Surgical and Anaesthetic management of a patient with diseased heart is always challenging. Specially it sweats more when the issue is PREGNANCY. It demands skillful and sophisticated handling of the patient. Moreover, when the finding is incidental, a single break of concentration can be fatal.
Kindly leave your comment if you found this helpful ;)
Some of the slides, i hide it from my real presentations for my own reference. Download to see all of them.
Anaestehsia for Cesarean section in a patient with Central Placenta Previa wi...Md Rabiul Alam
Central placenta praevia with percreta carries a very high mortality rate for mother and foetus. Prior multidisciplinary consultation, strategy, contingency plan, skill and expertise can provide optimistic outcomes.
Anesthetic Management of a Patient with Peripartum Cardiomyopathy for LUCSMd Rabiul Alam
Peripartum cardiomyopathy is one of the leading causes of death in obstetric patients since it is usually diagnosed incidentally. Echocardiogram remains the mainstay to diagnose it. Many of the peripheral hospitals are deficient of echocardiogram facilities, so there are possibilities to send the patient to OR without diagnosis. To manage such a case and bring out the success depends on quick detection of the problems & immediate medical intervention after confirming the diagnosis. Obviously, any surgical intervention requires lot of clinical experiences of the whole team, particularly the anesthesiologists.
A Case of Primigravida with 36 weeks of pregnancy with IUD with obstructed la...Faisal Abdullah
This case was presented on weekly seminar of Department of Gynaecology and Obstetrics ( Unit 1) of Faridpur Medical College Hospital, in October 2019, by Intern Doctor Dr. Faisal Abdullah.
my patient is at 38+ weeks of pregnancy comes term prom without labour pain. As it was more than 12 hours of term PROM , Portable USG and Clinical examination was consistent with severe oligohydramnios and we planned for emergency CS
Ultrasound-Guided Transversus Abdominis Plane BlocksMd Rabiul Alam
# Identifying the patients who would benefit from Transversus Abdominis Plane (TAP) blocks # Relevant anatomy associated with TAP blocks # Several techniques to approach TAP blocks # Importance of an interprofessional team
করোনা পরিস্থিতি এবং প্রাথমিক ও মাধ্যমিক শিক্ষা কার্যক্রমMd Rabiul Alam
চলমান ভয়াবহ করোনা পরিস্থিতির তীব্রতা কমে আসার সাথে সাথেই শিক্ষার্থীদের প্রাতিষ্ঠানিক পাঠদান কার্যক্রম শুরু করতে হবে। সে লক্ষ্যে পূর্ব-প্রস্তুতি হিসেবে ডব্লিউএইচও, ইউনিসেফ এবং ইন্টারন্যাশনাল ফেডারেশন অব রেডক্রস অ্যান্ড রেডক্রিসেন্ট সোসাইটিজ কর্তৃক প্রণীত নীতিমালা অনুসরণ করে বাংলাদেশের প্রেক্ষাপটে করণীয় নিয়ে এই বক্তব্য উপস্থাপন করা হয়েছে।
•Don’t make firm predictions
•Do what predictions you do for yourself
•Don’t communicate unless asked
•Don’t be specific
•Don’t be extreme
•Be compassionate and optimistic
Good health Good life: Bankers perspectiveMd Rabiul Alam
Importance, concepts and day to day practicing activities for a banker to remain healthy in order to achieve a goal-directed lifestyle. Reaching the peak of one's own potentials.
Ten objectives: 1. Correct patient, Correct site 2. Safe anesthesia, Proper analgesia 3. Difficult airway, Respiratory problem 4. Preparation for possibility of high blood loss 5. Avoid any allergic or adverse drug reaction 6. Reduce surgical site infection 7. Prevent retention of instrument/ gauze/ mops 8. Accurate labeling of specimens 9. Communicate/ exchange critical patient info 10. Surveillance of capacity, volume, and results
* Fluid resuscitation is mandatory in shock from traumatic haemorrhage * Massive use of resuscitative fluids following injury is now being disputed * Adequate resuscitation is no longer judged by presence of normal vital signs * Normalcy of organ and tissue specific measured values are to be achieved * Search for a single endpoint that works for all trauma patients, is unrealistic * Resuscitate with appropriate fluid, in appropriate amount, at appropriate time
Perioperative considerations for OSA in ChildrenMd Rabiul Alam
Death after tonsillectomy related to haemorrhage may not be preventable. But death due to apnoea is preventable. More considered management is needed since: 10 deaths occurred at home, 2 in PACU and 3 in wards within 24 hrs of operation. These children could be saved by proper monitoring during operation night. Be aware of marked opioid sensitivity; reduce the dose by 50%. Codeine is to be avoided; Use NSAID, Dexamethasone. Develop an improved safety net for these high-risk children. High-risk patient : Nurse = 2 : 1
Anaesthetic Management of Elderly PatientsMd Rabiul Alam
The Scopes of the presentations are: Anaesthetic definition of elderly & workload, Brief on age-related changes, Importance of good anaesthetic evaluation, Practice of functional reserve/capacity assessment, Morbidity and Mortality, Decision of Surgery & Planning of Anaesthesia & Perioperative management in nutshell.
Anaesthetic Management of a Patient with HELLP SyndromeMd Rabiul Alam
HELLP syndrome can be an extremely serious and complex multisystem disorder involving much more than just eclampsia. Special considerations in obstetric and anaesthetic management are necessary, to minimize the morbidity and mortality are associated with this syndrome and its complications.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
2. • Name : Buly Akhter
• Spouse : Snk Shamim Mollah
• Age : 21 years
• Gender : Female
• Religion : Islam
• Marital Status : Married
• Hailing from : Borogoni, Chitolmari, Bagerhat
• Date of Admission : 4th November 2016
Particulars of the Patient
3. • Amenorrhea due to
pregnancy for 35+ weeks
• Lower abdominal pain for
3 days
• Watery vaginal discharge
for 2 days
Chief complaints
4. The patient had been amenorrhoic due to pregnancy
for 35+ weeks. She had complaints of lower
abdominal pain for last 3 days which was initially dull
and intermittent in nature, radiated towards back and
groins, not associated with hardening of uterus.
She also complained about per-vaginal discharge for
last 2 days, which was initially whitish and foul-
smelling then gradually watery in nature.
H/O Present illness
5. With these complaints, she got admitted to this CMH
in ORs’ Family Gynae ward. After 2 days of her
admission, she developed severe respiratory
difficulties in the ward which was treated by O2
inhalation, nebulisation and diuretics, but did not
improve significantly.
Then, she was shifted to PACU from the Gynae ward
immediately.
H/O Present illness (Continued)
6. There was NO history of -
• Diabetes Mellitus
• Systemic Hypertension
• Bronchial asthma
• Pregnancy Induced Hypertension
• Gestational Diabetes Mellitus
• Tuberculosis
• Rheumatic fever
H/O Past illness
7. Nothing contributory
Drug History
The patient was on Iron, Vitamin B complex &
Calcium supplementation during her pregnancy. She
was on irregular antenatal check up.
Treatment History
Nothing contributory
Family History
Low middle class
Socio-economic History
8. Married for : Two and half years
Para : 0
Gravida : Primi
Obstetric History
Menstrual period : 5 days
Menstrual cycle : 28 days
Menstrual flow : Regular
LMP : 3 Mar 2016
EDD : 10 Dec 2016
Menstrual History
9. • Appearance : Anxious
• Built : Average
• Nutritional status : Average
• Decubitus : Propped up
• Anaemia : Mild
• Cyanosis : Absent
• Jaundice : Absent
• Clubbing : Absent
General Examination
10. • Koilonychias : Absent
• Leukonychia : Absent
• Oedema : Absent
• Dehydration : Absent
• Pulse : 120 b/min
• BP : 130/80 mm of Hg
• Temperature : 98.4˚F
• Lymph node : Not palpable
• Thyroid gland : Not enlarged
General Examination (Continued)
11. Systemic Examination
Respiratory system:
Inspection Palpation Percussion Auscultation
• Shape: Normal
• Chest
movement:
symmetrical on
both side
• No visible scar
mark
• No visible
engorged vein
• Respiratory
rate: 28/min
• Trachea:
centrally placed
• Apex beat:
normal
• Chest
expansibility:
symmetrical on
both side
• Vocal fremitus:
normal
• Percussion:
Resonant
• Cardiac
dullness:
Normal
• Vesicular
breath
sound with
Bilateral
basal
crepitation
on both
lung
12. Systemic Examination (Continued)
Cardiovascular system:
Inspection Palpation Auscultation
• Not done • Apex Beat: Left
5th inter costal
space
• Thrill: Present in
apical & left
parasternal area
• 1st & 2nd heart
sound: Normal in
all areas
• Murmur: Mid
diastolic murmur in
mitral area and
Early diastolic
murmur in left
lower parasternal
area
13. Per-abdominal Examination:
Inspection Palpation Percussion Auscultation
• Normal in
shape
• Umbilicus:
Centrally
placed
• Relaxed
• Symphysio
fundal height:
Reveals 36
weeks of
pregnancy
• Abdominal
girth: 115 cm
• Fetal
movement:
present
• Normal • Fetal heart
rate: 148
beat/min
Systemic Examination (Continued)
14. Per-vaginal Examination:
• Cervix : Soft
• OS : 1.5 cm dilated
• Presentation : Cephalic
• Station : 0
• Movement : Regular
Systemic Examination (Continued)
15. Salient Features
A 21-years-old primi reported to Gynae OPD of CMH
Dhaka with the complaints of amenorrhea due to
pregnancy for 35+ weeks. She had complaints of lower
abdominal pain for last 3 days which was initially dull and
intermittent in nature, radiated towards back and groins,
not associated with hardening of uterus. She also noticed
per-vaginal discharge for last 2 days, which was initially
whitish and foul-smelling, then watery in nature.
16. With those complaints, she got admitted in the ORs’
Family Gynae ward. After 2 days of her admission, she
developed severe respiratory distress in the ward which
was treated by O2 inhalation, nebulisation and diuretics;
but did not improve significantly.
Then, she was shifted from ward to PACU immediately.
The patient was thoroughly examined in PACU and was
found to have tachycardia and tachypnoea.
Salient Features (Continued)
17. Her CVS examination revealed thrill and mid-diastolic
murmur on apical area and early diastolic murmur on
parasternal area. On respiratory system examination,
there were basal crepitations on both lungs fields.
Her per-abdominal and per-vaginal examination revealed
36 wks of pregnancy with labour. Her other systems
shown no abnormality. Then, the patient was referred to
Cardiologist for further cardiac evaluation.
Salient Features (Continued)
19. Differential diagnosis
Primi gravida with 35+ weeks of
pregnancy with PROM with preterm
labour with Fluid over load
Primi gravida with 35+ weeks
of pregnancy with PROM with
preterm labour with Pneumonia
24. Ultrasonogram of Pregnancy profile:
Investigations (Continued)
Uterus is gravid containing single living foetus with
regular cardiac pulsations and normal foetal movement
Foetal presentation: Cephalic
EDD: 4 Dec 2016 ± 1 week
Placenta: Anterior, away from os
Gestational age: 35 wks & 2 days
25. Figure: ECG tracing showing P mitralae with Tacycardia
Electrocardiogram:
Investigations (Continued)
Sinus tachycardia
P mitralae
26. Rheumatic heart disease
Moderate mitral stenosis (MS)
Mitral vulve area: 1.2 cm2
Moderate mitral regurgitation (MR)
Mild to moderate aortic regurgitation (AR)
Severe pulmonary hypertension (PASP: 68 cm of H2O)
Good left ventricular function (LVEF: 60%)
Echocardiogram (bed-side):
Investigations (Continued)
27. Confirmatory diagnosis
Primi gravida with 35+ weeks pregnancy with
PROM with preterm labour with moderate MS
and MR with mild to moderate AR with severe
pulmonary hypertension
28. Decision of Emergency Surgery
Immediately after confirmation of the
diagnosis, decision of performing the
emergency Cesarean section was taken
30. Anaesthetic considerations
Anaesthetic management for an emergency
Caesarean section with double valve heart disease
which was diagnosed just prior to the operation.
Administering anaesthesia in a compromised
patient with respiratory distress and basal
crepitations due to valvular heart disease and
pulmonary hypertension which were not
optimised by preoperative treatment.
31. Prevention and management of intra-operative
complications due to pulmonary hypertension.
As the mother was on preterm labour with
PROM, so there were great concerns of safety of
two lives on distress.
Anaesthetic considerations
(Continued)
32. Pre-anaesthetic assessment
Pre-anaesthetic check-up was done with detailed
history, proper clinical examination and
assessment of the investigation reports.
Immediately after the check-up in PACU patient
was shifted to Operation Theatre.
33. Pre-anaesthetic assessment
(Continued)
Considering her preterm labour with PROM and
stat diagnosis of moderately advanced valvular
heart disease and severe pulmonary hypertension,
the patient was assessed as:
NYHA classification : NYHA class - IV
Airway assessment : Mallampati class - II
ASA Grading : ASA Grade - IV (E)
Patient was planned for emergency Caesarean
section.
34. Propped up position
O2 inhalation @ 2-4 l/min
Airway management eqpt
Different sized ET tube
Gum elastic bougie
Breathing circuits
Drugs for GA and
emergency carts
Preparation for Anaesthesia
35. Defibrillator
Syringe pumps
Large-bore 16 gauze I/V line was
established through left cephalic
vein
Inj. Frusemide 20 mg I/V stat given
Urinary catheterization was done
Paediatric team was brought in the
OT.
Preparation for Anaesthesia
(Continued)
36. A central venous catheter line was established
through the right internal jugular vein (IJV) with 7
Fr, 20 cm central venous catheter.
Preparation for Anaesthesia
(Continued)
37. An intra-arterial line was established in the right
radial artery to monitor the continuous invasive
blood pressure.
Preparation for Anaesthesia
(Continued)
38. Inj. Metoclopramide (10 mg)
Inj. Ranitidine (50 mg)
Inj. Ceftriaxone (1 gm)
Inj. Fentanyl (100 mcg)
Premedication
Medications given on the OT table before operation
39. Induction was done by Inj.
Thiopentone Sodium
(300mg)
Intubation was done after
adequate muscle relaxation
with Inj. Suxamethonium
(100mg)
Induction and Intubation
The patient was reassured with compassion to allay
her fear and anxiety
40. Anaesthesia was maintained with O2 and
intermittent Midazolam.
Adequate analgesia was ensured with intravenous
Fentanyl (150 mcg)
Adequate muscle relaxation was provided with
intermittent NMBA (Inj. Vecuronium Bromide)
Intravascular volume was kept optimised by Inj.
Frusemide.
Per-operatively, only 200 ml of Hartmann solution
was given.
Maintenance
41. Control of HR & rhythm: By Inj Esmolol
Maintaining CVP within 5-6 cmH2O by optimum
volume of IV Fluids (only 200 ml) and judicious use of
diuretics (Inj Frusemide 20 mg)
Emergency medicines were kept ready to combat any
unforeseen complications which include - Inj GTN,
Adrenaline, Noradrenaline, etc.
Measures to overcome
Anesthetic challenges
42. Further deterioration of PAH was
managed by:
100% O2 (to prevent hypoxia)
Avoidance of Halothane and N2O
Adequate analgesia by Inj. Fentanyl (150 mcg)
Moderate hyperventilation (to prevent of acidosis)
Low-dose infusion of Inj. Dobutamin to reduce
Pulmonary vascular resistance
Measures to overcome Anesthetic
challenges (Continued)
43. Routine monitoring of
ECG and SpO2.
Continuous ETCO2 was
monitored and kept below
30 mmHg to prevent
further deterioration of
pulmonary hypertension.
CVP was monitored to
restore normal volume
status.
Intra-operative monitoring
44. Beat-to-beat IBP was monitored through arterial line.
Urine output was monitored (50 ml in 45 minutes).
Per-operative ABG analysis was done and kept within
normal ranges.
Intra-op monitoring (Continued)
45. A male baby with 2 kg body weight was delivered per-
abdominally and after immediate resuscitation at the OT
by the attending Paediatric Team, the baby was shifted
to NICU for further evaluation and management.
Baby resuscitation
46. The conventional reversal and emergence usually
provokes tachycardia and agitation which are
considered as the detrimental factors for the patients
with VHD and PAH. Moreover, this patient needed a
less stress and pain free reversal. So, she was not
reversed on the OT table and kept on elective
mechanical ventilation, then shifted to CCC, with an
endotracheal tube in situ.
Issue of Reversal
47. Postoperative Management
In the CCC, all invasive and non-invasive monitoring
were continued.
MAP was kept within 70-90 mmHg.
Cardiac output was monitored by flow trac module.
Analgesia & sedation was provided with Inj Fentanyl
and Inj Midazolam.
Fluid maintenance was ensured by 0.45% DNS @ 70
ml/hr
The patient was on pressure-supported ventilation for
48 hours in the CCC with measured VT of 7 ml/kg.
48. Postoperative Management
(Continued)
On 2nd POD, she was
extubated and shifted to Post-
Anaesthesia CU from CCC.
On 5th POD, a follow-up
Echo was done & her cardiac
status was found comparable
with the pre-existing
condition.
On 6th POD, the patient was
shifted from Post-Anaes CU
to Gynae ward.
49. Postoperative Management
(Continued)
On 7th POD, the stitches of the surgical wound were
removed.
On the same day, Cardiologist visited the patient and
prescribed Tab. Furosemide+Spironolactone, Tab.
Metoprolol, Tab. Bosentan & Tab. Phenoxymethyl
Penicillin and she was advised to come for follow-up
after 4 weeks.
On the same day, the patient was discharged from CMH
Dhaka.
51. Parameter
Average changes from
non-pregnant values (%)
Plasma volume +45
Cardiac output +40
Heart rate +15
Stroke volume + 30
Systemic vascular resistance -15
Oxygen consumption +20
Renal blood flow and GFR -50
Haemodynamic changes in
normal pregnancy
52. Increases significantly by 5 weeks gestation.
At the end of 1st trimester : CO increases by 40%
At the end of 2nd trimester : Increases by 50%
Immediately postpartum : Increases by 75%
Overall, cardiac output get increased by 40% during
pregnancy period from non-pregnant values.
It has a significant effect on maternal physiology and
pharmacology during anaesthetic procedure.
Critical periods
Cardiac output
53. Incidence of valvular heart disease in developed
country is 2.5%, amongst all valvular heart
disease.
Mitral valve prolapse is most common affecting
1% to 2.5% of all population of developed
countries.
Most commonly women of child bearing ages are
affected.
Incidence of Valvular Heart
Disease
54. Pregnancy can cause following cardiac complication
in a patient with valvular heart disease:
Atrial fibrillation
Pulmonary oedema
Pulmonary hypertension
Right ventricular failure
Congestive cardiac failure
Bacterial endocarditis.
Effect of Pregnancy on
Valvular heart disease
55. Effect of Valvular heart disease
on Pregnancy
Valvular heart disease has some detrimental effect on
pregnancy it includes:
Abortion
Preterm labour
Intra uterine growth retardation
Congenital heart disease in baby – 5%
Intrauterine fetal death
56. Anaesthetic challenges
(Mitral stenosis)
Challenges Management
Sinus tachycardia, atrial fibrillation
Cardioversion or IV administration
of Beta blockers, Ca++ channel
blockers, digoxin
Marked increase in central blood
volume
Judicious use of IV fluid
Drug induced decrease in systemic
vascular resistance
Use of sympathomimetic drug
(Phenylephrine)
Pulmonary Hypertension and right
heart failure
Avoidance of hypoxaemia and
hypercarbia, Ionotropes,
Pulmonary vasodilating drugs.
57. Anaesthetic challenges
(Mitral & Aortic regurgitation)
Challenges Management
Bradycardia Avoid volume overload
Increased systemic
vascular resistance
After load reduction with a
vasodilator(Nitroprusside)with or
without inotropes, maintenance of
cardiac output by modest increase in
heart rate.
Myocardial depression Judicious use of drugs.
58. Anaesthetic challenges
(Pulmonary Hypertension)
Challenges Management
Right heart
failure
• Reduce RV after load
• Avoid hypoxemia, hypotension and
inadequate RV preload
• Continuous use of pulmonary
vasodilator s (Ca channel blockers,
Inhaled NO, GTN)
Pulmonary
Oedema
Use of diuretics.
Hypoxia,
Hypercarbia,
acidosis
Use of 100% oxygen and judicious use of
inhalation anesthetics and sedatives
59. Choice of Anaesthesia
Condition Choice of Anaesthesia
NYHA class 1 & 2
Normal vaginal delivery, forceps
delivery with epidural analgesia
NYHA class 3 & 4 LUCS under G/A
It is better to avoid spinal anaesthesia except MR
60. Postoperative Care
Risk of:
Sudden death in early postoperative period due to
worsening of pulmonary hypertension
Pulmonary oedema and Right heart failure
Pulmonary thromboembolism and Dysrhythmias
Hypoxaemia, hypercarbia and respiratory acidosis due
to pain & hypoventilation
61. Postoperative Care (Continued)
These can be managed by:
Intense cardiovascular monitoring
Proper oxygenation, mechanical ventilation (if
necessary).
Maintenance of hemodynamic variables at acceptable
levels
Optimal pain control
62. Surgical and Anaesthetic management of a patient with
diseased heart is always challenging. Specially it sweats
more when the issue is PREGNANCY.
It demands skillful and sophisticated handling of the
patient. Moreover, when the finding is incidental, a
single break of concentration can be fatal.
Conclusion