anesthetic management of a patient requiring placement of a y- stent presented by 林起翎...
TRANSCRIPT
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Anesthetic management of a patient requiring placement of a Y- stent
Presented by 林起翎 蔡鵠遠 戴家煌
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Brief History
呂 xx, 61 y/o, male
Persistent dry cough since 3 yrs ago. Dyspnea and wheezing on left side down.
Tuberculosis was diagnosed at 署立新竹H. He started to receive regular medical therapy.
CXR showed a granuloma at LUL on OPD follow-up in Aug. 2001.
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He was transferred to Dr. 李元麒‘ s OPD in Oct. 2001.
Echo-guide biopsy was performed. Pathology report revealed tuberculosis.
Sputum culture yielded “Mycobacterium gordonae” in March, 2002.
Chest CT-scan showed persisted granuloma in May, 2002.
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Left main bronchus stenosis was noted. Tracheostomy with left main bronchus dilation was done first on 10/3, 2002.
Stenting for left main bronchus was inserted on 10/21, 2002.
Productive cough with massive sputum was noted after he was discharged on 10/26.
He was admitted again and bronchoscope revealed granulation tissue over distal end of the stent on 11/8.
Arrange Y-stent on 11/11.
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Past History
Old MI at 4 years ago
DM(-), HTN(-), other systemic dz.(-)
No known food or drug allergy
Smoking(+), quitted for 3 yrs
Alcohol(-), betel nut(-)
Family history : non-contributory
Previous operation history : tracheostomy and stenting
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Physical Examination
Consciousness:clear, E4M6V5, easy-looking
Vital signs:BP=115/75mmHg, HR=68/min, RR=20/min, BTR=37.0℃HEENT:conjunctiva:not pale, sclera:anicteric, pupil:isocoric, prompt light reflex L/R:+/+
Neck:supple, JVE(-), LAP(-), carotid bruit(-), tracheostomy(+)
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Chest:L’t side decreased breathing sound
Heart:Regular heart beat, murmur(-), thrill(-), heave(-)
Abdomen:soft and flat, tenderness(-)
Extremities:freely movable, pitting edema(-)
Peripheral pulsation:intact
51.6 kg, 156.4 cm
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Laboratory data
Complete Blood Cell Count (91-11-07) RBC:4.09 Hb:12.7 Hct:36.3 HCV:88.8 MCHC:35 PLT:466 WBC:7360
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Coagulation Profile (91-11-07) PT:11.8/11.5 PTT:39.8/35.5
Blood Biochemistry (91-11-07) Albumin:4.06 Globulin:3.63 Bilirubin(T):0.3 Bilirubin(D):<0.1
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ALP:196 Na:138AST:21 K:3.65ALT:111 Cl:96BUN:10.9 Ca:2.31Creatinine:0.96 Glucose AC:105
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EKG: normal sinus rhythm, Q wave at V1~3
CXR: left apical fibrotic change
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Anesthesia
IVA
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Monitor
EKG , BP , A line , 2 IV line
end-tidal CO2 , pulse oxymeter
Urinary output
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Induction:Fentanyl: 1mlPentothal: 250mgAtracurium: 25mg
Xylocaine: 100mgRobinul: 0.2mg
Nitroderm: 1TTSVitacal: 1amp
Maintenance:
IV propofol infusion: 50~100
mg/h
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Tube without seal air leakage
no gas anesthesia
ventilation efficiency SaO2 PaCO2
Left bronchial stenosis
Problem
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dilated the left main bronchus
check the lesion of left main bronchus
with flexible scope
measure the length to insert Y stent
procedure
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Tube without seal air leakage
no gas anesthesia
ventilation efficiency SaO2 PaCO2
Irritation of airway laryngospasm, bronchospasm
HR BP
Problem
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Remove the granulation tissue and
blood clot
13mm Y stent insertion by rigid
bronchoscope
Adjust Y stent position via tracheostomy tube under flexible
scope guide
procedure
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Apnea: O2 supply via side hole of rigid
bronchoscope
SaO2: 99% 92% in about 5 mins
Irritation of airway laryngospasm, bronchospasm
HR BP : BP up to 180/110
Problem
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Blood clot and debris: lower airway
obstruction
Problem
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T.B. Poor ventilation efficiency
upper airway leakage lower airway obstruction
Apnea during procedure
Surgical airway manipulation is a strong stimulus resulting in bronchospasm
Blood clot and debris: lower airway obstruction
Major Problems
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Discussion
Airway management ventilation laryngospasm and bronchospasm bleeding due to surgical manipulation
Tuberculosis
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Ventilation
Intermittent ventilation
Closely monitor
Avoid continuous positive pressure ventilation increased intrathoracic pressure
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Laryngospasm
Anesthetic depth should be adjusted
If laryngospasm occursRemove the offending stimulusGive 100% oxygen Increase anesthetic depthSuccinylcholine
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Bronchospasm
Intravenous aminophylline or salbutamol
Volatile anesthetic agents and ketamine are also effective bronchodilators
Epinephrine is indicated in life-threatening situations
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Bleeding during surgery
Suction
One lung intubation
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Anesthesia in patients with TB
Delay elective surgical procedures until no longer considered infectious
Perform tracheal intubation in a negative pressure environment
Place a high efficiency particulate air filter between the Y-connector and mask or tracheal tube
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Place bacterial filters on the exhalation limb of the anesthesia delivery circuit
Use a dedicated mechanical ventilator
Postoperative care in an isolation room
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Conclusion
O2 saturation
Anesthetic depth
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Thank you for your attention!