Your SlideShare is downloading. ×
  • Like
Cholecytectomy
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×

Now you can save presentations on your phone or tablet

Available for both IPhone and Android

Text the download link to your phone

Standard text messaging rates apply
Published

 

Published in Education , Health & Medicine
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
155
On SlideShare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
1
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. PROBLEM ORIENTED DISCUSSION
    • INNOVATIVE METHODS OF MANAGING OPEN CHOLECYSTECTOMY
    • Moderator - Dr.Vidushi
    • Presenter - Dr.Parameswaran
  • 2. PRESENTING COMPLAINTS
    • 80 year old lady presents to the hospital with the complaints of
    • Right upper abdominal pain – 10 days
    • Nausea and vomiting - 3 days
  • 3.  
  • 4.  
  • 5.  
  • 6.  
  • 7.  
  • 8.  
  • 9.  
  • 10.  
  • 11. PRESENTING COMPLAINTS
    • Pain - localized in right upper abdomen , dull aching type aggravating on food intake.
    • Nausea and vomiting - Non bilious type, no haemetemesis.
    • No history of loss of weight , yellowish discoloration of eye, dysphagia.
  • 12. PRESENTING COMPLAINTS
    • No history of fever
    • Complains of dysuria .
    • No history of chest pain, breathlessness on lying down.
    • Patient has been bedridden since past 3 months due to lethargy and easy fatigability.
  • 13. PRESENTING COMPLAINTS
    • She requires support to move around the house.
    • Bystanders give history of excessive
    • day time somnolence with history of
    • snoring at night.
  • 14. PAST history
    • A pparently normal 4 months and actively mobile in the house when admitted for urinary tract infection.
    • Diagnosed as hypertensive, hypothyroidism , OSA , urinary tract infection and hyponatremia.
  • 15. TREATMENT HITORY
    • Started on T.Amlodipine 5 mg B.D and T.Eltroxine 150 mcg O.D
    • Hyponatremia corrected.
    • Since then has been admitted for recurrent UTI and has been lethargic and bedridden since.
  • 16. ON EXAMINATION
    • Wt - 85 Kg Ht – 153cms
    • BMI – 36.3
    • Patient sleepy difficult to arouse and goes back to sleep if no verbal communication maintained.
    • No pallor, icterus, pedal edema
  • 17. ON EXAMINATION
    • Pulse rate 80/ min and regular.
    • Blood pressure 150/90 mm Hg
    • Breath holding time 12 sec
    • AIRWAY
      • Mouth opening 2.5 cm
      • Mallampati – class IV
      • Neck extension limited to 40-50*
      • Anterior bulky neck
      • Protruding upper incisors
  • 18. ON EXAMINATION
    • CVS and RS : within normal limits
    • SPINE –thoracic spinous process felt very vaguely and on deep palpation.
  • 19. INVESTIGATIONS
    • Hb 9.4 gm%.
    • TC 8,900 N: 88 L: 10 E: 01
    • Urea 43 mg % creatinine 1.4 mg%
    • LIVER FUNCTION TEST
      • T. bilirubin 2.6 mg%
      • D. bilirubin 1.5 mg%
      • Albumin 3.0 gm%
      • Globulin 4.5 gm%
      • ALP 408 u/l
  • 20. INVESTIGATIONS
    • BT 1’ 40” CT 4’00”
    • PT 14 sec (12 sec ) INR 1.21
    • THYROID FUNCTION TEST
      • T3 1.14
      • T4 12.84
      • TSH 0.73
    • ECG and CXR within normal limit.
  • 21. INVESTIGATIONS
    • USG abdomen – enlarged gall bladder with thickened wall with multiple calculi 10 – 18 mm . Suggestive of calculus cholecystitis
    • ABG
      • PH - 7.346
      • Pco 2 - 51.2
      • Po2 - 59
      • Spo2 - 88.2
      • Hco3 - 28.0
      • Tco2 - 29.6
  • 22. SUMMARY
    • Acute obstructive cholecystitis
    • Elderly
    • Obesity
    • Hypertensive
    • Hypothyroidism
    • Obstructive sleep apnea
    • Recurrent UTI
  • 23. Intra op management
    • NPO of 7hrs.
    • No premedication
    • Plan – combined spinal epidural
    • IV access – 16 G cannula in left UL,
    • Patient in lateral position
    • 17G tuohy needle in T6-T7 space
    • Space reached at 4.5cms
  • 24. Intra op management
    • Needle through needle tech used – 27G spinal needle used.
    • Free flow of CSF confirmed – 1.8ml of 0.5% bupivacaine (heavy) administered in the subarachnoid space
    • 20G epidural catheter threaded and fixed at 11cms.
    • Patient was repositioned
    • Rt radial artery cannulated for continuous BP monitoring
    • Inj. Dopamine 200mg in 50 ml started as an infusion at 3-5mcg/kg/min.
  • 25. Intra op management
    • Oxygen through face mask with a flow of 5l/min
    • Epidural infusion - 0.5% bupivacaine @ 5ml/hr was started.
    • The procedure lasted for 1hr and 30 min
    • The patient was hemodynamically stable throughout the surgery
    • At the end of surgery patient was shifted to post – op ward with stable vitals.
  • 26. POST op management
    • Oxygen – flow of 5l/min
    • Epidural infusion – 0.25% bupivacaine + 2mcg/cc fentanyl at 5ml/hr
    • Dopamine infusion at 3ml/hr stopped in the evening of the same day
    • IV fluids RL @ 100ml/hr
  • 27. First post op day
    • central line was put
    • I/O was maintained – 2100/2017
    • Na-139, K-3.2, Hb-9.2
    • ABG
      • PH - 7.4
      • Pco 2 - 34
      • Po2 - 141
      • Spo2 - 99.2
      • Hco3 – 21.3
      • Tco2 - 22.3
      • BE – 2.7
    • She was started on Inj. Fragmin 2500U S/C
  • 28. Second post op day
    • Patient was hemodynamically stable
    • I/O – maintained 2650/1340
    • Epidural infusion with bupivacaine continued
  • 29.  
  • 30. Third post op day
    • Arterial line removed
    • Patient was comfortable
    • No complaints of pain
    • Epidural infusion continued
    • RBS-136
    • Creat – 1.2
    • Na – 150
    • K – 3.6
    • Hb – 8.2
    • Patient was shifted to the ward on the third post op day after removing epidural catheter.
  • 31.