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贲门失迟缓症患者麻醉诱导中出现过敏反应伴高血压危象1例

2017-12-19 佚名 临床麻醉学杂志

贲门失迟麻醉过敏高血压危象
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患者，男，49岁，172cm，77kg，ASAⅡ级

【一般资料】

患者，男，49岁，172cm，77kg，ASAⅡ级

【主诉】

因“进食梗阻感1年，加重伴反流呕吐3个月”入院

【现病史】

诊断“贲门失迟缓症”。拟在全麻下行“胃镜下经口内镜下肌切开术（peroralendoscopicmyotomy，POEM）”，

【既往史】

患者既往有磺胺类药物过敏史，否认有高血压、支气管哮喘等慢性疾病史。

【辅助检查】

入院时肺部CT示：右肺下叶结节，双肺炎症，考虑误吸相关肺炎，经过抗炎治疗后好转。余心、肺功能和各项实验室检查结果均未见异常。

【体格检查】

入室时BP134/89mmHg，HR68次/分，SpO299%

【治疗】

麻醉诱导前10min静脉注射地塞米松10mg+盐酸戊乙奎醚0.5mg。静脉注射咪达唑仑1mg、依托咪酯14mg、舒芬太尼30μg和罗库溴铵50mg行麻醉诱导，给药后1min面罩通气后，SpO2逐渐下降至89%，听诊双肺呼吸音低，HR118次/分，BP201/114mmHg，考虑出现支气管痉挛，即刻加深麻醉，静脉推注丙泊酚30mg及甲泼尼龙琥珀酸钠40mg，加大面罩正压通气量。5min后出现头面部皮肤潮红，胸前区皮疹，双肺哮鸣音，SpO2维持在90%~93%。考虑为过敏反应，同时伴有严重支气管痉挛及不明原因高血压。以50%葡萄糖注射液稀释氨茶碱0.25g至20ml，缓慢推注至4ml时，BP升高至242/130mmHg，HR加快至133次/分，立即停止推注氨茶碱，改为喘定250mg间断静脉注射，同时尼卡地平间断静脉注射降低BP。置入4号Igel喉罩行机控呼吸，VT450ml，RR16次/分，气道压35cmH2O。七氟醚吸入维持麻醉，10min后出现胃液反流，抽吸胃液约30ml。急查动脉血气：PH7.27，K+3.2mmol/L，PaCO244.7mmHg，PaO2102mmHg，BE-6.5，提示代谢性酸中毒伴低钾血症，给予5%碳酸氢钠液125ml，静脉补钾，诱导后约40min患者生命体征逐渐稳定，皮疹亦逐渐消退，恢复自主呼吸，且呼吸音转清。1h后患者意识清醒，肌力恢复，拔除喉罩，复查血气各项指标在正常范围，暂停手术送回病房。患者返回病房后，完善相关检查，包括血儿茶酚胺、双侧肾上腺CT等，排除嗜铬细胞瘤。两周后再次安排手术，麻醉前行罗库溴铵100μg/ml皮内试验，并以组胺为阳性对照，生理盐水为阴性对照，结果为阳性。麻醉前30min给予甲强龙、抑酸剂，置入胃管引流。诱导时采用头高脚低位，小潮气量辅助通气。诱导用药：咪达唑仑、舒芬太尼、丙泊酚、苯磺酸顺式阿曲库铵，气管插管后行机械通气。麻醉维持：丙泊酚、盐酸瑞芬太尼、七氟醚，整个麻醉过程顺利。

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    2018-01-31 gostraight

    #贲门#

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=1747129, encodeId=54d61e47129fa, content=<a href='/topic/show?id=d9d192468dd' target=_blank style='color:#2F92EE;'>#贲门#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=92468, encryptionId=d9d192468dd, topicName=贲门)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d50035925343, createdName=gostraight, createdTime=Wed Jan 31 17:53:00 CST 2018, time=2018-01-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1813402, encodeId=676e18134026a, content=<a href='/topic/show?id=2c91924e174' target=_blank style='color:#2F92EE;'>#贲门失迟#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=92471, encryptionId=2c91924e174, topicName=贲门失迟)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdqq.qlogo.cn/qqapp/1103841572/C2EFD5CFB07FE291138AD4FD0C98E3DE/100, createdBy=e3d52500031, createdName=膀胱癌, createdTime=Wed Nov 14 15:53:00 CST 2018, time=2018-11-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=272527, encodeId=a9882e25273a, content=学习谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=66, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib2JlGvwpAibiaovVhfA9DbO7X7JLGGjM4Cic6oMgxLdnuS9piaP9cnG2OwIbkzHvX0qzS1boibyYNqR5vHZu7HQs5EIB/0, createdBy=298d1398341, createdName=lou.minghong, createdTime=Tue Dec 26 01:43:00 CST 2017, time=2017-12-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1336628, encodeId=1835133662824, content=<a href='/topic/show?id=543794035c9' target=_blank style='color:#2F92EE;'>#过敏反应#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=94035, encryptionId=543794035c9, topicName=过敏反应)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKeia4TJeMGvEH3wKKIBNjuHuIic1HDNOB10j4tCd3nbylxkxm6HSMfEaKkSu6OZOak4uZv7UVicsWEg/132, createdBy=bc9a2500116, createdName=zywlvao, createdTime=Thu Dec 21 03:53:00 CST 2017, time=2017-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=270906, encodeId=40492e090654, content=非常好的文章.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo7LIiaRZTzJ3SEfiauCzTMPW7YvPPYLNJBXG9oh6Al1icq2VQQkIHWxqXehcicTS62YKJVBhxeth3wggw/0, createdBy=7ce01621306, createdName=天涯183, createdTime=Wed Dec 20 12:26:44 CST 2017, time=2017-12-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=270710, encodeId=ca722e071025, content=好资料学习了!, beContent=null, objectType=article, channel=null, level=null, likeNumber=62, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=92191944782, createdName=thlabcde, createdTime=Tue Dec 19 21:31:02 CST 2017, time=2017-12-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=270694, encodeId=4df42e069459, content=学习了受益匪浅, beContent=null, objectType=article, channel=null, level=null, likeNumber=66, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLDicHg2ldsSNmib46PmdzpO7CQEmPjuULp1v45zPWwMYhrnXgvl3OtmUCZSQfgITWn96X9moL94nUGA/0, createdBy=28072041016, createdName=131****1460, createdTime=Tue Dec 19 19:26:41 CST 2017, time=2017-12-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=270649, encodeId=e2002e0649a7, content=非常好的文章.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo7LIiaRZTzJ3SEfiauCzTMPW7YvPPYLNJBXG9oh6Al1icq2VQQkIHWxqXehcicTS62YKJVBhxeth3wggw/0, createdBy=7ce01621306, createdName=天涯183, createdTime=Tue Dec 19 15:15:35 CST 2017, time=2017-12-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=270637, encodeId=f9d32e0637de, content=学习一下知识了, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160718/IMG578C993D395567540.jpg, createdBy=59b81918946, createdName=flysky120, createdTime=Tue Dec 19 13:46:48 CST 2017, time=2017-12-19, status=1, ipAttribution=)]
    2018-11-14 膀胱癌

    #贲门失迟#

    0

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    2017-12-26 lou.minghong

    学习谢谢分享!

    0

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    2017-12-21 zywlvao

    #过敏反应#

    0

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    2017-12-20 天涯183

    非常好的文章.学习了

    0

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    2017-12-19 thlabcde

    好资料学习了!

    0

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    2017-12-19 131****1460

    学习了受益匪浅

    0

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    2017-12-19 天涯183

    非常好的文章.学习了

    0

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    2017-12-19 flysky120

    学习一下知识了

    0