CASE PRESENTATION. Dr.M.Pramod kumar Final year PG MD Anaesthesia Department of anaesthesia

Transcription

1 CASE PRESENTATION Dr.M.Pramod kumar Final year PG MD Anaesthesia Department of anaesthesia

2 Patient name : XXX Sex : male Age : 60 years Address : madirala (V), suryapet. Date of admission : Date of operation : Date of discharge :

3 CHIEF COMPLAINTS: Patient presented with swelling over the right side of upper neck since 10 days associated with fever. H/O PRESENTING ILLNESS patient was apparently asymptomatic 10 days back. Later he developed swelling on right side of upper neck which was initially pea size, progressed to present size(10 X 7 cm) associated with fever and pain radiating to right ear. H/O tooth extraction 9 days back by RMP without any antibiotic cover. H/O difficulty in swallowing & speaking. No H/O difficulty in breathing, stridor, regurgitation, weight loss, cough, nasal obstruction, headache, vomiting.

4 PAST HISTORY: No history of similar complaints in the past. No H/o hypertension/ diabetes/bronchial asthma/tuberculosis/epilepsy. No H/o previous surgeries. PERSONAL HISTORY: Mixed diet Normal appetite, No h/o of loss of weight Regular bowel and bladder habits Regular alcoholic stopped 10 days back Not a smoker

5 Family history: Not significant. Drug history: No history of any previous drug allergy.

6 GENERAL PHYSICAL EXAMINATION: Patient conscious, coherent, oriented to time, place and person. Pt. was moderately built and moderately nourished. No pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema, stridor VITALS: Patient febrile(100 0 f) PR-106/min regular rhythm, normal volume BP-110/80mm of Hg RR-20/min

7 SYSTEMIC EXAMINATION RESPIRATORY SYSTEM: B/L air entry + Normal vesicular breath sounds heard CARDIO VASCULAR SYSTEM: S1S2 + No murmers. P/A : Soft, non tender.

8 LOCAL EXAMINATION Inspection : Single diffuse swelling of size 10 X 7 cm on right side of neck, extending from angle of mandible to chin anteriorly, till 2 cm above the Rt. clavicle and involving the submental, submandibular, carotiod triangle. No localized pus pointing No scars, sinus, fistulae. No engorged veins, visible pulsations. No lymph nodes were palpable

9 Palpation : Inspection findings are confirmed. Soft in consistency Local rise of temperature Tenderness present (mild)

10 ORAL CAVITY : No bulge on alveolus Extraction socket was healthy No granulations & pus

11 INVESTIGATIONS Complete blood picture: Hb-15gms% Total count-16,500/mm3 platelets-2.64lakhs/mm3 CUE: WNL RFT: blood urea-100mg/dl serum creatinine-1.25mg/dl serum electrolytes- Na , K , Cl Blood group: O+

12 Bleeding time : 2min clotting time : 4min 30 sec LFT: total bilirubin-1.31mg/dl direct bilirubin-0.49mg/dl total protiens-5.4mg/dl albumin-2.9mg/dl Serology: HIV, HBsAg- non reactive chest Xray: Normal.

13 RBS : 91 mg/dl APTT : 47 sec PT : 23 sec INR : 1.79 ESR : 15 mm

14 CHEST X-RAY

15 NECK X-RAY

16 PROVISIONAL DIAGNOSIS Deep Neck space abscess posted for incision and drainage. Preanaesthetic checkup: history - No comorbidities - No h/o anaesthetic exposure - consumes Alcohol daily

17 CLINICAL EXAMINATION Moderately built Weight : 60 kgs Hydration- mild dehydration Trachea mid line TM joint movement adequate Cervical spine movement - adequate Neck edema Mouth opening- 2 fingers No loose /protruding teeth Mallampati grade III

18 Vitals: PR-102/min BP-110/70 mmhg RR-18/min Ausculation: B/L AE +, clear S1S2 +, No murmurs Preanesthetic checkup was done and posted for I&D with high risk under general anesthesia with ASA 2E. -informed & written consent for anaesthesia and surgery was taken. -nill by mouth from midnight.

19 patient was shifted to operation theater and connected to multipara monitor to record baseline vitals PR, NIBP,Spo2. An 18 guage iv line was secured on left hand and iv fluid started. Preoxygenation with 100%oxygen was done for 3 minutes. Premedication: inj.glycopyrrolate 0.2mg/iv inj.ondansetron 4mg/iv inj.fentanyl 60mcg/iv inj.midazolam 1mg/iv Induction: inj.thiopentone 250mg/iv inj.succinylcholine 100mg/iv

20 intubation: intubated with 7.5 cuffed ET tube by using bougie, B/L air entry checked and confirmed, fixed at 22 no. lip mark. Maintanence: oxygen and nitrous oxide 3:5 veceuronium 4mg/iv Ventilation done with co-axial Bain s circuit & Boyle s anaesthetic machine.

21 Intraoperative monitoring: Pulse rate, Non invasive blood pressure, Spo2,ECG were continuously monitored. All vitals were stable through out the procedure.

22 Extubation: After completion of the procedure, extubation was planned. inj. Glycopyrrolate 0.6mg/iv and inj. Neostigmine 3mg/iv were given after attaining spontaneous respiratory efforts. After spontaneous eye opening, obeying commands, adequate muscle power, tidal volume and airway reflexes, thorough oral suction was done and patient was extubated. Oxygen supplementation was given at 6 lit/min with face mask.

23 Pt. was alright till 5 minutes after extubation, then developed difficult in breathing and fall in saturation. Mask ventilation was done but no improvement in saturation was noted. As oxygenation was falling, re intubation was attempted. Intubation with smaller size tube (7.0,6.5,6.0 and 5.5) was attempted, but as airway was edematous, could not visualize the glottis, this was a cannot intubate and cannot ventilate situation.

24 Emergency tracheostomy was done to secure airway under local anaesthesia. 7.5 TT was placed and connected to bain s circuit, adequate chest movements, b/l air entry was confrimed and there was improvement in oxygen saturation and came to normal. Procedure was uneventful and patient became hemodynamically stable. He was shifted to POW and connected to ventilator(ippv Mode) with fio2 0.6.

25 ABG PH :7.45 Po2: 90 mm hg Pco2 : 29.9 mm hg Hco3 : 20.8 O2 sat : 90 % CHEST X RAY: normal with tracheostomy tube in situ

26 Pt. was continously monitered 2 nd hourly TT suction or SOS Inj.hydrocortisone 100mg/iv TID Inj.midazolam 2mg/iv SOS Neb.duolin & budecort TID IV ml/min Foley s and ryles tube insertion Ventilator settings : V t : 450 ml Fio 2 : 0.6 Rate : 16/min PEEP : 3

27 POD-1 Pt. C/C/C Afebrile GCS : E 4 V T M 6 Pupils : B/L Equal NSRL RS: B/L AE +, clear CVS: S1S2 +, No murmers Ventilator settings changed to CPAP

28 POD-1 As Pt. was comfortable with CPAP mode for 3 hrs, changed to T-piece with 6 lit O2/min. ABG was normal. Ryles Tube feeds of 150 ml/hr started. Continued inj.hydrocortisone 100 mg/iv TID Neb.duolin & budecort TID

29 ABG WITH T-PIECE(6LIT O2/MIN) PH : 7.4 Po2: 113 Pco2 : 33.2 Hco3 : 20.8 O2 sat : 97.1

30 POD-2 Pt. C/C/C Afebrile GCS : E 4 V T M 6 Pupils : B/L Equal NSRL RS: B/L AE +, clear CVS: S1S2 +, No murmurs T-piece was disconnected and kept on room air. Inj.hydrocortisone 100 mg/iv TID continuied for 3 days.

31 On POD-6 TT was blocked by ENT surgeon for trial to remove of TT. On POD-7 TT was removed,asd applied & Shifted to ward. On POD-12 tracheostomy wound was healthy, Pt.was comfortable and discharged.

32 THANK YOU