确诊断为:子宫内膜癌。治疗方式:择期行广泛全子宫切除术。既往史:患者结肠癌术后30年,高血压病史10年,血压最高160/90mmHg,规律口服硝苯地平片控制,血压控制在130/70mmHg,糖尿病病史30年,近2年使用诺和灵30R早36U、晚34U皮下注射规律监测血糖FPG:9.3mmol/L,OGTT2h:10.0mmol/L;腰椎间盘狭窄病史6年并伴有明显的神经刺激症状。
 
术前检查:ECG提示T波底平;24h动态心电图示:心肌缺血;心脏彩超示二尖瓣及主动脉瓣轻度关闭不全,左室舒张功能减退EF:56%;胸部X线示主动脉硬化,支气管炎;其他化验检查均在正常范围内。麻醉前评估:老年女性ASA III级心功能NYHA II级Mallampati分级I级甲颏距6 cm 张口度3指颈后仰无异常。否认药物食物过敏史否认吸烟、酗酒等不良嗜好否认呼吸系统并发症;拟行全身麻醉。
 
麻醉前常规监测:无创血压、SpO2、ECG、ETCO2。入室SpO2:100%(未吸氧状态下正常人血氧96%-99%)HR:80bpm,BP:180/95mmHg尿袋内尿量50ml。常规静脉麻醉诱导,顺利气管插管插管后1min血压下降为80/60mmHg心率65次/分立即给予麻黄碱10mg静注。1min后血压没有上升趋势,心率80次/分立即静脉注射4μg去甲肾上腺素,血压60/40mmHg开始泵注去甲肾上腺素(40μg/ml),速度为5ml/h血压仍然无明显上升趋势,逐渐向上调整去甲肾上腺素泵注速度。
 
3min后麻醉医生发现血压测不出,重新测量血压发现仍然测不出,检查袖带完好发现颈部皮肤出现丘疹,此时血压仍然测不出,遂立即快速滴入羟乙基淀粉500ml静脉注射肾上腺素0.2mg甲泼尼龙80mg,血压仍然测不出,又静脉注射地塞米松10mg、阿拉明2mg。紧急动脉血气分析示:pH 7.16;BE-9.5;Ca2+0.95;K+2.1。尿袋内尿量仍50ml,遂给予速尿10mg静注10%葡萄糖酸钙1g静注1%KCl 1.5g(300mg/mL)泵注碳酸氢钠250ml快速滴入。
 
2min后患者血压开始升高达70/50mmHg 3min后患者血压90/60mmHg5min后患者血压100/70mmHg,10min后患者血压稳定在110/65mmHg,遂延期手术,转入重症医学科(ICU)治疗。在ICU科经过补液、抗休克、对症及支持等综合治疗后生命体征平稳,但患者出现苏醒后意识障碍脑部CT示:多发脑梗。
 
2. 讨论
 
探讨如何快速诊断过敏性休克及正确的处理方式。过敏反应是免疫球蛋白E(IgE)介导的I型变态反应。主要病理改变是全身血管扩张、通透性增强,平滑肌痉挛,导致喉头水肿、支气管痉挛、肺水肿。最常见的临床表现是血压下降、胸闷气憋、面色苍白、呼吸困难、四肢厥冷。本病例中患者在接受全麻药物后随即出现血压测不出的循环障碍表现、皮肤出现丘疹表现,因为已经机械通气尚没有呼吸道表现但仍可以确诊为药物所致过敏性休克。对于过敏性休克的快速诊断有文献表明,过敏性休克临床表现没有特异性的症状,组织病理学上也缺少特异的病理形态学改变,用于检测的生化指标也都存在一定的局限,要想单靠任何一项指标就做出诊断是很困难的。
 
因此为了预防过敏性休克首先我们不能盲目的进行临床麻醉,更必要的是在麻醉之前详细询问病史研究病历甚至进行麻醉药物的试敏试验;其次临床麻醉过程中麻醉医生应该认真守护患者,认真对待监护仪上的每一个指标的变化并随即作出正确的处理;最为重要的是每一名麻醉医生都要熟知过敏性休克的抢救流程。对于过敏性休克的急救必须就地进行、分秒必争切忌转院、转科而延误治疗。需要时可进行气管插管、气管切开、人工或机械呼吸、胸外心脏按压等急救措施。
 
呼吸心跳停止是最危险的情况,多数为过敏反应的最终症状,经过抢救大多能脱险,故即使出现呼吸心跳停止也不要轻易放弃抢救。对已发生过药物过敏性休克的患者在抢救成功后还要观察较长时间防止再次休克现象的发生。另据文献报道,药物过敏性休克10%发生在用药30min以后。在世界范围内,由于对过敏性休克认识的局限性和对其治疗的滞后性,部分患者因未得到及时正确的治疗而死亡,为此,世界变态反应组织呼吁各国政府的医疗管理部门和医生应高度重视过敏性休克,在国民中加强过敏性休克急救知识的普及,教会每一位高危患者在出现严重过敏反应时的基本自救方法,减少过敏性休克的死亡率,对于术中出现的过敏性休克首选的抢救药物是关键,肾上腺素为最佳选择。
 
肾上腺素可提高细胞内CAMP含量从而抑制组织肥大细胞和循环中嗜碱性细胞的激活与介质的释放。其β受体效应能使支气管扩张增强心肌收缩力使血管收缩血压上升。本例病人抢救过程中当患者血压测不出,心率迅速增快,提示循环血容量严重不足脑实质血流供应不充分,须快速输液扩容以改善组织灌注。中心静脉通路一方面可以用于快速补液,另一方面也可以监测CVP进而指导补液。
 
综上所述,对于该类病人的临床麻醉建议麻醉医生在临床麻醉前做好动脉血压监测及中心静脉穿刺以备不时之需;其次关心病人,仔细认真询问病史,在临床麻醉前做到心中有数;最为重要的是过敏性休克不仅可以发生在老年人,其他年龄段病人也可发生,因此要求麻醉医生不论病人年龄大与小、不论病人体质差与优、不论手术大与小都应该在临床麻醉前备好抢救药品。
 
原始出处:

石宏宇,路畅,黄美佳,刘铁成.老年女性患者全麻诱导致过敏性休克1例[J].中国实验诊断学,2018,22(07):1224-1225.

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    2019-06-25 txqjm

    谢谢了,学习

    0

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    2019-06-25 深海的鱼

    学习学习啊你

    0

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