Trust is the most beautiful language between people, the sublimation of family affection between relatives, the beginning of friendship between friends, the basis of communication between strangers, and the cornerstone of communication between doctors, patients and families. The trust and support of patients and their families is the motivation for doctors to rise to the occasion in the face of difficult conditions. This reminds me of the operation and communication between a 97-year-old grandmother Chen who underwent minimally invasive semi-hip arthroplasty under anesthesia not long ago, and her family.
Case summary
The grandmother, 97 years old, 150cm tall and 40kg in weight, suffered from "left hip swelling and pain with mobility impairment for 5 days. "Admission.
The grandmother's son complained of a swelling and pain in his left hip caused by an accidental fall at home 5 days ago, accompanied by limited movement, and could not standThere was no other discomfort at the time. He was in good health in the past, and had no special medical history except for a history of Alzheimer's disease for 6 years.
Admission examination: t 365, P: 87 times, R: 20 points, BP: 153 103mmHg, conscious, spirited, left hip swelling and limited movement, abduction and external rotation deformity of the left lower extremity, positive tenderness at the femoral tuberosity, positive longitudinal percussion pain in the left lower extremity, palpable bone rubbing sensation. Scoliosis is prominent, the spinous process is not tender, percussion is painful, and spinal mobility is limited. Tooth loss. There were no other positive signs.
Ancillary tests: blood routine: leukocytes 71 10 9 l, red blood cells 317 10 12 l, hemoglobin concentration 99 g l, platelet count 165 10 9 l. Liver function: total bilirubin, direct bilirubin, indirect bilirubin values increased slightly, total protein, albumin, and prealbumin values decreased slightly, and there were no abnormal indicatorsCardiac enzymes: lactate dehydrogenase, a-hydroxybutyrate dehydrogenase, creatine kinase values slightly increased;d—dimer quantification 725mg/l；There were no abnormal indicators in renal function, electrolytes, and blood coagulation.
Normal electrocardiogram (ECG), cranial CT showed senile encephalitis, white matter degeneration;Chest CT showed aortic heart shape with thickened lung markings. CT of the hip showed that the left intertrochanteric fracture of the femur with avulsion of the small trochanteric and the degenerative changes of the sacroiliac joints and hip joints on both sides. Cardiac ultrasound showed hypodiastolic left ventricular function, a small amount of pulmonary valve, tricuspid valve, mitral valve, and moderate aortic regurgitation.
Admission Diagnosis:1Left intertrochanteric fracture of the femur2Alzheimer's disease.
Three days after admission, "left artificial minimally invasive hemi-hip arthroplasty" was planned
Preoperative visits
The morning before the operation, when I saw my grandmother's surgery notice pasted in the elective surgery column for tomorrow, I thought to myself: my elderly grandmother has a history of Alzheimer's disease, and the anesthesia of this surgery tomorrow will not be easy. In the afternoon, I took the signature slip and the inpatient case to the director of the same department to the ward to learn more about the grandmother's physical condition. The grandmother's son said that the grandmother was usually in good health, could move independently, and had no other discomfort except for a history of Alzheimer's disease. Alzheimer's disease makes the grandmother unable to understand the speech of others, and cannot cooperate well with the doctor's examination and operation. I asked the grandmother to expose her back and checked the spine, the scoliosis was obvious, the palpable vertebral space L3-4 was very narrow, and the rest of the vertebral space was not clear. Neuraxial anesthesia is preliminarily judged to be difficult. After comprehensive consideration, the grandmother's ASA rating: level 3.
Subsequently, the grandmother's family was informed of the risk of anesthesia (the risk of anesthesia operation, the risk of the impact on cardiovascular and cerebrovascular diseases). The grandmother's son said: "Anesthesiologist, I am an internist, I know the perioperative risks, I believe in the anesthesia technology of your hospital, agree to the anesthesia of tomorrow's operation, and am willing to bear all the unexpected risks in the anesthesia of the operation." In order to get my mother out of the pain at the fracture, I had to give it a go even if I had only one chance." Hearing this, the head of the department said, "I am very happy that you can fully trust the anesthesia surgery technology of our hospital, and we will do our best to ensure the safety of your mother's anesthesia." You can rest assured that our hospital has done many cases of minimally invasive hip replacement surgery for patients in their 90s, and it is also the characteristic surgical technique of our hospital, and the postoperative recovery of patients is very good. After hearing this, the family members had great confidence in tomorrow's operation, showed a happy smile, and signed the informed consent form.
Anesthesia protocol
Back in the department, the head of the department thought that the grandmother was in a special situation and it was necessary to discuss the anesthesia in the department. After discussion, it was believed that although the elderly grandmother had no history of systemic chronic diseases, the functions of the heart, brain, lungs, kidneys and other organs had deteriorated, and she could not tolerate general anesthesia well. The preferred anesthetic regimen was determined to be neuraxial anesthesia.
Although the grandmother had scoliosis, the puncture path was evaluated by ultrasound before the anesthesia operation, and neuraxial anesthesia was performed by the lateral entry method. Before the administration of anesthesia, all vasoactive drugs should be prepared, and blood pressure and heart rate can be used in time. When performing deep venipuncture catheterization, it is necessary to calm the grandmother's emotions while stabilizing the grandmother to avoid the grandmother's uncooperation. Before turning over with neuraxial anesthesia, left perihip block (PENG) can be performed with ultrasound to reduce the turning pain. Neuraxial manipulation is performed slowly when the drug is injected into the subarachnoid space. During the operation, the ECG monitoring and the grandmother's facial expressions and mood fluctuations should be closely observed.
Anesthesia process
The grandmother was immediately monitored by electrocardiogram (EEG) after entering the operating roomImmediately after the right internal jugular vein puncture and catheterization was opened under ultrasound, the grandmother was also quite cooperativeThis was followed by a left perihip block (PENG) performed on ultrasound to relieve the turn-over pain. After a few minutes, the pain in the left hip joint of the grandmother was significantly reduced, and after the grandmother was slowly placed in the left decubitus position, and a small amount of sedative was slowly administered intravenously, the grandmother was more able to cooperate with and tolerate the surgical position, and the lateral entry method was used to perform neuraxial anesthesia in the L3-4 space. Neuraxial anesthesia went smoothly, and a small amount of vasoactive drugs was given to maintain blood pressure and heart rate stabilityAfter 10 min, the anesthesia plane was satisfied. Position yourself and the surgery begins. A small amount of vasoactive drugs were added several times during the operation to maintain blood pressure and heart rate stability. During the operation, the grandmother was more cooperative. The total duration of the operation was 50 minutes, and the amount of bleeding was less than 50ml. The surgery ended perfectly. After surgery, he was returned to the intensive care unit for observation.
Postoperative follow-up visit
At 8 a.m. on the first day after surgery, I went to the intensive care unit to visit my grandmother. As soon as I entered the door of the ward, I saw the old grandmother sitting on the bed and being fed white rice porridge by her daughter-in-law, eating happily. The grandmother's son was happy to see me and said, "Thank you, doctor, my mother is recovering well from the operation and can eat a bowl of white rice porridge." I didn't say anything about wound pain, low back pain or anything, blood pressure and heart rate were stable. Thank you, doctor, your medical skills are good. When I saw the grandmother and heard her son's words, I said happily, "No thanks." This is what I should do as a doctor, and I am as happy as your family to see that my grandmother is recovering well. The family trusts the doctors, and even if the surgical anesthesia is very challenging, we will try our best to overcome the difficulties and relieve the pain of the patients. ”
The relationship between doctors, patients and their families is like that of comrades in a battle, and illness is the common enemy of both sides. The high trust of life is the greatest motivation for doctors, and I will do my best to trust and entrust you. This is a heavy responsibility of the doctor, which inspires the doctor to move forward. I also want to uphold the principle of being a doctor and a doctor who is ordinary, writing the sincerity of a great doctor, paying without regrets, fighting for the medical cause for life, and escorting the health of patients.
Department of Anesthesiology, Zhejiang Orthopedic Hospital, Ma Shengnan.
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