(C) Wang Xiaoping, Department of Respiratory Medicine, Shandong Chest Hospital
I. Advantages of general anesthesia.
1. Compared with the method of local anesthesia + monitoring anesthesia, it can further improve the comfort of patients and relieve their anxiety.
2. Make the various diagnostic and treatment operations of tracheoscopy under the calm state of patients.
3. Memory forgetting.
4. Avoid complications caused by excessive stress reaction.
II. Disadvantages.
1. The anesthesiologist and the bronchoscopist share the same airway, which requires higher anesthesia technique.
2. Higher cost.
Preoperative evaluation of tracheoscopic general anesthesia
Adequate preoperative preparation is directly related to the success rate of the procedure. The purpose of evaluation is to have a comprehensive understanding of the patient’s condition, such as the patient’s underlying and other coexisting diseases, psychoneurological and nutritional status, possible complications, etc. Preoperative preparatory measures should be improved to prevent complications of anesthesia and surgery and to improve the safety and success rate of surgery.
Preparations before tracheoscopic general anesthesia surgery.
I. Cardiovascular system :
1. hypertension: If the surgery is not an emergency, the blood pressure of the patient undergoing surgery should be controlled at the level of 140/90 mmHg. And understand the type and dose of anti-hypertensive drugs in patients, whether there is synergistic effect with anesthetic drugs.
2. Coronary artery disease: control heart rate and blood pressure, correct arrhythmia, and prevent myocardial ischemia or coronary vasospasm.
II. Respiratory system.
1. Obstructive lung disease: preoperative infection control, preoperative bronchodilator therapy, reduction of perioperative bronchospasm or asthma attack.
2. restrictive lung disease: control infection if necessary, administer oxygen, instruct patients in respiratory exercises, and encourage coughing and other promotion of airway secretion discharge. If combined with pleural effusion and pneumothorax, give preoperative treatment.
3. Alveolar protein deposition: Patients requiring large volume alveolar lavage under general anesthesia should have preoperative pulmonary function and CT examinations, and have warm saline and other relevant surgical items available.
Attachment: endoscopic mask
Some time ago, we shared with you the method of local anesthesia + monitoring anesthesia. Since it is easy to have hypoxemia and other conditions, here we introduce the endoscopic mask, which can effectively improve the patient’s blood oxygenation. The endoscopic mask is usually performed under patient sedation, with an endoscopic mask fastened to the face. The central silicone cover of this mask has holes of 5mm diameter for the passage of bronchoscopes of different outside diameter sizes, and while performing bronchoscopic treatment, the patient can be assisted or controlled ventilated by connecting the anesthesia ventilator through the mask extension tube, which solves the problem of simultaneous operation and ventilation, and the patient, even if respiratory depression occurs, will Even if the patient suffers from respiratory depression, hypoxemia will not occur and lead to cardiovascular accidents, which greatly improves the safety of intraoperative bronchoscopy.
Commonly used intravenous anesthetic drugs for bronchoscopic general anesthesia consultation and surgery.
Sedative drugs: isoproterenol, etomidate, imipramine, etc.
Analgesics: fentanyl, sufentanil, remifentanil, etc.
Muscle relaxants: rocuronium bromide, vecuronium bromide, atracurium, etc.
Isoproterenol.
Fast-acting, short duration of action, must be combined with analgesics .
5-10min after stopping the drug is awake and can respond .
Anti-emetic effect.
Myocardial depression and peripheral vasodilatation, hypotension and transient apnea, hypoxemia, injection should be slow.
Injection pain.
Etomidate
Fast onset of action, better vascular tolerance.
More suitable for patients with cardiovascular instability, especially in the elderly, coronary artery disease, heart failure, etc.
Injection pain, muscle stiffness after injection in some patients.
Makes the pro-corticosteroid effect disappear, corticosteroid release is reduced, and cannot be pumped for a long time.
Imipramine
Sedative-hypnotic, anxiolytic.
Parasympathetic amnesia.
Preserves verbal communication skills and cooperation.
Improves patient tolerance and reduces stress response.
Rifentanil
New strong, short-acting analgesic with analgesic effect similar to or stronger than fentanyl.
The blood-brain equilibration time is only 1min, and the effect disappears in 5~10min.
Dose and speed can be adjusted quickly and precisely according to the depth of anesthesia and surgical needs.
Myoclonus, nausea and vomiting, respiratory depression, bradycardia, hypotension .
Sufentanil
The new most potent analgesic drug with rapid onset of action and better hemodynamic stability.
The sedative-hypnotic effect is significantly stronger than that of fentanyl.
Shorter and weaker respiratory depression, less adverse reactions such as nausea, vomiting and pruritus.
Long-term intravenous infusion without accumulation.
The time to recovery of consciousness after surgery is faster and more suitable for prolonged continuous infusion .
Atracurium and vecuronium bromide
Medium-latency non-depolarizing inotropes.
Their action can be antagonized by acetylcholinesterase inhibitors.
Only suitable for patients with laryngeal mask placement, tracheal intubation, rigid bronchoscopy.
Atracurium has a faster onset of action, shorter duration of action and is more controllable than vecuronium bromide, and is particularly suitable for induction administration.
Management of general anesthesia
Cardiopulmonary function must be assessed preoperatively.
The degree of tracheal obstruction is understood, and the treatment plan and anesthesia method are determined in consultation with the treating physician.
Intraoperatively, it is important to ensure effective ventilation and oxygenation of the patient as well as to provide an open view for treatment.
Commonly used methods of general anesthesia
Scopolamine 0.3 mg or atropine 0.5 mg.
Inhale pure oxygen for 5 min before induction.
Induction drugs in order: remifentanil 1.5 ug/kg, isoproterenol 1 to 2 mg/kg or etomidate 0.1 to 0.2 mg/kg, vecuronium bromide 0.08 to 0.1 mg/kg or atracurium 0.15 mg/kg.
Placement of laryngeal mask, tracheal tube or rigid bronchoscope.
Maintenance: isoproterenol 4-6 mg/kg/h, remifentanil 0.1-0.2 ug/kg/min, and additional inotropes as appropriate intraoperatively.
30 min before the end of treatment, dexamethasone 10 mg or methylprednisolone 80 mg was given intravenously.