Endotracheal anesthesia for cesarean section in Graves patient

The article was professionally consulted by Specialist Doctor II Le Minh Viet - Anesthesiologist - General Surgery Department - Vinmec Ha Long International General Hospital.

Graves' disease in pregnant women can cause dangerous complications during pregnancy and at birth. Therefore, cesarean section on Graves patient requires the use of general anesthesia intubation to control the patient's breathing during and after surgery.

In the cesarean section on Graves' patient, the technique of general anesthesia with intubation, also known as endotracheal anesthesia, is used to control the patient's breathing during and after surgery. art.
Endotracheal anesthesia is indicated in the following cases:
Pregnant women with Graves' disease but have not been treated or have been treated and are at risk of thyroid storm. Pregnant woman with Graves' disease and high-output heart failure. Pregnant women cannot perform or refuse regional anesthesia.

To perform endotracheal anesthesia for cesarean section on Graves' patient, the following means, machinery, equipment, and medications are required:
The system includes an anesthetic machine (with breathing), an oxygen balloon. , monitors for vital functions (such as arterial blood pressure, breathing rate, temperature, ECG, EtCO2, SpO2), suction machine, defibrillator, ... endotracheal tube sizes to place, laryngoscope, mask, straw, oropharyngeal cannula, squeeze bulb, soft mandrin, Magill pliers. Anesthetics, analgesics, muscle relaxants, Beta blockers, Solumedrol, Salbutamol and Lidocaine 10% spray. Other means of supporting endotracheal anesthesia for cesarean section surgery on Graves' patients to prevent difficult intubation: laryngeal mask, Cook tube, flexible bronchoscope, mouth opener, tracheostomy kit , ...

Before surgery, patients need to be examined under anesthesia to promptly detect and prevent possible risks during and after surgery. Patients should be fasted 6-8 hours before anesthesia. However, it should be noted that if the goiter is large, it can cause compression, making internalization difficult.
In addition, some other signs should pay attention such as high body temperature, shaking hands, bulging eyes, heart palpitations, agitation, changes in thyroid tests (T3, free T4 increased, TSH decreased). .
The procedure of endotracheal anesthesia for cesarean section on Graves' patient is considered anesthesia on difficult intubated patients, including the following steps:
Step 1: Place the patient in supine position, before When the induction of anesthesia is at least 5 minutes, give 100% oxygen at a dose of 3 - 6 liters/minute. Install machines to monitor and set up transmission lines. If necessary, the patient can be given sedatives from the night before surgery.
Step 2: Rapid induction of anesthesia begins with intravenous injection (drugs, etomidate, propofol) volatile anesthetics (sevorane...), analgesics (fentanyl, sentanil...), and muscle relaxants if necessary. (rocuronium, succinylcholine,...). It is necessary to ensure conditions for endotracheal intubation in cesarean section on Graves' patient (the patient is in deep sleep with sufficient muscle relaxation).
Step 3: Carry out oral intubation as follows:
Open the patient's mouth, place one hand under the neck to help the neck straighten, insert the laryngoscope to the right side of the mouth, slide the tongue to the left side of the mouth , insert the light deeply, and at the same time combine with the right hand to press the cricoid cartilage to find the lid and the glottis. Perform rapid induction of anesthesia and perform the Sellick maneuver when the stomach is full (as soon as the patient loses consciousness, proceed with the procedure. Press the cricoid cartilage until the intubation is complete) The next step in endotracheal anesthesia for cesarean section in Graves' patient is to gently intubate the endotracheal tube through the glottis, when the endotracheal tube is ballooned. Pass through the vocal cords about 2-3 cm, then stop Gently remove the laryngoscope Inflate the endotracheal tube Listen to the lungs, check the EtCO2 index to check that the endotracheal tube is in the correct position Use a sticky bandage endotracheal tube setting. In case, if it is necessary to avoid biting the endotracheal tube, the cannula can be placed into the patient's mouth. Note, apply difficult intubation procedure for difficult intubation cases.
Step 4: The next step in anesthesia for endotracheal intubation for cesarean section on Graves' patient is to maintain anesthesia with anesthetics (intravenous or volatile), analgesics, muscle relaxants (if necessary) and Control the patient's breathing with a ventilator.

During endotracheal anesthesia for cesarean section on Graves' patient, it is necessary to monitor the following signs and indicators:
Depth of anesthesia: Monitor blood pressure, heart rate, blood pressure, sweating status sweat, tears, BIS, MAC, SPI, Entropy (if any) ... Vital signs: Monitor blood pressure, heart rate, body temperature, EtCO2, SpO2 indicators. Monitor in case of wrong position of endotracheal tube, or blocked, folded tube. Before extubating the patient, the patient will be given local anesthesia of the lumbar square muscle to reduce postoperative pain. the following criteria before performing extubation:
Patient is awake and can follow orders. Breathe spontaneously, breathe evenly, breathing rate is within normal limits. Blood pressure and pulse are stable. Body temperature over 35 degrees C. TOF index > 0.9 (if any). The patient had no complications from anesthesia and surgery.

During endotracheal anaesthesia, cesarean section surgery on Graves' patients may occur some complications that need to be treated as follows:
Gastroesophageal reflux: When digestive juices are detected in the oral cavity. and airway, immediately drain the fluid, place the patient in a low lying position and tilt the head to the side. Rapidly intubate the endotracheal tube and remove all fluid from the airway. Monitor patients for lung infections after surgery. Hemodynamic disorders: Depending on the cause and symptoms such as arrhythmia, increase or decrease in blood pressure, ... will be treated appropriately. Difficult intubation in cesarean section anesthesia in Graves' patient: Switch to difficult intubation procedure or proceed to another method of anesthesia. Misplaced endotracheal tube into the stomach: Re-intubate the endotracheal tube when misplaced with symptoms of auscultation of the lungs without alveolar murmurs, no measurement of EtCO2. Constriction of the larynx, trachea, bronchi: Complications during endotracheal anesthesia for cesarean section in Graves' patients may cause difficulty or inability to ventilate. At this time, there will be a crackling sound when listening to the lungs. mute lung. For management, it is necessary to provide adequate oxygen, and at the same time give sleeping pills and muscle relaxants, bronchodilators and corticosteroids to ensure ventilation. If breathing is not controlled, a difficult intubation procedure should be used. Trauma in endotracheal intubation: Depending on the injury such as tooth fracture, bleeding, foreign body in the airway, ... will be treated appropriately. Respiratory complications: Find and treat the cause, ensure ventilation and provide 100% oxygen when endotracheal anesthesia for cesarean section on Graves' patients causing respiratory complications such as folded endotracheal tube, drop or push deep into one lung, open or drop the respiratory system, the oxygen runs out, the effect of soda is gone, causing hypoxia. Thyroid storm: When a patient has symptoms of a thyroid storm such as fever, rapid breathing, tachycardia, increased blood pressure, sweating, diarrhea, if not treated, timely treatment can lead to to a deep coma leading to multiple organ failure and death. At this time, the patient needs oxygen, fluids and glucose, pain relief, electrolyte balance, deep sleep, ... Complications after extubation: Depending on the cause, choose the appropriate treatment when Symptoms appear after extubation such as respiratory failure, hoarseness, sore throat, spasms of the larynx, trachea, bronchi, larynx and trachea, and upper respiratory tract infection. Endotracheal anesthesia for cesarean section on Graves' patient needs to ensure safety for the mother and fetus, and at the same time prevent thrombosis and allergic reactions that cause embolism, pay attention to the treatment of diseases related to stroke. thyroid storm such as hypoglycemia, infection.
Vinmec International General Hospital is one of the hospitals that not only ensures professional quality with a team of leading medical doctors, modern equipment and technology, but also stands out for its examination and consultation services. comprehensive and professional medical consultation and treatment; civilized, polite, safe and sterile medical examination and treatment space. Customers when choosing to perform tests here can be completely assured of the accuracy of test results.
Specialist II Le Minh Viet has more than 30 years of experience in the field of Anesthesia - Resuscitation, including more than 2 years as a Medical expert in Yemen and former Head of Anesthesia - Resuscitation Department - Hospital Thanh Nhan, Hanoi. Currently, Dr. Le Minh Viet is an anesthesiologist, Anesthesia Unit - operating room, Vinmec Ha Long International Hospital.
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