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This document presents the case of a 35-year-old male patient who presented with swelling and pain in the floor of his mouth for 4 days. He was diagnosed with Ludwig's angina and underwent incision and drainage surgery under awake fiberoptic intubation. Post-extubation, the patient experienced airway obstruction and respiratory distress requiring emergency tracheostomy. He developed negative pressure pulmonary edema but stabilized in the ICU. On post-op day 2, the patient exhibited agitated behavior and pulled out his tracheostomy tube due to underlying alcohol dependence syndrome.
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3) The primary outcome was 28-day mortality. Mortality at 28 days was lower in the prone position group compared to the supine position group, suggesting prone positioning improves survival in severe ARDS.
Post tonsillectomy bleed & anesthesia considerations
A 10-year-old boy presented with complaints of oral bleeding and vomiting after undergoing a tonsillectomy 2 days prior. On examination, he was tachycardic and hypotensive with delayed capillary refill time, indicating possible hemorrhagic shock from post-tonsillectomy bleeding. The plan was for the boy to undergo general anesthesia for cauterization or ligation to control the bleeding. Anesthetic considerations included the risk of hypovolaemic shock, pulmonary aspiration, and a potentially difficult airway. A modified rapid sequence induction was performed while maintaining cricoid pressure to secure the airway and address the bleeding surgically.
initial assessment of critically ill patients(PRESENTED AT IMA HOUSE,CUTTACK)
1. A 52-year-old male presented with severe breathlessness and sweating for 5 hours and was admitted to the ICU in a critically ill state.
2. Initial assessment and resuscitation focused on the ABCDE approach to address airway, breathing, circulation, disability and exposure/environment. Basic investigations were sent.
3. The patient was diagnosed with an acute exacerbation of COPD. He was treated with oxygen, steroids, bronchodilators and antibiotics. Due to worsening, non-invasive ventilation was added and the patient showed gradual improvement.
Ventilation Powerpoint
The document discusses various topics related to the respiratory system including:
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2. A case study of a patient presenting with respiratory distress and hemoptysis.
3. Review of anatomy and physiology of the respiratory system.
4. Nursing assessment and management of patients with respiratory problems including diagnostic tests, oxygen therapy, and mechanical ventilation.
Atls review and burn
1. A 25-year-old male patient arrived at the ED after a motorcycle collision with signs of airway compromise, reduced breathing, and bleeding requiring immediate intubation, chest tube placement, and fluid resuscitation to address life-threatening injuries.
2. Management of major trauma involves a primary survey addressing the immediate ABCDE threats with airway control, breathing support, hemorrhage control, and disability assessment as the highest priorities.
3. Burn management similarly focuses first on securing the airway, assessing for inhalation injury, and aggressively resuscitating to prevent shock from ongoing fluid losses through the burned skin.
ARDS (Case study)
This is an ARDS case study presentation done by a group of Respiratory care students in UOD:
Aziza AlAmri, Fay AlBuainain, Mashail AlRayes, Nora AlWohayeb, Salma Almakinzi .
The original case study:(http://www.researchgate.net/publication/50399037_Acute_Respiratory_Distress_SyndromeA_Case_Study)
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This document provides information about epidural anaesthesia. It discusses the history and development of epidural techniques. It then describes the anatomy of the spinal cord, meninges, epidural space and sacral canal. It explains the mechanism of action of epidural anaesthesia and factors affecting drug distribution and elimination. Finally, it outlines the physiological effects of epidural anaesthesia on the cardiovascular, respiratory, gastrointestinal, genitourinary and neuroendocrine systems.
Review roleija originalstudy 2
This document provides guidelines for peer reviewers to evaluate original articles submitted to the Indian Journal of Anaesthesia. It includes a checklist of criteria to assess for various sections of the article like the title, abstract, introduction, methods, results, discussion, and references. Reviewers are asked to evaluate if the manuscript includes the necessary components for each section, follows ethical guidelines, and uses appropriate statistical analyses and language. The goal is to promote high-quality scientific writing while maintaining constructive feedback to authors.
Review roleija originalstudy
This document provides guidelines for peer reviewing original articles and clinical investigations submitted to the Indian Journal of Anaesthesia. It outlines key areas to check such as headings, title, abstract, keywords, and main sections of the article including introduction, methods, results, discussion, and conclusion. Reviewers are asked to check that appropriate approvals and consent were obtained, the study design and statistical analysis are sound, results are clearly presented, discussions are supported by citations, and references are formatted correctly. Guidelines also cover reviewing images, illustrations, videos andlegends.
Mcquade2017
This randomized crossover study compared end-tidal oxygen (ETo2) levels during preoxygenation with a bag valve mask (BVM) alone and with supplemental nasal cannula (NC) oxygen at different flow rates. Healthy volunteers underwent 3 minutes of preoxygenation with a BVM alone or a BVM with NC at 0, 5, 10, or 15 liters per minute. The primary outcome was ETo2 after 3 minutes of preoxygenation. NC flows of 0 and 5 L/min resulted in significantly lower ETo2 levels compared to the other groups. There were no differences in ETo2 between the BVM alone, NC 10 L/min, and NC 15 L/
Narasingam (1)
This document summarizes the case of a 72-year-old male patient who presented with injection abscess in his left gluteal region, lower limb cellulitis, and sepsis. He had a history of hypertension and diabetes. He underwent incision and drainage of the abscess 10 days prior and then developed fever, pain, swelling, and breathlessness. He was found to have pleural effusion, abdominal collections, and acute kidney injury. He underwent further surgical drainage and was managed in the ICU with antibiotics, fluid resuscitation, oxygen supplementation, and thoracic epidural anesthesia for pain management. His condition stabilized and he was successfully weaned off the ventilator the next day.
Arhi morb
Dr. Yasha, Dr. Tina, Dr. Arthi, and Dr. Janani treated a 55-year-old female patient with a retroperitoneal mass, septic shock, acute kidney injury (AKI), and severe metabolic acidosis. She presented with a history of diarrhea, vomiting, and decreased urine output. Imaging showed dilated bowel loops and ascites consistent with small intestinal obstruction. The patient was intubated, started on vasopressors, and underwent an exploratory laparotomy which revealed a retroperitoneal mass causing obstruction. Despite resuscitative measures including hemodialysis, bicarbonate infusion, and escalating vasopressors, her condition deteriorated and she
Comp+ breathing
Compliance refers to the change in lung volume for a given change in pressure. It is the reciprocal of elastance. Compliance of the respiratory system (CRS) depends on the interaction of lung compliance (CL) and chest wall compliance (CW). CL is affected by lung volume, surface tension, blood volume, and edema, while CW is affected by posture, obesity, costal cartilage ossification, and scarring. Dynamic compliance includes the effects of resistance and hysteresis during breathing, while static compliance is measured without gas flow at equilibrium. The difference between static and dynamic compliance reflects airway resistance.
Arthi
The document discusses temperature monitoring and thermoregulation in the human body. It explains that body temperature depends on heat production and heat loss. The core body temperature is normally 36-37.5°C and vital organs must operate within this optimal range. When core temperature rises above 37°C, the hypothalamus activates mechanisms like sweating and vasodilation to increase heat loss and cool the body. When core temperature falls below 37°C, shivering and vasoconstriction occur to generate more heat and reduce heat loss. The hypothalamus precisely regulates these responses through negative feedback to maintain core temperature. General anesthesia disrupts all elements of thermoregulatory processing and control, which can lead
Journal 2
1. The document summarizes a journal club presentation which discussed different types of articles published in journals including editorials, review articles, original research articles, case reports, and letters to the editor.
2. It provided details on what constitutes each type of article and their purposes. For example, it stated that an editorial can critique other articles, review recent topics, and deliver concise messages from the editor.
3. The document also discussed other topics like how impact factor is calculated to measure a journal's importance, how to write a literature review, and the components of original research articles and case reports. It provided guidance on writing different types of academic articles and participating in journal club discussions.
Untitled
The study compared two dose regimens of tranexamic acid (TA) for reducing blood loss in hip surgeries: 1) a single 10 mg/kg bolus before incision, and 2) a 10 mg/kg bolus followed by a 1 mg/kg/hr infusion for 4 hours post-op. The bolus+infusion group saw significantly less blood loss at 6 hours post-op and higher hemoglobin levels at 6 hours. Both TA groups required fewer blood transfusions compared to the placebo group. The authors conclude that continuing TA infusion post-op is more effective at reducing early blood loss than a single pre-op bolus alone.
Arthi (1) copy
The document discusses thermoregulation and temperature monitoring. It summarizes that the hypothalamus regulates body temperature through heat production and loss mechanisms like radiation, conduction, convection, and evaporation. General anesthesia affects all aspects of thermoregulation by inhibiting responses like vasoconstriction and shivering that normally maintain core body temperature. This can lead to perioperative hypothermia if not prevented through measures like warmed fluids and surgical drapes.
Untitled
The study compared two dose regimens of tranexamic acid (TA) for reducing blood loss in hip surgeries: 1) a single 10 mg/kg IV bolus before incision, and 2) a 10 mg/kg IV bolus followed by a 1 mg/kg/hr infusion for 4 hours post-op. The infusion group saw significantly less blood loss at 6 hours post-op compared to bolus or placebo groups. Both TA regimens reduced 24-hour drain blood loss and need for blood transfusions compared to placebo. The authors conclude that a bolus plus infusion of TA maintains therapeutic levels longer to more effectively inhibit fibrinolysis and reduce early post-op bleeding in hip surgeries
Indian j anaesth60119-6203009_171350
- The document describes a study that assessed whether the antifibrinolytic drug tranexamic acid (TA) could reduce blood loss in patients undergoing surgery for head and neck cancer.
- 240 patients were randomly assigned to receive either TA or a placebo during surgery. Blood loss, need for transfusions, and coagulation parameters were compared between the groups.
- While post-operative blood loss was lower in the TA group, intraoperative blood loss and need for transfusions were similar between groups. Coagulation parameters indicated a hypercoagulable state in both groups.
Referral pain and phantom pain
1. Referred pain is pain perceived in a location other than where the painful stimulus originated. Common examples include pain from a heart attack referring to the left arm.
2. There are several proposed theories to explain referred pain, including axon reflex theory of shared nerve fibers and convergence-projection theory of shared spinal pathways. More recent theories involve central sensitization in the spinal cord.
3. Phantom limb pain refers to painful sensations felt in an amputated or missing limb. Approximately 60-80% of amputees report phantom limb sensations, with most being painful. Treatment is challenging but may involve drugs, nerve blocks, or spinal/brain stimulation in difficult cases.
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The document discusses various patient positioning techniques used in anaesthesia and their goals, risks, and complications. It describes positions like supine, lithotomy, prone, lateral decubitus, and their effects on cardiovascular and respiratory systems. Common risks include nerve injuries, pressure sores, compartment syndrome, and visual complications. Careful patient assessment, padding of pressure points, monitoring for nerve injuries are emphasized. Position changes should be gradual and extremities checked regularly during long procedures to prevent injuries.
Paediatric breathing systems
- Dr. Phillip Ayre developed the T piece breathing system for children in 1937 after losing his own child to high gas pressures during anesthesia.
- Breathing systems for pediatric use have since undergone many modifications to suit different patients and situations. They aim to minimize resistance, dead space, and work of breathing while allowing for controlled or spontaneous ventilation.
- Common pediatric breathing systems include the T piece, Jackson Rees, Mapleson D and Bain circuits, and pediatric-modified circle systems. Low fresh gas flows can be used with these systems to decrease costs and heat/fluid loss while maintaining normocarbia. Proper selection and setup of the breathing system is important for safe anesthesia in children.
Paediatric anaesthesia practical tips
This document provides an overview of pediatric anesthesia considerations. It discusses key differences in pediatric physiology compared to adults, including higher oxygen consumption and metabolic rate in infants, differences in the cardiovascular and respiratory systems, and immature hepatic and renal function in young children. It also reviews airway anatomy variations, appropriate tube and LMA sizes, and pharmacokinetic considerations for commonly used anesthetic drugs in pediatrics. The principles of maintaining temperature, adequate oxygenation and IV fluids are emphasized for safe pediatric anesthesia.
Oxygen therapy
The patient may be developing CO2 narcosis due to suppression of hypoxic drive by high FiO2. Reduce FiO2 and consider non invasive ventilation. Monitor ABG.
Oxygen dissociation curve
This document discusses the oxyhemoglobin dissociation curve. It provides background on oxygen transport by hemoglobin and factors that influence the curve. Key points include:
- Hemoglobin transports oxygen through cooperative binding of up to 4 oxygen molecules per heme-globin molecule.
- The sigmoidal dissociation curve arises from cooperative binding - as one oxygen binds it increases affinity for others.
- Factors like pH, CO2, temperature can shift the curve left or right, altering oxygen unloading in tissues.
- Fetal hemoglobin has a higher affinity, helping oxygen transfer to the fetus in utero. Myoglobin also has higher affinity and acts as an oxygen storage in muscle.
Pain the basics
Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It is classified in several ways including by type (nociceptive, neuropathic, psychogenic), duration (acute, chronic), and location. Theories of pain transmission include the specificity, pattern, and gate control theories. Pain signals travel along A-delta and C fibers to the spinal cord and then ascend to the brain via the spinothalamic tract. Descending pathways from the brainstem modulate pain transmission through the release of neurotransmitters like serotonin and norepinephrine.
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Presentation1
- 1. CASE PRESENTATION OF LUDWIG’S ANGINA – INCISION & DRAINAGE -Dr .Arthi -Dr.Madhula OT CONSULTANT- Dr .Gayathri(ASSO.PROF)
- 2. Name – Harikrishnan Age – 35/M Brief History Past History No h/o URI,LRI No previous surgical history c/o swelling & pain in floor of mouth for 4 days. h/o difficulty in mouth opening,h/o difficulty in protruding tongue, Trismus present. Recently Diagnosed DM on Insulin Recently Diagnosed AKI No other Comorbities
- 3. ON EXAMINATION GPE VITALS SYSTEMIC EXAMINATION Weight-50kg Height-161cm Moderately built Venous access -good HR-74/min BP-120/80mmHg Spo2-98%RA Temperature- afebrile CVS-S1S2+ RS-B/LAE+ P/A-SOFT CNS-GCS- 15/15,No neurological Deficit
- 4. AIRWAY EXAMINATION Mouth opening – Restricted(1.5cm) Nasal patency -patent Neck movement –Restricted, no edema Mallampatti – not able to access Mentohyoid -less than 2 FB Upper lip bite test – (-1) Teeth – caries tooth+,NLT
- 5. INVESTIGATIONS Hb -13.7gm/dl Total count- 20700 Platelet count -2.65 lakh RBS -198 Urea -50 Creatinine - 2.09 Sodium -141 Potassium -3.6 Chloride -108 CXR -Normal ECG - Normal
- 6. PERI-OP RISK FACTORS PATIENT FACTORS Ludwig’s angina Compromised airway Sepsis Diabetic AKI SURGICAL FACTORS Infection Bleeding Distortion of plane Spread of abscess Post surgical edema Extension of resection ANAESTHESIA FACTORS Difficult airway Difficult extubation Risk of aspiration Airway obstruction
- 7. In Pre-op room,patient was assessed & history noted. Prepared the patient for awake fibreoptic Nasal packing was done with 2% lignocaine with adrenlaine Nebulisation given with 4% lignocaine with adrenaline IV line secured with 18g venflon. Shifted the patient inside ot,monitors connected,baseline vitals noted HR – 102/min, BP – 120/70mmHg,Spo2-100% Midaz -1mg, Glyco – 0.4mg,Buprenorphine -90mcg Transtracheal block was given with 2%lignocaine
- 8. Awake fibreoptic nasal intubation done with 7 size ET Tube fixed with 19cm. Propofol – 100mg, vec – 4mg given,dexa-8mg, Agent – sevoflurane 2,O2 & N2O on low flow 500ml fluid on flow Hemodynamics were stable throughout surgery At the end of surgery,agent cut off, patient started breathing, reversal given, nasopharyngeal airway 7 size introduced, patient opened the eyes, swallowing reflex present, extubation done. Patient was monitored on ot table for 15 minutes.Throughout patient was conscious,oriented,vitals stable. Nasoppharyngeal airway was kept.airway removed on patient request not able to tolerate
- 9. After extubation,patient was shifted ,nasopharyngeal airway removed, suddenly patient has some abnormal breathing noticed,then shifted the patient to on table become hypoxic may be due to airway obstruction,spo2 falls to 70% Mask ventilation done with 100% oxygen.CPAP was given. Nasopharyngeal airway was introduced,from that blood &mucous with pus were spilling out,then we could not ventilate,we could not able to intubate we started getting ready for emergency tracheostomy fastrack. Consent for tracheostomy obtained. Explained the condition to patient attenders about patient condition Immediate Tracheostomy done
- 10. After Tracheostomy ,ABG done Diagnosed Respiratory acidosis On auscultation-B/L creps + Mask ventilation done with 100%oxygen,ventilator parameters settings done with PEEP – 8. peak airway pressure -34 ,propofol-30,midaz-2mg, Continous ooze from tracheostomy site Fibreoptic was done to rule out source of bleeding , Suspect of negative pressure pulmonary edema ,?aspiration Morphine – 6mg, Lasix – 20mg given. Before shifting patient to ICU, patient sedated with propofol 40, midaz 3mg, On auscultation – B/L creps +, PH-7.24,pco2-61,po2-90,Fio2-100%
- 12. After shifting to ICU, ABG repeated PH -7.23, pco2 – 48, po2-93,Fio2-40,HCo3-31 Hemodynamics stable. Repeated CXR PH -7.41, pco2 – 41, po2-93,Fio2-40,HCo3-31
- 16. On post op day 1,morning ABG done Hemodynamics stable, on auscultation – minimal creps present. At 12pm – patient was extubated in ICU,ABG repeated, Hemodynamics stable, On auscultation- B/LAE+, no creps,no secretions. PH-7.46,pco2-39,Hco3-27,po2-153 PH-7.58,pco2-38,HCO3-35PO2-58
- 17. On post op day 2,patient shifted to A0 post op ward. On morning,patient was not cooperative,went out from ward,mild disoriented, agitated behaviour,patient pulled tracheostomy tube, chronic alcoholic ,got psychiatry opinion. Psychiatry opinion – Alcohol dependence syndrome,adviced Inj.Thiamine,Inj.Haloperidol Patient was restrained in bed.Tracheostomy care was given. Hemodynamics stable.
- 20. DISCUSSION Ludwig’s angina is a life threatening condition. Airway obstruction may lead to negative pressure pulmonary edema
- 21. THANK YOU