Transcript Morbidity Review Tsumawi

MODERATOR:DR KHAIRUDDIN
Mr A,58 years old Malay gentleman, retired teacher
Underlying hpt and diabetis mellitus under GP follow up
Chronic smoker,30 sticks cigarettes /day
History of fall from stairs 7 years ago, experienced shooting
pain from buttock to right calve but no muscle weakness
not seek medical treatment
Went to traditional massage
Worsening for 1 year, shooting pain untill both calves assc.
with numbness right foot, unable perform ‘rukuk’ during
prayer due to pain, disturb daily activities
Seek medical treatment ,diagnosis: PID with right sciatica
pain ,
under ortho follow up
Manage with physiotheraphy and analgesic ( gabapentin
300mg od + celebrex 200mg prn)
Physical examinations:alert concious pink, bmi
25 (weight 71kg, height 1.68m)
Back:no deformity, no tenderness, straight leg
raise positive on right side,power 3/5 right
lower limb, sensory intact
Other systems were unremarkabke
Xray lumbosacral:reduced interverttebral space
at t12,l1
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Proceed with mri lumbosacral:revealed mixed
enhancing solid-cystic intradural lesion at
level L4 could be due to an ependymoma with
impression intradural lesion L4
Differential: astrocytoma, metastasis spinal
mets ? Primary
Referred to neurosurgery for intradural mass
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Was seen by neurosurgical with plan for
laminectomy L2-L5 and excision of intradural
tumour
Refer to anaest clinic
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First seen in anaest clinic 23/10/2013, plan
operation 10/11/2013
He was walking
Underlying chronic smoker, hypertension and
DM with no other comorbidities or complaint
Bp 130/75mmhg, hr 79, weight 71kg, height
1.68m, bmi 25.2
Airway: interdental gap > 3fb, malampati 2,
thyromental distance > 4fb, no neck
abnormality, normal dentition
Other systemic review were unremarkable
 Ecg cxr normal
 Hb 14.1/plt 174/twbc 8
 Buse:4.4/136/4.7/99, creat 76
Classsified as ASA II
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Admit ward 1 day prior to operation
Advised to stop smoking
To bring antihypertensive & DM medications to
ward
Knbm at 2am
Tab midazolam 7.5mg on and once ot call
Repeat all blood investigation once admitted to
ward
Gsh as protocol
Case d/w with specialist, for AIBP, ICU back up
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He admitted to ward 9/11/2013 to 2ef and
again seen for preop assessment
No recent urti/no sob/chest pain/failure
symptoms
o/e alert concious pink , TMD> 3fb
,Malamapati III, good neck extension
Lungs clear, cvs s1s2 no murmurs
Bp 117/72, hr 82
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Knbm 2am
Optimised bp, aim < 140/90mmhg
Continue antihypertensive drug on morning
of op with sip of clear fluid
Start sliding scale once knbm
Aim discan 6-10mmol/l
Gxm per protocol
Gac,AIBP, ICU back up
Case d/w anaest specialist:may need icu back
up if anticipate long ot time
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Operation done in acc ot
Seen patient before push to ot, noted
features of difficult intubation, tmd 2fb, small
chin, poor denture
He was lying flat but look uncomfortable,
asking for any snoring during sleeping and he
admit he was snoring but resolved with
positioning,need to sleep 2 pillow, felt more
comfortable
No daytime somnolence, apnoea
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He were on and off cough, heard like chesty,
but no urti .he said the cough was normal like
that many years already.
Never admitted due to lungs infection before.
Anticipate difficult intubation-activated for
standby difficult intubation devices, bougy,
glidescope, procile.suction functioning
Case attempted with 2 specialist, trainee and
2 medical officer
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Attach monitoring devices, bp 132/74, hr 74
Spo2 100% under ra
ivl functioning well
Put patient in 30 degree
Preoxygenation given longer with 100% O2
Difficult intubation devices and glidescope
standby
Oral suction done
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Induced with iv fentanyl 100mcg, profopol
140mg
Able to ventilate but with some difficulties
Iv scoline 100mg given
Laryngoscopy done, unable to visualised the
epiglottis, seen large mass whitish in colour
obstructed the laryngeal inlet
Pass stat to specialist
Spo2 maintain 100%
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Unable to intubate, obstructed airway
Secretion +++ from oral cavity
Difficult to ventilate, given o2 100%
Start desaturated, proseal inserted, still
difficult to ventilate
desat till spo2 34%, patient blue
Good head thin chin lift applied
Wake up patient
No episode of bradycardia or hypotensive
episode during hypoxia episode
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After patient had spontaneous breathing,
tidal volume increasing slowly, spo2
increased but best under 100% oxygen was
92%
Not tachypnoic
After fully awake, explained regarding the
incidence and need for referral on table to ent
team for diagnostic airway assessment (ent
surgeon just next operation theater)
Refer on table to ent collegue next door
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Iv glycopyrulate 200mcg given
Prepare for fibreoptic videoscope
Left nasal packed with gauze soaked with
coccaine
Fibreoptic videoscope attempted by ent
surgeon
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Findings: glandular mass at base of tongue
Cystic mass > right side of epiglottis anterior
surface
Piriform fossa and valleculae look clear
Posterior pharyngeal wall are bulky and
inflammed
Narrow airway, all tissues oedematous
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Operation abandoned
Suggest by ent surgeon to get biopsy and
further ent assessment before proceed op
in view anticipate difficult intubation next
time with possibility of tracheostomy.
Anest plan for next operation to combine
ent and neurosurgical
Was plan for ct neck early
Laryngoscope done by consultant ent next
day with the findings same as videoscope,
vocal cord moving symmetrical with
phonation, no vc mass next day
Patient was discharged home with tca ent
clinic 25/11/2013
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Patient had no new complaints
No voice changes, noisy breathing, sob,
loa/low, urti
Laryngoscope done: findings same as before
discharged
Cxr clear
Explained need for biopsy to confirm the
diagnosis, plan elms+biopsy on 2/12/2013
Refer anaest clinic, 27/11/2013 , admit ward
1/12
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Imp: soft tissu mass at base of tongue with
cystic epiglottic mass and supraglottic soft
tissue mass causing oropharyngeal and
hypopharyngeal airways obstruction.
Diff:lymphoma,hypopharyngeal carcinoma
with cervical lymphadenopaties
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Nil new complaint, alert ,pink
Bp 121/67,hr 84
Airway assessment:interdental gap>3fb,
malampati 2, tyromental distance <4fb, poor
dentition
Other systemic review were unremarkable
Cxr clear, ecg sr, nil ischaemic changes
Blood investigations all within normal range
Gac, fibreoptic intubation, icu back up
Advised to stop smoking
Was explained high risk for icu admission in
view had airway obstruction, and nature of
awake fibreoptic intubation.patient
understood and agreed
Case d/w specialist incharge,for awake
fibreoptic intubation, icu back up
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Elective admitted to ward 6A for elms+biopsy
Nil complaints
Details airway assessment done in ent clinic
flexible endoscopy :
no deviated nasal septum,
it hypertrophy
adenoid 50% enlarged
retropalate collapse < 50%
retrolingual collapse> 50% during normal
inspiration (lateral collapse)
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Lateral pharyngeal wall redundant
Base of tongue-redundant tissue(hyperplasia of
base of tongue)
Mass at right lingual surface of epigglotis
Epiglottic rigid, not easily collapse
Aryepiglottic fold/aryhtenoid normal
Vestibular fold redundant
Present of ? Fatty tissue accumulation
Vocal cord normal
No mass at true cord
Subglottic area clear, no mass
No collapsing wall at level of upper trachea
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Plan for op as plan next morning with high
risk consent and icu back up
Next morning, case not proceed after further
detail discussion from anaesthetic and
surgeon. Not to risk patient with unindicated
tracheostomy by surgeon.
plan to combine with neurosurgical team
Discharged home with next operation was
plan combined ent and neurosurgical team on
15/12/2013
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Mr A admitted 1/7 before op, classified as
ASA III with icu backup, awake fibreoptic
intubation
Attended in ot 2 anaesthetics, 2 mo
Alert concious, bp 142/92, hr 92,spo2 100%
under RA
Difficult intubations trolley standby nearby,
fibreoptic ready
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Iv glycopyrulate 200mcg, fentanyl 100mcg
given
Nasal pack with cocaine
Preoxygenation given
Awake fibreoptic intubation done using
armoured size 7 anchored at 26cm succesfully
Spo2 maintain 100% during procedure
Iv propofol 120mg, esmeron 30mg given
Connected to ventilator tv 425ml, rate 12, peep
4
Proceed op first with laminectomy L4 and
excision intradural mass at 1200noon
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Anaesthesia maintained with TIVA
remifentanyl/propofol
Intraop, bp stable
Minimal blood loss
Op uneventhful
Ended neurosurgical op at 1545h, op almost
4 hours
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Proceed with DL+biopsy+ excision of
epiglottic mass at 1620 after reposition
patient from prone to supine
Nil complications during operation.ended
case at 1730h, op 1hour 10minutes
Not proceed with tracheostomy, trial of
weaning in icu
Neurosurgical:well defined smooth surface,
solid and cystic tumour firmly adherent to 2
nerve roots.90% excision of tumour with
small part of tumour capsule adherent to
nerve root was coagulated and left in-situ
IMP:neurofibroma
Intraoperatively monitoring showed 10%
improvement
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Ent: mass(retention cyst)arising from tip of
epiglottis, broad base, ruptured with cheesy
material ++, cystic sac excised with
microscissor, redundant mucosa of lateral
pharyngeal wall, arytenoid swollen and bulky
IMP: epiglottic retention cyst
Plan: for iv dexamethasone 8mg tds 3/7
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Admitted icu for weaning
Need high sedation post op in view patient
restless
Patient haemodinamically stable in icu
D1 post op was plan for extubation but
patient apnoe on cpap, done direct
videoscope in icu through right nasal cavity
which unable to pass through the videoscope
Proceed with glidescope, noted soft tissue
swelling surrounding the supraglottic area,
erythematous, cannot visualised epiglottis
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Was then plan for DL+ Trachy by ent on
17/12/2012-D2 post op
Patient intubated sedated, In ot, attended by
3 anaesthetics
Direct laryngoscope done, noted bilateral
enlarged tonsil(almost kissing)distorted
anatomy
Glidescope: able to visualize epiglottis and
anterior vocal cord, both oedematous
Proceed tracheostomy by ent , uneventhful
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Trachea slunted deep, slight deviated to left
side
Thyroid enlarged
Ishmectomy done, part of thyroid tissue cut,
bleeding secured
Direct laryngoscopy-supraglottic region
oedematous, redundant mucosa of pharyngeal
wall
Only can visualised tip of epiglottis
Unable to access vocal cord due to limited view
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Post tracheostomy, weaning in icu
Able maintain spo2> 95% under
tracheventimask, patient alert concious and
haemodinamically stable
Discharged to general ward after D1 post
tracheostomy, D3 post laminectomy L4+
excision intradural tumour, D3 post direct
laryngoscopy+biopsy+ excision epiglottis
mass
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Throughout ICU stay, nil complications
encountered.Hemodinamically stable , able
wean ventilator setting,good renal profile,
tolerate feeding well, discan well controlled
and sepsis parameter static, no documented
fever.
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Was t/o to 2ef on 18/12/2013
Under neurosurgical and ent reviews
He was well, on regular physiotheraphy and
bed rest
On regular tracheostomy suction
Tracheostomy off on 6/1/2014
He was able to walk without aided
Discharged home 7/1/2014with tca ent and
neurosurgical
Hpe result still pending