Case 1
1. Medical History Summary
The patient was a Chinese male aged 47, with a height of 170cm, a weight of 54kg and an ASA physical status of Level Ⅲ. He was admitted to the hospital with an abdominal discomfort for 1 month as the main reason, and was diagnosed to have a gastric remnant cancer. The patient underwent "radical total gastrectomy, vagus nerve dissection, laparoscopic exploration and abdominal drainage as well as irrigation", together with 3 courses of SOX chemotherapy (oxaliplatin + tegeo) 2 years ago. The abdominal discomfort appeared almost one month ago without any obvious cause. Since the onset of the disease, he had poor diets and sleep, but had not lost any significant weight. The patient had a history of hypertension for 5 years, who had not been taking antihypertensive drugs regularly, but had a moderate blood pressure control. He denied the history of diabetes mellitus, coronary heart disease, food or drug allergy, hepatitis or tuberculosis and smoking or alcohol consumption.
After admission to the hospital for gastroscopy, abdominal CT, PET-CT and other related examinations, multiple metastases of gastric cancer were considered. The patient was treated with SOX chemotherapy regimen with an intravenous oxaliplatin infusion of 200mg, taking tegeo capsules orally 3 capsules/time, 2 times/day. On the second day after chemotherapy, the patient suddenly felt bloated with an urge to defecate after dinner, together with sudden severe abdominal pains after straining to defecate, which persisted without relief. Repeat emergency abdominal CTs suggested a gastrointestinal perforation. Therefore, "intestinal resection, enterostomy, intestinal perforation repair, abdominal adhesion release and abdominal flushing as well as drainage" were performed in the emergency. Preoperative blood gas analysis: PH: 7.458, PCO2: 32.2mmHg, Hct: 32%, tHb: 10.8g/dL, Na+: 133.6mmol/L, K+: 4.61 mmol/L, Glu: 6.30 mmol/L, Lac: 2.21 mmol/L.
2. Anesthesia and Surgical Procedure
Admission to the operating room: The patient was admitted at a lateral recumbent position with significant abdominal pains, a heart rate of 120 beats/min, a blood pressure of 150/110 mmHg and SpO2 of 97%. He was clearly conscious and had a painful face.
Induction and maintenance of anesthesia: 2mg of midazolam, 16mg of etomidate, 15ug of sufentanil and 30mg of rocuronium were given for the induction of anesthesia. 3min after induction, the BIS value was 40 and his eyelash reflex disappeared. After a rapid intravenous injection of 40ug of remifentanil and 3mg of propofol, a visual laryngoscopic tracheal intubation was performed. Vital signs were stable during intubation, with a heart rate of 90 beats/min and a blood pressure of 115/85 mmHg immediately after intubation. 0.37mg/kg.h of propofol and 0.0074mg/kg.h of remifentanil were pumped intravenously with 2% sevoflurane inhaled to maintain the BIS value at 40–50. 0.003mg/kg.h of norepinephrine was pumped to maintain the blood pressure at 20% of the basal value.
Intraoperative condition: After 20min of anesthesia induction, the ventilator indicated that the patient's spontaneous respiration was restored, with a respiratory rate of 12 breaths/min, a tidal volume of 300ml and a BIS value of 45. After confirming that there was no abnormality in the intravenous infusion route, 10mg of l rocuronium was infused as a supplement dose. 2min later, there was no significant change in the spontaneous respiratory rate or tidal volume. 10mg of rocuronium was infused additionally, the spontaneous respiratory rate remained unchanged at 12 breaths/min and the tidal volume was reduced to 200ml. After another 2min of continuous observation, the ventilator indicated that his spontaneous breathing was still present. We replaced the former rocuronium with another anpoule of the latest production date, and another 10mg was infused. Meanwhile, manually-controlled ventilation and intermittent recruitment were performed and the ventilator mode was switched from VCV to PCV. The patient's spontaneous breathing disappeared and his respiratory waveform returned to normal under mechanical ventilation mode. No further recovery of the patient's spontaneous breathing had occurred. During this period, BIS value was maintained between 40 and 50 with a muscle relaxation detector applied. The results suggested that T1 was elevated by up to 20% at one time when the patient showed a recovery of spontaneous breathing. During the preparation for an abdominal closure, the operator indicated abdominal muscle tension, and three doses of additional 10mg of rocuronium was added at 2-min intervals until a good muscle relaxation was achieved. After the completion of peritoneal suturing, the anesthetic maintenance medication was reduced. 4mg of ondansetron was given intravenously, and all maintenance medication was discontinued at the start of skin sealing. Immediately after the operation, the patient’s breathing recovered, who opened his eyes naturally, could respond correctly to verbal commands, and had a tidal volume > 350ml. The tracheal tube was removed only 25min after the last addition of rocuronium. The patient was well awakened and could respond spontaneously, who was transferred to the PACU for observation. The patient was questioned in the PACU and it was confirmed that he had no intraoperative awareness. 20min later, the patient returned to the ward.
Postoperative condition: After returning to the ward, a blood gas analysis was performed: PH: 7.315, PCO2: 38mmHg, PO2: 145.3mmHg, HCO3−: 18.90mmol/l, Hct: 36%, tHb: 12.1g/dL, Na+: 134.7mmol/L, K+: 3.79 mmol/L, Glu: 7.5mmol/L, Lac: 1.94mmol/L. The patient presented a decrease in serum cholinesterase level to as low as 1541 U/L, a drop of leukocytes to 0.43×10^9/L and a progressive decrease in platelets, together with anemia, recurrent fever and hypokalemia after a surgery, which were probably caused by chemotherapy, postoperative immune deficiency and severe infection. Symptomatic supportive treatments such as blood transfusion, platelet supplementation, leukocyte elevation, potassium supplementation and anti-infection were actively given. The patient was also given a thoracentesis and a drainage for bilateral pleural effusion. Half a month after the operation, the patient was discharged after thoracic and abdominal drains were withdrawn, after which his condition was relatively stable and he could eat on his own.
Case 2
The patient was a Chinese male aged 71, with a height of 174cm, a weight of 70kg and an ASA physical status of Level Ⅲ. He was admitted to the hospital as an emergency patient with "cerebral hemorrhage" due to a sudden onset of confusion for 12h, accompanied by nausea and vomiting for 5 times, which were non-jetting and the stomach contents were mixed with blood. The diagnosis of "cerebral hemorrhage from the left basal ganglia region into the ventricles" was confirmed through a multi-row CT scan of the skull and brain, meanwhile "left stereotactic minimally-invasive borehole drainage and external ventricular drainage" were performed on an emergency basis. The patient's preoperative blood biochemistry, liver functions and other test results were not significantly abnormal, and leukocytes shown in his blood routine were10.74×10^9/L with a neutrophil percentage of 0.9. On admission, he was in a deep coma, with a body temperature of 39°C, a heart rate of 120 beats/min, a respiration rate of 25–30 breaths/min and a blood pressure of 196/83 mmHg. The induction of anesthesia was given with 20mg of etomidate, 20ug of sufentanil and 40mg of rocuronium. Intravenous pumping of 0.43mg/kg.h propofol, 0.0057mg/kg.h remifentanil and the inhalation of 1% sevoflurane were used to maintain anesthesia. Intraoperatively, multiple respiratory waveform changes were observed in his mechanical ventilation mode, which was considered as the recovery of spontaneous breathing, and 20mg of rocuronium was added every 20min, but human-machine confrontation still occurred frequently. Muscle relaxation monitoring during this period showed that T1 was between 10% and 20%. As the patient was suspected to be insensitive to rocuronium, he was given 10mg of supplemented cisatracurium instead. The procedure ended 40min later and the patient's spontaneous breathing resumed. The patient was transferred to NSICU with tracheal intubation afterwards due to his advanced age and the fact that his consciousness had not recovered, who continued to be treated with CPAP-mode assisted ventilation. The patient still had an elevated leukocyte and neutrophil percentage postoperatively, but the rest of the test results were unremarkable. Symptomatic supportive treatments such as anti-infection treatment, dehydration to a lower cranial pressure and nerve nutrition were also given. As the patient remained in a light coma with tubes, a tracheotomy was performed one week later, and he was transferred back to the local hospital for continued treatments after half a month.
Case 3
The patient was a Chinese female aged 43, with a height of 160cm, a weight of 67kg and an ASA physical status of Level Ⅱ. She was diagnosed with left breast cancer in the hospital and underwent an elective “radical left mastectomy” after 4 weeks of chemotherapy with doxorubicin and cyclophosphamide combined with paclitaxel (AC-T). The patient was routinely monitored for vital signs after entering the operating room. Anesthesia was induced sequentially with 20mg of intravenous etomidate, 25ug of sufentanil and 40mg of rocuronium. Anesthesia maintenance was conducted with 0.45mg/kg.h propofol, 0.012mg/kg.h remifentanil, an intravenous pump and an inhalation of 1% sevoflurane. During the operation, 10mg of rocuronium was added 10min before an axillary lymph node dissection, but a significant muscle fibrillation was still noted by the surgeons during the lymph node dissection. At this point, the muscle relaxation monitor indicated that T1 had recovered to 10%. 10mg of additional rocuronium was given at 2min intervals, and the muscle fibrillation disappeared. The last dose of rocuronium was given 30min before the end of the operation, and the continuous infusion of general anesthetic drugs was stopped at the time of skin suturing. After the patient's spontaneous breathing, consciousness, choking reflex and swallowing reflex were restored, the tracheal tube was removed and the patient was sent to the PACU. Upon questioning, it was learned that the patient had no intraoperative awareness, who recovered well after surgery and was discharged one week later.
Table 1
Basic Characteristics and Rocuronium Usage for Three Patients
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Case 1
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Case 2
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Case 3
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Age, years
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47
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71
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43
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Gender
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Male
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Male
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Female
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Weight, kg
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54
|
70
|
67
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ASA Physical Status
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Ⅲ
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Ⅲ
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Ⅱ
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Ethnicity / Nationality
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Han / Chinese
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Han / Chinese
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Han / Chinese
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Surgery Type
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Emergency
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Emergency
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Selective
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Duration of Surgery, min
|
155
|
112
|
98
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Average dosing interval, min
|
30
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20
|
20
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Satisfactory-supplementary dose, mg
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30 (ROC)
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10 (CIS)
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20 (ROC)
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Interval from final dose to extubation, min
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25
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Unextubated
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30
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Total dose at extubation, mg
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90mg (ROC)
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100 (ROC) + 10 (CIS)
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70 (ROC)
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ASA, American Society of Anesthesiologists; ROC, rocuronium; CIS, cisatracurium.
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