PROBLEM ORIENTED DISCUSSION <ul><li>INNOVATIVE METHODS OF MANAGING OPEN CHOLECYSTECTOMY </li></ul><ul><li>Moderator  -  Dr...
PRESENTING COMPLAINTS <ul><li>80 year old lady presents to the hospital with the complaints of </li></ul><ul><li>Right upp...
 
 
 
 
 
 
 
 
PRESENTING COMPLAINTS <ul><li>Pain  -  localized in right upper abdomen , dull aching type aggravating on food intake. </l...
PRESENTING COMPLAINTS <ul><li>No history of fever </li></ul><ul><li>Complains of  dysuria . </li></ul><ul><li>No history o...
PRESENTING COMPLAINTS <ul><li>She requires support to move around the house. </li></ul><ul><li>Bystanders give history of ...
PAST  history <ul><li>A pparently normal 4 months and actively mobile in the house when admitted for urinary tract infecti...
TREATMENT HITORY  <ul><li>Started on T.Amlodipine 5 mg B.D and T.Eltroxine 150 mcg O.D </li></ul><ul><li>Hyponatremia corr...
ON EXAMINATION <ul><li>Wt - 85 Kg  Ht – 153cms  </li></ul><ul><li>BMI – 36.3 </li></ul><ul><li>Patient sleepy difficult to...
ON EXAMINATION <ul><li>Pulse rate 80/ min and regular. </li></ul><ul><li>Blood pressure 150/90 mm Hg </li></ul><ul><li>Bre...
ON EXAMINATION <ul><li>CVS and RS  : within normal limits  </li></ul><ul><li>SPINE –thoracic spinous process felt very vag...
INVESTIGATIONS <ul><li>Hb 9.4 gm%.  </li></ul><ul><li>TC 8,900  N: 88 L: 10 E: 01 </li></ul><ul><li>Urea 43 mg %  creatini...
INVESTIGATIONS <ul><li>BT 1’ 40”  CT 4’00” </li></ul><ul><li>PT 14 sec (12 sec )  INR 1.21 </li></ul><ul><li>THYROID  FUNC...
INVESTIGATIONS <ul><li>USG abdomen – enlarged gall bladder with thickened wall with multiple calculi 10 – 18 mm . Suggesti...
SUMMARY <ul><li>Acute obstructive cholecystitis </li></ul><ul><li>Elderly  </li></ul><ul><li>Obesity </li></ul><ul><li>Hyp...
Intra op management  <ul><li>NPO of 7hrs. </li></ul><ul><li>No premedication </li></ul><ul><li>Plan – combined spinal epid...
Intra op management  <ul><li>Needle through needle tech used – 27G spinal needle used. </li></ul><ul><li>Free flow of CSF ...
Intra op management  <ul><li>Oxygen through face mask with a flow of 5l/min  </li></ul><ul><li>Epidural infusion  - 0.5% b...
POST op management  <ul><li>Oxygen – flow of 5l/min  </li></ul><ul><li>Epidural infusion – 0.25% bupivacaine + 2mcg/cc fen...
First post op day <ul><li>central line was put </li></ul><ul><li>I/O was maintained – 2100/2017 </li></ul><ul><li>Na-139, ...
Second post op day <ul><li>Patient was hemodynamically stable  </li></ul><ul><li>I/O – maintained 2650/1340 </li></ul><ul>...
 
Third post op day <ul><li>Arterial line removed  </li></ul><ul><li>Patient was comfortable  </li></ul><ul><li>No complaint...
 
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Cholecytectomy

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Cholecytectomy

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

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