Mmr03032011

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Mmr03032011

  1. 1. DR.IKHWAN BIN WAN MOHD RUBI ANAESTHESIOLOGY & INTENSIVE CARE, HSNZ 3 rd MARCH 2011
  2. 3. <ul><li>19/MALAY/GIRL </li></ul><ul><li>DOA: 3/2/2011 </li></ul><ul><li>Op:5/2/2011 </li></ul><ul><li>ICU:5-9/2/2011 </li></ul><ul><li>Status: alive and well </li></ul>
  3. 4. <ul><li>Alleged MVA (2/2/2011@5pm) with: </li></ul><ul><ul><li>Mild Head Injury (GCS 14/15) </li></ul></ul><ul><ul><li>CT Brain: Lt Parietal bone fracture with small EDH, pneumocranium and cerebral edema </li></ul></ul><ul><ul><li>Open Comm fracture distal 3 rd Rt Femur (IIIa) </li></ul></ul><ul><ul><li>Open Comm fracture m/s Rt Tibia/Fibula (IIIa) </li></ul></ul><ul><ul><li>Closed fracture Left superior pubic rami </li></ul></ul>
  4. 5. <ul><li>LOC, retrograde amnesia, mild headache, vomit </li></ul><ul><li>No ENT bleed </li></ul><ul><li>GCS:14/15 (E4 V4 M6) </li></ul><ul><li>Pupils 3mm bilaterally reactive </li></ul><ul><li>Restless </li></ul><ul><li>Hematoma 2x2 cm at frontal area </li></ul><ul><li>CT Brain: Lt parietal bone fracture, pneumocranium, small EDH@parietal area, cerebral edema </li></ul>
  5. 6. <ul><li>Conservative management in view of small EDH </li></ul><ul><li>IV Mannitol 20% 200mls </li></ul><ul><li>GCS improved the next day 3/2/2011@8.30am (15/15) </li></ul><ul><li>Headache, vomiting </li></ul><ul><li>GCS never dropped since admission </li></ul><ul><li>Pupils equal and bilaterally reactive </li></ul><ul><li>KNBM quit few days in ward </li></ul><ul><li>IVD N/saline 5 pint/ day </li></ul>
  6. 7. <ul><li>Operation: WD Rt femur and External Fixator Rt Tibia </li></ul><ul><li>Notification: 3/2/2011, renotify 4/2/2011 </li></ul><ul><li>Operation:5/2/2011@1320H </li></ul>
  7. 8. <ul><li>ReNBM at 2am 5/2/2011 </li></ul><ul><li>Nil allegic history </li></ul><ul><li>Potential difficult airway: Broken Upper Lt front molar </li></ul><ul><li>Mallampati II </li></ul><ul><li>Clinically pale, HR:120/min, peripheries cold </li></ul><ul><li>Hb:10.3g/dL </li></ul><ul><li>Denied dypsnea, other system-unremarkable </li></ul><ul><li>Classified: ASA II E </li></ul>
  8. 9. <ul><li>TWC: 11.0 HB:10.3g/dL </li></ul><ul><li>PCV:0.311L/L MCV:75.5fL Plt: 166 </li></ul>Anaesthetic Plan <ul><li>GA (IPPV) </li></ul><ul><li>GXM </li></ul>
  9. 10. <ul><li>BP:130/80mmHg PR: 110-120/min </li></ul><ul><li>Preload 1 pint Hartman </li></ul><ul><li>Induction: </li></ul><ul><ul><li>Fentanyl 100mcg </li></ul></ul><ul><ul><li>Lignocaine 2% 60mg </li></ul></ul><ul><ul><li>Propofol 60+40mg </li></ul></ul><ul><ul><li>Esmeron 50mg </li></ul></ul><ul><li>Analgesic: Morphine 5mg, Parecoxib 40mg </li></ul>
  10. 11. <ul><li>Intubation x 2 – bucked and broken tooth </li></ul><ul><ul><li>?Cromack Lehan </li></ul></ul><ul><ul><li>No manipulation of airway </li></ul></ul><ul><ul><li>No barking </li></ul></ul><ul><ul><li>Cricoid pressure applied </li></ul></ul><ul><li>Intraoperatively: </li></ul><ul><ul><li>SBP 70-80/DBP 31-38, PR: Tachycardia </li></ul></ul><ul><li>Volume: 1L colloid (gelafundin & voluven) </li></ul><ul><li>BP not improved- Tx 1 pint WB and started inf Dopamine (6mcg/kg/min) </li></ul>
  11. 14. <ul><li>BP improved, able to off inotrope </li></ul><ul><li>Plan to extubate, reversal given when TV>200mls, volatile agent discontinue </li></ul><ul><li>2 minutes after extubate, pt struggling and cyanosed </li></ul><ul><li>Reintubation- SpO2 (bagging) 70% </li></ul><ul><li>Lungs-gen crepts, with loose blood stain secretion in ETT </li></ul><ul><li>Ventilated in OT (while arranging bed in ICU) PC 15cmH2O, FiO2 0.42, PEEP 10 Rate 12 </li></ul>
  12. 15. <ul><li>What cause the above diagnosis? </li></ul>
  13. 16. <ul><li>D.O.A to ICU: 5/2/2011@21:05H </li></ul><ul><li>D.O.D fr ICU:9/2/2011 </li></ul><ul><li>Progress: Extubated on 6/2/2011@12.19 </li></ul><ul><li>Post extubation-requred HFM O2 </li></ul><ul><li>Started Diuretic-weaning of FiO2 due to poor oxygeantion, I/O –ve balance, </li></ul><ul><li>Discharged to ward on 9/2/2011 </li></ul>
  14. 17. <ul><li>Clinical condition before discharged </li></ul><ul><li>Alert, conscious, obey command </li></ul><ul><li>On NPO2 3L/min </li></ul><ul><li>Able to tolerated orally, less tachypnea </li></ul><ul><li>ABG: pH:7.49, paCO2:36.5, paO2:96.7, HCO3 28.4 </li></ul><ul><li>Rx on discharged: </li></ul><ul><ul><li>IV Lasix 40mg TDS </li></ul></ul><ul><ul><li>IV Ranitidine 50mg TDS </li></ul></ul><ul><ul><li>S/C Heparin 5000 unit BD </li></ul></ul><ul><ul><li>Chest Physio </li></ul></ul>
  15. 18. <ul><li>Hypotensive post induction </li></ul><ul><ul><li>Possible causes ? </li></ul></ul><ul><li>Intraoperative Assessment & Monitoring </li></ul><ul><ul><li>Are there any pitfall? </li></ul></ul><ul><li>Fluid resuscitation </li></ul><ul><ul><li>How do we resust exactly-are there any guide? </li></ul></ul><ul><li>Can we prevent it from happening </li></ul>
  16. 19. <ul><li>Postoperative pulmonary edema is avoidable </li></ul><ul><li>It cause significant morbidity and mortality to patient </li></ul><ul><li>Prolonged hospitalization and high treatment cost </li></ul>
  17. 20. <ul><li>physiologic state in which the arterial blood pressure is abnormally low </li></ul><ul><li>SBP<90 mmHg/ DBP<60 mmHg </li></ul><ul><li>Causes: </li></ul><ul><ul><li>Hypovolemia due to hemorrhage or dehydration (reduces venous pressure and cardiac output). </li></ul></ul><ul><ul><li>Blood volume redistribution caused by postural changes or gravitational forces (reduces venous pressure and cardiac output). </li></ul></ul>http://www.cvpharmacology.com/clinical%20topics/hypotension.htm
  18. 21. <ul><li>Causes: </li></ul><ul><ul><li>Reduced cardiac output caused by acute or chronic heart failure (e.g., cardiogenic shock), arrhythmias, or autonomic neuropathy. </li></ul></ul><ul><ul><li>Reduced systemic vascular resistance due to loss of sympathetic tone caused by drugs or autonomic neuropathy, or vasodilation caused by sepsis (septic shock) or anaphylaxis. </li></ul></ul>http://www.cvpharmacology.com/clinical%20topics/hypotension.htm
  19. 22. http://www.cvpharmacology.com/clinical%20topics/hypotension.htm
  20. 23. <ul><li>Is the degree of hypotension SERIOUS? </li></ul><ul><ul><li>20% or more below baseline values </li></ul></ul><ul><ul><li>If YES then validate reading (if possible) </li></ul></ul><ul><li>Hypotension validation: </li></ul><ul><ul><li>Check NIBP monitor </li></ul></ul><ul><ul><ul><li>Repeat cycle, check cuff size, check manually </li></ul></ul></ul><ul><ul><li>Confirm with palpation of large artery for pulse </li></ul></ul><ul><ul><li>Check arterial line </li></ul></ul><ul><ul><ul><li>Flush, open to air and quickly confirm zero, pulsatile waveform </li></ul></ul></ul><ul><ul><li>Independent pulse source – SpO 2 </li></ul></ul><ul><ul><li>Has ETCO 2 level fallen? </li></ul></ul><ul><ul><ul><li>Low ETCO 2 = Low cardiac output or Embolism </li></ul></ul></ul>
  21. 24. http://www.modernmedicine.com
  22. 25. <ul><li>Increased inspired OXYGEN </li></ul><ul><li>Is the hypotension EXPECTED? </li></ul><ul><ul><li>Is it the result of an anticipated surgical intervention? </li></ul></ul><ul><ul><li>If YES then manage in context of surgical causes </li></ul></ul><ul><li>If UNEXPECTED, quickly check that there are no obvious surgical issues e.g. </li></ul><ul><ul><li>Sudden massive blood loss </li></ul></ul><ul><ul><li>IVC compression (including obstetrics / laparoscopy) </li></ul></ul><ul><ul><li>Femoral shaft reaming etc. </li></ul></ul><ul><ul><li>CO 2 insufflation </li></ul></ul><ul><ul><li>Tourniquet or Vascular Clamp release </li></ul></ul>
  23. 26. <ul><li>If Asystole / VF or pulseless VT then manage CARDIAC ARREST </li></ul><ul><li>If TACHYARRHYTHMIA (AF/SVT/VT) then </li></ul><ul><ul><li>Control rate with Vagal Manouvres / Vagotonic Drugs or Synchronized Cardioversion </li></ul></ul><ul><ul><li>Review possible causes including LIGHT ANAESTHESIA </li></ul></ul><ul><li>If SEVERE BRADYCARDIA then </li></ul><ul><ul><li>Increase rate with vagolytic agents (atropine) </li></ul></ul><ul><ul><li>Use chronotropic pressors (ephedrine, adrenaline) </li></ul></ul><ul><ul><li>Review possible causes including HYPOXIA </li></ul></ul>
  24. 27. <ul><li>Volume resuscitation </li></ul><ul><ul><li>First priority in context of recent neuraxial block </li></ul></ul><ul><ul><li>IV fluids </li></ul></ul><ul><ul><li>Posture legs up (if practical) </li></ul></ul><ul><ul><li>Consider wide-bore access </li></ul></ul><ul><li>Vasopressors </li></ul><ul><ul><li>Especially if GA or unresponsive to volume or limited ability to rapidly infuse fluids </li></ul></ul><ul><ul><li>Ephedrine / Phenylephrine / Noradrenaline / Adrenaline / Vasopressin </li></ul></ul>
  25. 28. <ul><li>Consider likely causes of SEVERE HYPOTENSION </li></ul><ul><ul><li>Sudden BLOOD LOSS (surgical) </li></ul></ul><ul><ul><li>Impaired VENOUS RETURN (surgery / posture / high airway pressures / pneumothorax) </li></ul></ul><ul><ul><li>VASODILATION (neuraxial block - assess block height, anesthetic agents, drug reactions including ANAPHYLAXIS) </li></ul></ul><ul><ul><li>EMBOLISM (Air / CO2 / orthopedic / venous thromboembolism) </li></ul></ul><ul><ul><li>CARDIAC ARRHYTHMIA </li></ul></ul><ul><ul><li>CARDIAC Dysfunction </li></ul></ul><ul><ul><li>Ischemia / Infarction </li></ul></ul><ul><ul><li>Depressants (anesthetic agents etc) </li></ul></ul>
  26. 29. <ul><li>If still severely hypotensive </li></ul><ul><ul><li>Call for assistance </li></ul></ul><ul><ul><li>Review Likely Causes </li></ul></ul><ul><li>If cause still not determined : Perform Systematic Review of </li></ul><ul><ul><li>AIRWAY: pressure, minute volume </li></ul></ul><ul><ul><li>BREATHING: CO2 exchange, oxygenation </li></ul></ul><ul><ul><li>CIRCULATION: rhythm, ischemia, volume (insert CVP, PAC, TEE) </li></ul></ul><ul><ul><li>DRUGS: check doses, agent </li></ul></ul><ul><li>Consider other RARE CAUSES </li></ul>
  27. 30. <ul><li>Validate reading </li></ul><ul><li>Attempt to IDENTIFY CAUSE </li></ul><ul><li>Treat by </li></ul><ul><ul><li>CORRECTING CAUSE </li></ul></ul><ul><ul><li>DECREASING ANESTHETIC DEPTH (if GA) </li></ul></ul><ul><ul><li>VOLUME (IV or posture) </li></ul></ul><ul><ul><li>VASOPRESSORS (if unresponsive to other measures) </li></ul></ul>
  28. 31. <ul><li>Identify and treat COMMON CAUSES of mild to moderate intraoperative hypotension </li></ul><ul><ul><li>Relative HYPOVOLAEMIA </li></ul></ul><ul><ul><ul><li>Neuraxial BLOCK (assess block height), inadequate fluid replacement </li></ul></ul></ul><ul><ul><li>Excessive relative DEPTH of ANESTHESIA </li></ul></ul><ul><ul><ul><li>Volatile agent / IV agent too high </li></ul></ul></ul><ul><ul><li>High AIRWAY PRESSURES </li></ul></ul><ul><ul><li>SURGICAL </li></ul></ul><ul><ul><ul><li>Blood loss, venous return compression, release of tourniquet or vascular clamp </li></ul></ul></ul><ul><ul><li>Mild RHYTHM disturbance </li></ul></ul><ul><ul><ul><li>Nodal rhythm, slow AF </li></ul></ul></ul>
  29. 32. <ul><li>If unable to identify a cause at this stage, proceed to a more thorough systematic assessment </li></ul><ul><ul><li>Perform Systematic Review of </li></ul></ul><ul><ul><ul><li>AIRWAY: pressure, minute volume </li></ul></ul></ul><ul><ul><ul><li>BREATHING: CO2 exchange, oxygenation </li></ul></ul></ul><ul><ul><ul><li>CIRCULATION: rhythm, ischemia, volume (insert CVP, PAC, TEE) </li></ul></ul></ul><ul><ul><ul><li>DRUGS: check doses, agent </li></ul></ul></ul><ul><ul><li>Consider RARE CAUSES </li></ul></ul>
  30. 33. <ul><li>Anaphylaxis </li></ul><ul><li>Drug Error </li></ul><ul><li>Transfusion Incompatibility </li></ul><ul><li>Acute Mitral Valve Rupture </li></ul><ul><li>Pericardial Tamponade </li></ul><ul><li>Septic Shock </li></ul><ul><li>Adrenocortical Insufficiency </li></ul>
  31. 34. Not just a famous neurosurgeon … but the father of anesthesia monitoring Invented and popularized the anesthetic chart Recorded both BP and HR Emphasized the relationship between vital signs and neurosurgical events ( increased intracranial pressure leads to hypertension and bradycardia )
  32. 35. Multiparameter Patient Monitors
  33. 36. Specialized Patient Monitors Depth of Anesthesia Monitor Evoked Potential Monitor Transesophageal Echocardiography
  34. 37. <ul><li>Routine monitoring </li></ul><ul><ul><li>Cardiac activity </li></ul></ul><ul><ul><li>Non-invasive blood pressure ( NIBP ) </li></ul></ul><ul><ul><li>Electrocardiography ( ECG ) </li></ul></ul><ul><li>Advanced monitoring </li></ul><ul><ul><li>Direct arterial blood pressure </li></ul></ul><ul><ul><li>Cardiac filling pressure monitor </li></ul></ul><ul><ul><ul><li>Central venous pressure </li></ul></ul></ul><ul><ul><ul><li>Pulmonary capillary wedge pressure </li></ul></ul></ul>
  35. 38. <ul><li>Electrocardiography </li></ul><ul><ul><li>Cardiac activity </li></ul></ul><ul><ul><li>Arrhythmia: Lead II </li></ul></ul><ul><ul><li>Myocardial ischemia: ECG criteria </li></ul></ul><ul><ul><li>Electrolyte imbalance </li></ul></ul><ul><ul><li>Pacemaker function </li></ul></ul>
  36. 39. <ul><li>Non-invasive blood pressure (NIBP) </li></ul><ul><ul><li>Cuff: width 120-150 % limb diameter, air bladder includes more than halfway around limb </li></ul></ul><ul><ul><li>Manometer: aneroid, mercury </li></ul></ul><ul><ul><li>Detector: manual, automated </li></ul></ul><ul><ul><li>Inaccurate: cuff size, inflated pressure, shivering, cardiac arrhythmia, severe vasoconstriction </li></ul></ul>
  37. 40. <ul><li>Direct arterial pressure monitor </li></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><li>Continuous blood pressure monitor: anticipated cardiovascular instability, direct manipulation of cardiovascular system </li></ul></ul></ul><ul><ul><ul><li>Frequent arterial blood sampling: ABG, Acid-base / electrolyte / glucose disturbance, coagulopathies </li></ul></ul></ul>
  38. 41. <ul><li>Direct arterial pressure monitor </li></ul><ul><ul><li>Contraindications/ caution: </li></ul></ul><ul><ul><ul><li>Local infection </li></ul></ul></ul><ul><ul><ul><li>Impaired blood circulation: Raynaud’s phenomenon, DM </li></ul></ul></ul><ul><ul><ul><li>Risks of thrombosis: hyperlipidemia, previous brachial artery cannulation </li></ul></ul></ul>
  39. 42. <ul><li>Direct arterial pressure monitor </li></ul><ul><ul><li>Complications </li></ul></ul><ul><ul><ul><li>Direct trauma: AV-fistula, Aneurysm </li></ul></ul></ul><ul><ul><ul><li>Hematoma </li></ul></ul></ul><ul><ul><ul><li>Infections </li></ul></ul></ul><ul><ul><ul><li>Thrombosis </li></ul></ul></ul><ul><ul><ul><li>Embolization </li></ul></ul></ul><ul><ul><ul><li>Massive blood loss </li></ul></ul></ul>
  40. 43. <ul><li>PCWP: Pulmonary capillary wedge pressure </li></ul><ul><li>CVP: Central venous pressure </li></ul><ul><li>Fluid Challenge test to optimize preload and maximize Cardiac performance </li></ul>
  41. 44. <ul><li>Crystalloid vs Colloid? </li></ul><ul><li>Amount? </li></ul>
  42. 49. <ul><li>72/MALAY/ELDERLY MAN </li></ul><ul><li>DOA: 29/1/2011 </li></ul><ul><li>ICU:29-31/1/2011 </li></ul><ul><li>Status: Succumbed to death on 31/1/2011@4.15am </li></ul>
  43. 50. <ul><li>Dx: </li></ul><ul><ul><li>ESRF with fluid overload </li></ul></ul><ul><ul><li>Bronchopneumonia cover ILI </li></ul></ul><ul><ul><li>COAD/HPT </li></ul></ul><ul><ul><li>IHD </li></ul></ul><ul><li>C/O: </li></ul><ul><ul><li>Sudden onset SOB, orthopnea, PND, no fever, occ cough, unsure re: sputum </li></ul></ul><ul><ul><li>h/o frequent admission for overload </li></ul></ul><ul><li>Intubated at casualty for resp distress </li></ul>
  44. 51. <ul><li>Admission hx </li></ul><ul><li>7-9/1/2011-Fluid overload, AOR discharged </li></ul><ul><li>10-11/1/2011-Fluid overload, HD once then discharged </li></ul><ul><li>12-16/1/2011-Fluid overload </li></ul>
  45. 52. <ul><li>Admit ICU-for weaning </li></ul><ul><li>BP:202/88 PR:94 </li></ul><ul><li>SpO2100% </li></ul><ul><li>CXR: opacities bilateral lung field>Rt </li></ul><ul><li>Mx: </li></ul><ul><li>T.amlodipine 10mg od </li></ul><ul><li>Plan HD </li></ul><ul><li>Neb Comb 4hrly </li></ul><ul><li>Rocephine/Azithro/Tamiflu </li></ul>
  46. 53. <ul><li>No inotropic support-done HD extract 2L </li></ul><ul><li>Plan for extubation on 31/1/2011 </li></ul><ul><li>At 3-4am, pt tachypnea, blocked ETT-unable to suction, tight bagging </li></ul><ul><li>Reintubation done, secretion+++, </li></ul><ul><li>Condition deteriorated </li></ul><ul><li>PEA, CPR commenced 10min, started inotrope </li></ul><ul><li>Reverted for awhile then asystole </li></ul>

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