One lung Ventilation (Slide Show)

One lung Ventilation

How To Read a Chest X-Ray ( Click on Heading )

Patient Control Analgesia

In a hospital setting, a PCA refers to an electronically controlled infusion pump that delivers an amount of intravenous analgesic (usually an opioid) that is set by the patient.PCA can be used for both acute and chronic pain patients. It is commonly used for post-operative pain management, and for end-stage cancer patients.

Narcotics are the most common analgesics administered through PCAs. It is important for caregivers to monitor patients for the first two to twenty four hours to ensure they are using the device properly

Hemolytic transfusion reactions

Hemolytic transfusion reactions (HTR)

v  Accelerated clearance or lysis of red cells in the transfusion recipient. Usually  d/t immunological incompatibility b/w blood donor and the recipient

A. C LASSIFICATION WITH RESPECT TO TIME OF OCCURRENCE

v  Acute  (AHTRs )
                During or within 24 hours of transfusion

v  Delayed ( DHTRs )
                After 24 hours of transfusion.( 5-7 days )

Signs and Symptoms of Acute HTR

Conscious patient

Abrupt onset                     Nausea, Vomiting                          

Anxiety                                                Shock   

Facial flushing                   Oliguria                               

Fever, chills                       Hemoglobinuria

Pain in back or flanks     Bleeding

                                                Dyspnoea

Under GA

•          Hypotension

•          Hemoglobinuria (This may be masked in patients

  undergoing GU surgeries due to hematuria)

•          Undue bleeding from surgical site

•          Complications of AHTRS

Renal failure  :- 36 %

Thrombus formation  in renal arterioles

DIC :- 10 %

Immediate Mx of suspected AHTRs

A. Action for nursing staff

In presence of fever > 38 ⁰ C and / or any S/s

•       Stop the transfusion

•       Check the pt identity and unit transfused

•       Save any urine the pt passes

•       Monitor pulse, BP and temp at 15 min interval

B. Action for medical staff

1. Isolated fever / fever & shivering, stable observations, correct unit given :- FNHTR  = Paracetemol 1 g orally , observe  P, BP and T every 15 min for 1 hr, then hourly. If no  improvement call hematology medical staff

2. Fever with pruritis, urticaria :- Allergic transfusion reaction = Chlorpheniramine 10 mg iv

3. Any other s/s, hypotension, incorrect unit :- AHTR = discontinue transfusion, N saline to maintain urine output   1ml /kg / h. full and continuous monitoring

Mx of AHTRs

v  Take immediate note and inform blood bank

v  Seek help immediately from skilled anaesthetist or emergency team

v  Complete the transfusion reaction form and appropriately record the following

•          Type of transfusion reaction

•          Time after the start of transfusion to the occurrence of reaction

•          Unit No. of component transfused

•          Volume of the component transfused

Investigation of suspected AHTRs

Send the following lab investigations:

                Immediate post transfusion blood samples (clotted and  EDTA) for:

Ø  Repeat ABO & Rh (D) grouping

Ø  Repeat antibody screen and crossmatch

Ø  Direct antiglobulin test

Ø  Complete blood count (CBC)

Ø  Plasma hemoglobin

Ø  Coagulation screen

Ø  Renal function test (urea, creatinine and electrolytes)

Ø  Liver function tests (bilirubin, ALT and AST)

                Blood culture in special blood culture bottles

                Blood unit alongwith BT set

                Specimen of patient’s first urine following reaction

Mx of confirmed AHTRs

Maintain adequate renal perfusion by

-          Fluid challenges

-          Frusemide infusion

-          If hypovolumic – dopamine infusion

Transfer  to high dependency area

 Repeat coagulation and biochemistry screens ever 2- 4 hrly

If urinary output not maintained seek expert renal advice

Hemofiltration or dialysis m/b required for acute tubular necrosis

DIC development – component therapy may be required

l  DELAYED HEMOLYTIC TRANSFUSION REACTIONS

Due to secondary  immune  responses following re-exposure  to a given red cell antigen

-          Ab most commonly involved – Rh , Kidd, Duffy  and  Kell

-          No clinical signs of red cell destruction but positive DAT

-          Rarely fatal

Sign and symptoms

 - fever

-  fall in Hb concentration

-          Jaundice and hemoglobinuria

Mx

-          Requires no Tt.

-          Hypotension  & renal failure – may require expert  medical advice

l  Diagnosis & Management

l  Routine examination

l  Stop Tx immediately

l  Monitor vital signs, urine out put

l  Verify identification of the patient

l   IV line kept open with NS

l  Evaluate for evidence of HTR, septic shock, anaphylaxis

                TRALI other D/D fever

l  Report and send transfusion set to B/B

l  Treatment

l  Antipyretics

                                acetaminophen ;   325-650mg orally  

                    (adult)  10-15mg/kg (children)

l  Meperiedine

                                severe chills  - 25-50mg IV

                                contraindication: renal failure

                                                                      Pts on MAO inhibitors             

l  Antihistaminics: not indicated

Tx should not be restarted for 30 min.

TRACHEOSTOMY

TRACHEOSTOMY

History

Tracheostomy is one of the oldest surgical procedures.

A tracheotomy was portrayed on Egyptian tablets dated back to 3600 BC.

Asclepiades of Persia is credited as the first person to perform a tracheotomy in 100 BC.

The first successful tracheostomy was performed by Brasovala in the 15th century. 

Tracheostomy
 History and indications

1932 prevent pulmonary infection in neurologically impair patients secondary to infections (poliomyelitis).

1943 remove bronchial secretions in cases of myasthenia gravis and tetanus.

1951 reduce the volume of dead space, use in COPD and severe penumonia.

1950 positive pressure through tracheostomy for patients with poliomyelitis.

1955 obstruction secondary to infection: diphteria, Ludwig’s angina.

1961 Obstructions secondary to tumour, infectious disease and trauma.

INDICATIONS FOR TRACHEOSTOMY

INDICATIONS FOR TRACHEOSTOMY

TRACHEOSTOMY VS TRANSLARYNGEAL INTUBATION

Increased patient mobility

More secure airway

Increased comfort

Improved airway suctioning

Early transfer of ventilator-dependent patients from the intensive care unit (ICU)

Less direct endolaryngeal injury

Enhanced oral nutrition

Enhanced phonation and communication

Decreased airway resistance for promoting weaning from mechanical ventilation

Decreased risk for nosocomial pneumonia in patient subgroups

Shiley tracheostomy tube: #6

Shiley tracheostomy tube: #8  for bronchoscopy.

TRACHEOSTOMY TUBE CARE

Securing tracheostomy around patient’s neck.

TRACHEOSTOMY TUBE CARE

Tube changes:

Indications: soiled, cuff rupture.

Complications: insertion into a false passage bleeding, and patient discomfort.

Avoid within 1^st week.

First tube change by surgeon.

Difficult cases (obese, short and thick neck), be prepared for endotracheal intubation.

TRACHEOSTOMY TUBE CARE

Tracheostomy tube cuff pressures in a range of 20 to 25 mm Hg.

Overly low cuff pressures < 18 mm Hg, may cause the cuff to develop longitudinal folds, promote microaspiration of secretions collected above the cuff, and increase the risk for nosocomial pneumonia.

Excessively high cuff pressures above 25 to 35 mm Hg exceed capillary perfusion pressure and can result in compression of mucosal capillaries, which promotes mucosal ischemia and tracheal stenosis.

Cuff pressure should be measured with calibrated devices and recorded at least once every nursing shift and after every manipulation of the tracheostomy tube.

TRACHEOSTOMY TUBE CARE

Chest Xray:

                        cuff has a width greater than the caliber of the trachea, which suggests the presence of a hyperinflated cuff and tracheal overdistention

TRACHEOSTOMY TUBE CARE

Humidification of the inspired gas is a standard of care for tracheostomized patients.

SPEECH

SPEECH

NUTRITION

Tracheostomy tube prevents normal upward movement of the larynx during swallowing and hinders glottic closure.

Between 20% and 70% of patients with a chronic tracheostomy experience at least one episode of aspiration every 48 hours

Evaluation by speech therapist

Keep head elevated to 45° during periods of tube feeding

WEANING FROM TRACHEOSTOMY

Demonstrate stability for 24 to 48 hours after discontinuation of mechanical ventilation.

Tracheostomy stomas can narrow markedly or close within 48 to 72 hours after tube removal.

Deflating the tracheostomy cuff and capping the tube.

WEANING FROM TRACHEOTOMY

The ability to breath and clear airway secretions around a small, capped tube signifies readiness for decannulation

Patients who fail breathing trials with capped tracheostomy tubes should be evaluated by flexible fiberoptic endoscopy for evidence of airway lesions and adequacy of airway function.

Complications of Tracheostomy

Complications 5-40%

Mortality <2%

Complications are more frequent in emergency situations, severely ill patients and small children.

Complications of Tracheostomy

Stoma

Stoma site infection

Stomal hemorrhage

Poor stoma healing after decannulation with scar, keloid, or tracheocutaneous fistula

Complications of Tracheostomy

Trachea

Granuloma

Tracheoesophageal fistula

                        fewer than 1% of patients as a result of pressure necrosis of the tracheal and esophageal mucosa from the tube cuff

                        risks: high cuff pressures, presence of a nasogastric tube, excessive tube movement, and underlying diabetes mellitus

Complications of Tracheostomy

Tracheoinnominate fistula:

                        0.4% with mortality rate of 85% to 90%.

                        Major airway hemorrhage may occur first within several days or as long as 7 months after performance of a tracheostomy.  

                        Risk factors : excessive tube movement, low placement of the tracheostomy, sepsis, poor nutritional status, and corticosteroid therapy

Tracheal stenosis:

                        can develop from 1 to 6 months after decannulation

                        risk for tracheal stenosis ranges between 0% and 16%

Tracheomalacia

CONCLUSION

The most common indications for tracheostomy is mechanical ventilation with prolonged tracheal intubation.

Tracheostomy: emergency and elective, improve quality of life.

Meticulous surgical technique.

Appropriate postoperative tracheostomy care to reduce complications.

PERCUTANEOUS DILATIONAL TRACHEOTOMY

PERCUTANEOUS DILATIONAL TRACHEOTOMY

PERCUTANEOUS DILATIONAL TRACHEOTOMY

TRACHEOSTOMY TUBE CARE

Securing tracheostomy around patient’s neck.

Tube changes:

Indications: soiled, cuff rupture.

Complications: insertion into a false passage bleeding, and patient discomfort.

Avoid within 1^st week.

First tube change by surgeon.

Difficult cases (obese, short and thick neck), be prepared for endotracheal intubation.

TRACHEOTOMY

BENIGN PROSTATIC HYPERPLASIA

BENIGN PROSTATIC HYPERPLASIA

—  Name : XYZ

—  Age/sex : 70years / male

—  Ward : urology/07

—  DOA : 15/2/2012

—  Weight : 58 kgs.

—  CHIEF COMPLAINTS :

• Difficulty in initiating micturation,
• Progressive increase in frequency in micturation,
• Progressive difficulty in micturation for 6 months.

—  Presenting illness: pt was alright 6 months back. then he developed progressively  urinary symptoms- increased frequency  of urine & nocturnal awakening, sense of incomplete evacuation, difficulty in initiation & dribbling.

—  Pt has no h/o burning micturation, haematuria pyuria,pelvic trauma, wt loss.

—  Pt has no past h/o of DM,TB,COPD,CAD.

—  During queries in personal history gives h/o occasional sutta &khaini for 10-15 yrs ,but non alcoholic.

—  No history of long term drug intake or previous operation.

—  General physical examination:-

—  Concious,alert, cooperative.

—  Average built.

—  No pallor, icterus, clubbing, oedema, lymphadenopathy,neck vein engorgement.

—  Vitals:Pulse:64/min,BP:148/86mm.Hg(supine),  RR:17/min. afebrile.

—  Systemic examination:-

—  Resp: bi-lateral air entry equal, no added sound.

—  CVS:S1,S2  normal, no murmur.

—  CNS: within normal limit.

—  Per abdomen: soft, bowel sound +ve.

—  Per rectal exam: unifomly firm, median sulcus and upper border palpable, no discrete nodule,rectal mucosa not fixed.

—  Investigations:-

—  Hb% - 11.0 g%,

—  TLC- 4200, DLC- P62,L23,E04,M01.

—  Blood sugar – 84 mg/dl.

—  S. urea- 40 mg/dl, S.creatinine-0.8mg/dl.

—  S.Na⁺-142, S.K⁺-4.8, S.Ca⁺⁺-3.14

—  Chest x ray-WNL

—  ECG-WNL.

—  PSA & alkaline phosphatase.(rule out ca prostate)

—  Differential diagnosis:-

—  BPH.

—  CA Prostate.

—  Urethral stricture.

—  Bladder neck hypertrophy.

—  Neurogenic bladder.

—  Positive finding

—  Progressive increase in frequency.

—  Frequent nocturnal awakening.

—  Progressive increase in difficulty in initiation & micturation.

—  Sense of incomplete evacuation.

—  Median sulcus palpable in PR exam.

—  Negative finding:-

•       No weight loss, anorexia.

•       No h/o trauma.

•       No haematuria/pyuria.

•       No palpable nodules.

—  Understanding the prostate

q  Walnut-shaped gland, composed of  glandular tissue in fibromuscular stroma that forms part of the male reproductive system.

Size:4cmx3cmx2 cm.

Wt: 8 gm.

q  Lobes:-anterior,median(imp for BPH),posterior(imp for CA),2 lateral lobes.

q  2 capsule is present(a)anatomical capsule formed by visceral layer of peritoneum.(b)surgical-condensation of prostatic tissue.

—  understanding the prostate

—  Nerve supply:-

q  Sympathetic supply from T11-L2 sympathetic chain.

q  Parasympathetic supply from S 2,3,4 through pelvic splanchnic nerve.

—  Blood supply:-

q  Arterial supply: inferior vesical artery,internal pudendal artery, middle rectal artery

q  Venous supply:vesicle plexus,internal pudendal veins,vertebral venous plexus.

—  What causes BPH?

q  BPH is part of the natural aging process, like getting gray hair. Half of all men over the age of 60 will develop an enlarged prostate.

q  BPH cannot be prevented.

q  BPH can be treated.

—  Common symptoms

Obstructive symtoms:-

q  Hesitancy.

q  Poor flow.

q  Dribbling or leaking after urination

q  Feeling that the bladder never completely empties

Irritative symtoms:-

q  Frequency

q  Nocturia

q  Urgency

q  Nocturnal incontinence

UTI:- burning sensation during urination

—  what causes these symptoms?

—  how is BPH diagnosed?

Medical history

Physical examination

Prostate exam

Urinalysis

PSA blood test

Transrectal ultrasound of

 prostate

—  When should BPH be treated?

BPH needs to be treated ONLY IF:

Symptoms are severe enough to affect the patient’s quality of life.

Patient has h/o frequent urinary tract infections.

—  Treatment options

“Watchful waiting”-decrease fluid intake

Medication

(1)alpha adrenergic antagonist

(2)5@ reductase inhibitors

Heat therapies

Surgical approaches

—  choosing the right treatment

Consider risks, benefits and effectiveness of each treatment

Consider your outcome and lifestyle needs

—  surgical treatment

—  The “gold standard”- TURP

Benefits

Widely available

Effective

Long lasting

Disadvantages

Greater risk of side effects and complications

1-4 days hospital stay

1-3 days catheter

4-6 week recovery

—  ANESTHETIC CONSIDERATION:-

—  Patient related problems:-

• Geriatric age group.
• Associated co-morbid condition.

—  Problems due to disease:-

• Back pressure changes to kidney.
• UTI.

—  Problems due to surgical procedure:-

—  Pre operative preparation:-

—  Optimizing the pre existing co- morbid condition.

—  Consideration of ongoing drug therapy.

—  Advise regarding fasting status.

—  Arrange blood.

—  Preoperative  sedation :-alprazolam.

—  Pre operative antibiotics if-

1. Preexisting urine retention.
2. Pts with prosthetic material in situ.

—  Choice of anesthesia :-

—  Regional anesthesia is preferred.

—  GA when RA is contraindicated.

—  Advantages of regional anesthesia?

ü  Allows monitoring of mentation, early signs of TURP syndrome, bladder perforation.

ü  Promotes vasodilatation & reduce circulatory overload.

ü  Reduce bleeding by reducing B.P.

ü  Low incidence of intra op MI & post operative DVT.

ü  Adequate post op analgesia.

—  Anesthesia for TURP:-

—  Level of anesthesia:-

• T 10 dermatome is blocked to reduce discomfort during bladder distension.
• T9 dermatome is required to eliminate pain on rupture of prostatic capsule.(capsular sign)

Ø  Disadvantage of regional block?

ü  It does not abolish obturator reflex=external rotation & adduction of thigh 2ndary to stimulation of obturator nerve by electrocautery through lateral pelvic wall. Blocked during GA.

—  Advantages of subarachnoid block?

—  Easy to perform.(single shot)

—  Better relaxation of pelvic floor muscle due to dense motor blockade.

—  Sacral sparing in epidural anesthesia is avoided.

—  Continuous epidural anesthesia is not needed  as duration of surgery is short.

—  Monitoring?

—  Orientation.

—  ECG.

—  Blood pressure.

—  Pulse oximetry.

—  Temperature.

—  Serum electrolyte.

—  Blood loss.

—  ETCO2 if GA is used.

— 
Problem due to surgical procedure:-

—  Lithotomy position.

—  TUR syndrome.

—  Bladder perforation (1%)

—  Bleeding and coagulation abnormality.

—  Hypothermia.(1*C/hr)

—  Transient bacterial septicemia.

—  Problems due to Lithotomy position

—  Injury to brachial plexus, saphenous ,common peroneal,siatic, femoral & obturator nerves.

—  Injury to major vessels near the joint.

—  Compartment syndrome.

—  Precipitation of CHF.

—  Breathing difficulty in patients with already diseased lung.

—  Hypotension if legs are rapidly lowered.

—  Physiological alterations in Lithotomy :-

—  Decrease FRC leads to more atelectasis & hypoxia which is further accentuated during trendelenberg & old age.

—  Elevation of legs –increase circulatory overload-rise in mean BP.

—  Decrease venous return due to lowering of legs-hypotension.

—  Irrigating fluids:-

—  Purpose of irrigation:-

ü  Distends bladder and prosthetic urethra.

ü  Improving visibility.

ü  Washout tissue debris and blood.

ü  decrease bleeding.

—  Characteristics of ideal irrigating fluid:-

1. Clear.                        5.Isotonic.
2. Cheap.                      6.Nonhemolytic.
3. Electrically inert.        7.Nontoxic.
4. No metabolism.         8.Rapidly excreted 

—  Factors affecting amount & rate of absorbtion:-

—  Size of gland.

—  Hydrostatic pressure of irrigating.(max height 60cm)

—  Duration of procedure.(max150 mins){20-120 ml/min}

—  Intigrity of capsule.

—  No of open sinuses.

—  Skill of operating sergeon.

—  Intravesical pressure (max 15 cm water)

—  Congestion of gland.

—  TURP SYNDROME:-

—  Incidence 1-8%.

—  Can occur 15 mins after starting to 24 hrs after end of surgery.

—  Rapid absorption of fluid leads to:-

Ø  Acute hypoosmolality.

Ø  Pulmonary oedema.

Ø  Hyponatremia.

Ø  Hyperglycinemia.

Ø  Hyperamonemia.

Ø  Visual disturbances.

Ø  Hemolysis.

—  Signs/symptoms of TURP syndrome

—  During R. Aneasthesia:-

• Restlessness,dizziness, tightness in chest, nausea,confusion.
• Hypertension, bradycardia, cyanosis, slugish reaction with dialated pupil.
• Tonic clonic convulsions, coma, cardiac arrest.

—  During G. Anesthesia:-

• Rise followed by fall in B.P.
• ST changes, nodal rhythm, widening of QRS complex in ECG
• Delayed recovery.
• Cardiac & respiratory arrest.

—  Prevention of TURP syndrome

—  Correct fluid & electrolyte imbalance.

—  Cautious administration of fluids.

—  Reduce surgical time<90 mins.

—  Max height of fluid bag 60 cms.

—  Max intra vesical pressure-15 cm water.

—  Use of vasoconstrictor at operative site.

q  Estimation of absorbed fluid?

Pre-op Na conc./post-op Na conc.    ECF-ECF.

—  Treatment of TURP syndrome

ü  Terminate surgery as soon as possible.

ü  Supplement oxygen.

ü  Pulmonary oedema?

     --ventilate the patient.

ü  Consider frusemide if-

    --pulmonary oedema develops.

    --to induce diuresis.

ü  Send sample for ABG,Na,osmolality.

—  Treatment of TURP syndrome

ü  Seizures:-BZD, thiopentone, phenytoin, muscle relaxants.

ü  Bradycardia &cardiac arrest:-atropine, adrenergic agonists, iv calcium.

ü  Invasive monitoring in pulmonary oedema& hypotension.

ü  If significant blood loss, transfuse packed RBCs

ü  Visual disturbances resolve spontaneously within 24 hrs.

—  Hypertonic saline:-

—  Overt signs of Hyponatremia. Na<120mg/dl.

—  Safe rate of administration?<10mmol/lit/24hr. Not more than 100ml/hr. Rapid administration causes central pontine myelinolysis. (quadriplegia & pseudobulbar palsy occurs without inflammation)

q  Mechanism of action:-

—  Corrects Hyponatremia.

—  Combats cerebral oedema.

—  Expands plasma volume.

—  Reduce cellular oedema.

—  Blood loss

—  Depends upon:-

1. Wt of resected tissue.
2. Surgical time:2-5 ml/min of resection time.
3. No of open prostatic sinuses.
4. Blood pressure.

—  Classical signs of hypotension &blood pressure are not seen immediately as there is increase in blood volume.

—  Postoperative care:-

—  Advisable to monitor in PACU.

—  Monitor vitals in particular CNS.

—  Continue irrigation.

—  As the pain after TURP is not severe routine  analgesia is usually sufficient.

ü  NSAIDS

ü  Opioids like tramadol, fentanyl may suffice.