Surge anes case

1. Berbano, Alain Justin S.
ANESTHESIA PLAN
Identifying Data Patient LG , Filipino, female, 65 years old, from Hagonoy, Bulacan, was admitted in UERM on February 19,
2019 for the first time.
Patient Medical-
Surgical History
Past Medical History:
No childhood diseases, known allergies, and accidents. Patient had stroke on 2014, was hospitalized for 1
week and was also diagnosed with HTN (highest SBP: 140) and is maintained currently on Losartan 50 mg
OD & Atorvastatin 80 mg OD
OB history – G6P6 T6P6A0L4
Past surgical history:
No previous surgeries
Family History:
Father died at 90 due to complications of HTN
Mother died at 78 due to complications of HTN
Eldest sibling died at 75 due to complications of HTN
4th sibling died at 37 due to epilepsy
Social History:
Patient is the 5th among 5 siblings, two of whom are dead. Patient lives with her husband and 2
grandchildren in a cemented house in a community not densely populated. They have access to electricity
and water. Garbage is collected daily. Patient used to work as a seamstress before she decided to tend to
their crops in the farm.
Patient’s diet consists mainly of rice with a viand of fish or vegetables. She usually gets 6 hours of sleep.
She denies smoking, alcohol and illicit drug use. Her form of exercise includes walking around their house.
Pertinent
Physical
Evaluation
Vital signs:
BP 120/80 , Temp 36.2 degrees celsius , RR 22 , HR 70 , O2sat at 97% at room temp
Chest, CVS, Abdomen, Neuro, HEENT PE were unremarkable
Skin and hair:
+ scars on both dorsum of hands d/t failed IV insertions, incision on the head with staples, well apposed,
no drainage
Airway assessment:
Mallampati score: Class 1
Interdental distance: 3 FB
Thyromental distance: 3 FB
Thyrohyoid distance: 2 FB
Pertinent
Laboratories
No laboratories available. These are laboratories that may be requested:
• CBC: to demonstrate possible hypochromic, microcytic anemia which suggests iron deficiency
• Blood Typing (ABO, Rh, cross matching): for possible blood transfusion
• Liver function tests: as part of preoperative workup
• Renal function tests (Na, K, Creatinine, BUN): as part of preoperative workup
• CEA test: baseline level is obtained before surgery and a follow-up level is obtained after surgery
• ECG: to determine cardiac abnormalities
• Chest Xray: to check lungs
• Blood sugar test: to determine presence of diabetes

2. • PT/aPTT: to determine hematological abnormalities
• Initial evaluation should include:
o Colonoscopy
o Biopsies of lesions
o Histopathologic review
• Metastatic evaluation should include:
o Chest/abdomen/pelvis CT scan
o CEA level, liver function test
o Endorectal ultrasound or endorectal or pelvic MR
o PET scan
• Pre-surgical evaluation should include:
o Digital rectal examination
o Rigid proctoscopy
Clinical decision making regarding primary or adjuvant chemotherapy or radiotherapy
ANESTHETIC PLAN
ASA
Classification
ASA 2
-Patient had history of Stroke (2014)
Contemplated
Procedure
Schedule of Operation:
Thyroidectomy
Preoperative
planning
• Routine investigation
o Thryoid function tests
o Hgb, WBC, Platelet count, Urea, Electrolytes
• AP Chest X-ray & Indirect Laryngoscopy – to document preoperative vocal cord dysfunction.
• Lateral Thoracic X-ray – to show tracheal compression
• CT – views of retrosternal goiters
• Obtain complete pre-operative surgical and anesthesia history and physical examination
• Stop or reduce anti-coagulative medications to reduce risk of bleeding
• Explain the procedure, induction of anesthesia and expected outcome
• Secure informed consent for anesthesia administration
• Inform and explain the post-operative care in term of pain management method
• Anemia, electrolyte imbalance, nutritional deficiency (e.g. hypoalbuminemia), and weight loss should
be identified and corrected
• Detailed evaluation and treatment of medical problems
• Identify deteriorating vital physiological and end organ functions and their causes in emergency
surgery
• Obtain history, clinical examination, review of monitored parameters and laboratory investigations
(e.g. arterial blood gas analysis and serum electrolytes)
• Identify cardiac or respiratory disease (e.g. through cardiopulmonary exercise testing (CPET))
• NPO Order:
o Clear liquids should not be taken 2 hours prior to surgery
o Light meal and nonhuman milk should not be taken 6 hours prior to surgery
o Regular meal should not be taken 8 hours prior to surgery
• Medications
o Cardiac medications should be continued, if applicable
o Stop smoking and alcohol intake, if applicable
o Stop herbal medications, if applicable
o Pre-medications for anxieties may be given
o Withhold ACE-inhibitors, if applicable

3. o Stop anti-platelets or anticoagulants except for certain cases (drug-eluding stent,
arrhythmias: aspirin may be continued)
o Stop hypoglycemic agents, if applicable
o Continue endocrine medications, if applicable
o Continue gastrointestinal medications, if applicable
o Continue steroid medications, if applicable
o Continue inhaled therapies for COPD or asthma, if applicable
• Antibiotic prophylaxis with aerobic and anaerobic coverage to reduce surgical site infection
• Venous thromboembolism prophylaxis
• Assess preoperative medical conditions which may predispose colonic tissue to hypoxia including
smoking, atherosclerosis, cardiac failure, and sickle cell anemia
• Placement of urinary catheter
Current medications (Losartan and Atorvastatin) are to be continued.
If general anesthesia is to be used, nothing should be eaten from midnight on the evening before the
surgery until the procedure is completed. This includes food, water, chewing gum, and candy. This is to
ensure a decrease in the possibility of vomiting during and after surgery. However, for local anesthesia,
dietary restrictions may vary. But sometimes, the guidelines for general anesthesia is followed since it may
be necessary to switch from local to general anesthesia during surgery.
Choice of
Anesthesia
General anesthesia with tracheal intubation and muscle relaxation
- It is the most popular anaesthetic technique for thyroidectomy. Intravenous anesthesia and
total intravenous anesthesia (TIVA) become wider in modern anesthetic techniques in thyroid
surgery.
- Induction and Maintenance of general anesthesia: Propofol and Alfenantil – they have the most
suitable pharmacokinetic and parmacodynamic profiles for administration by continuous
infusion. Propofol provides rapid onset of anesthesia (short equilibration half times) and rapid
recovery. It also has very low incidence of postoperative nausea and vomiting and it could be
safely used in patients susceptible to malignant hyperthermia.
Airway
Management
• Start with airway assessment by devising airway plans, anesthesia plans, preoperative fasting
and informed consent.
• Check preparation and equipment
• Proper patient positioning
• Preoxygenation
o Oxygen is delivered by mask for several minutes prior to anesthetic induction
• Bag and mask ventilation
o Precedes attempts at intubation in an effort to oxygenate the patient due to implicit
risk of aspiration
• Intubation (if indicated)
• Confirmation of ET placement
• Intraoperative
If general anesthesia is used, endotracheal intubation and muscle relaxants are needed. Endotracheal
intubation is needed to open the airway to give oxygen, medicine or anesthesia. Also, this may support
breathing in illnesses such as pneumonia, emphysema, heart failure, collapsed lung or severe trauma;
blockages from airway may also be reomoved; a better view of the upper airway may also be provided.
Lastly, this may protect the lungs in people who are unable to protect the airway from aspiration.
Intubation is needed as general anesthesia decreases ability to breath effectively.
Monitoring Preoperative
• Prior to procedure, patient should be informed about the anesthetic options as well as their
benefits, risks, and complications. The preanesthetic assessment form should be properly filled
out prior to the anesthetic procedure.
• Preoperative fasting guidelines should be followed to avoid or mitigate the occurrence of
aspiration. ASA recommendations for fasting include:

4. o 2 hours for clear liquids (water, clear tea, black coffee)
o 4 hours for breast milk
o 6 hours for light meals (toast with clear liquids), infant formula, nonhuman milk
o 8 hours for full milk
• Laboratory examinations such as CBC for monitoring and have baseline values as well as
electrocardiogram, chest radiography to check lungs and heart are in good condition prior
surgery
• Intake of over the counter drugs such as Aspirin, and Ibuprofen is also stopped 10 days or 1
week prior to surgery which might increase bleeding during the procedure
• Immediately prior to surgery, patient should also be reexamined to confirm presence of hernia
and its laterality
• It is also important to ensure patient can tolerate anesthesia especially if general anesthesia is
planned
• Prior to surgery, preoperative prophylaxis such as thromboprophylaxis and prophylactic
antibiotics may be required to prevent complications like venous thromboembolism or surgical
site infections.
Intraoperative
• Identify RLN, nerve is stimulated until an evoked EMG is obtained.
• Ensure atraumatic dissection of the RLN.
• Intraoperative electro-physiologic monitoring - Tracheal tube w/ integrated EMG electrodes
positioned at the level of the vocal cords to protect the recurrent laryngeal nerve during
thyroidectomy.
Postoperative
• Hematoma – Maintain patient’s intrathoracic pressure positive for 10-20s in order to assess
hemostasis before wound closure.
• Trachemalacia – Tracheal collapse is a life threatening complication, management requires
urgent re-intubation, possibly tracheostomy and some forms of tracheal support such as
ceramic rings.
• Laryngeal oedema – rare cause of post-thyroidectomy respiratory obstruction
• Hypocalcemia – Occurs in 20% of patients about 36 h postoperatively. Might be reduced by
more careful inspection of the thyroid capsule.
• Postoperative nausea and vomiting – high risk for the development of postoperative nausea and
vomiting. Effective prevention by combination of antimetic therapy with granisetron plus
droperidol or granisetron plus dexamethasone.
Pain
Management
Plans
Postoperative pain – patients usually tolerate thyroidectomy very well and require minimal analgesia.
They often complain of a stiff neck because of the position during surgery rather than pain from the
surgical incision itself. Combination of NSAIDs and acetaminophen has been found to be effective in
addressing this concern.