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Interesting case conference

Interesting case conference. นำเสนอ โดย พ.อรนุช ศรีสวัสดิ์ พ.กมลทิพย์ ประสพสุข ควบคุมโดย อ.วรวุธ ลาภพิเศษพันธุ์ วันที่ 5 มิย. 2546 เวลา 7.30 น. Interesting case conference. ID : ผู้ป่วยหญิงไทยคู่ อายุ 79 ปี อาชีพ คนชรา

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Interesting case conference

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  1. Interesting case conference นำเสนอ โดย พ.อรนุช ศรีสวัสดิ์ พ.กมลทิพย์ ประสพสุข ควบคุมโดย อ.วรวุธ ลาภพิเศษพันธุ์ วันที่ 5 มิย. 2546 เวลา 7.30 น

  2. Interesting case conference ID : ผู้ป่วยหญิงไทยคู่ อายุ 79 ปี อาชีพ คนชรา ภูมิลำเนา อ.ป่าซาง จ.ลำพูน เชื้อชาติ ไทย สัญชาติ ไทย CC : ปวดท้อง 3 วันก่อนมาโรงพยาบาล PI : -2 เดือนก่อนมาโรงพยาบาล เริ่มมีอาการปวดท้อง คลำก้อนได้ที่ท้อง ปวดบริเวณก้อนตลอดเวลา ไปพบแพทย์ที่โรงพยาบาลลำพูน ,u/s พบมี large abdominal aortic aneurysm just below renal arteries to biforcation but no evidence of dissection

  3. Interesing case coference Dx. Abdominal aortic aneurysm โรงพยาบาลลำพูน conservative treatment มาตลอด - 3 วันก่อนมาโรงพยาบาลผู้ป่วยมีอาการปวดบริเวณก้อน ตำแหน่งเดิม แต่มีอาการปวดมากกว่าเดิม ไปพบแพทย์รพ.ลำพูนให้การรักษาโดยให้ยาแก้ปวด อาการไม่ดีขึ้น จึงส่งตัวมารักษาต่อที่รพ. มหาราชนครเชียงใหม่

  4. Interesing case conference • PH : ปฏิเสธ underlying disease มีประวัติ chronic smoking ปฏิเสธ ประวัติ alcoholic drinking ปฏิเสธประวัติแพ้ยา เคยผ่าตัด ใส้ติ่งอักเสบ 30 ปีก่อน

  5. Interesing case conference Physical examination V/S : BP=170/100 in all extermities PR=74/min , Temp=36.5C ,RR=15/min General appearance : an old woman with normal conciousness body weight =30 kgs ,height=145 cm HEENT : no pale conjunctiva ,no juandice

  6. Interesting case conference Heart : normal heart sounds,regular rhythm , no murmur Lung : normal contour, no tachypnea normal breathing sounds Abdomen : pulsatile mass ขนาดประมาณ 4cm*4cm just below umbilicus , no abdominal distension BS active Extremities : no deformity,normal pulse in all extremities

  7. Interesting case conference Airway assessment • Interinciser gap > 3 cm • thyromental distance >5 cm • mallampati classification : II • neck movement : no limitation

  8. Interesting case conference • Impression : Abdominal aortic aneurysm with impending rupture

  9. Interesting case conference • Work up CBC : Hb = 13.5 g% Hct=42.3 Wbc=7300 Plt =212000 Electrolyte : Na =126 K=3.4 Cl =93 CO2=24 BUN=5 Cr =0.6 FBS =132

  10. Interesting case conference • Work up ( Cont. ) PT=10.3(11.8) , PTT=31.4(31.0) Ca =9.5 , Mg=1.28 , P=2.8 UA: Sp.gr. 1.010 , Wbc = 8-10/HPF Rbc = 1-3/HPF

  11. Interesting case conference Work up( Cont. ) CXR: widening mediastinum R/O Thoracic aortic aneurysm EKG : inverted T in V1 -V3 Trop T : negative CT abdomen :

  12. Interesting case conference • Set OR emergency for aneurysmorhappy รับ set case เวลา 16.30 น. วันที่ 25/05/03 • NPO time เวลา 9.00 น. วันที่ 25/05/03

  13. Interesting case conference • Problem list 1. Infrerenal AAA 2. Old age 3. Hyponatremia 4. R/O HT 5. Widening mediastinum R/O Thoracic aneurysm 6. Abnormality of EKG 7. Moderate renal insufficiency

  14. Interesting case conference Anesthetic consideration • 1. Preoperative evaluation • 2. Preoperative preparation &Premedication • 3. Mornitoring • 4. Anesthetic technique • 5. Intraoperative complication • 6. Postoperative care

  15. Interesting case conference • 1. Preoperative evaluation Laboratory test CBC with Plt count Serum electrolyte : Hyponatremia BUN ,Cr : CCr =33.9 Coagulation profile

  16. Interesting case conference Urine analysis CXR : Widening mediastinum EKG : Inverted T • 2. Preoperative preparation & Premedication Cross maching No premedication

  17. Interesting case conference • 3. Mornitoring O2 saturation NIBP EKG CVP A- line

  18. Interesting case conference • 3. Mornitoring (cont.) Temp I/O • 4. Anesthetic technique Balance anesthetic technique with Nacrotic , muscle relaxant and volantile agent

  19. Interesting case conference • 4. Anesthetic technique ( Cont.) Induction Maintainance Revese • 5. Intraoperative complication • 6. Post operative care Pain control

  20. Abdominal aortic aneurysm • Multiple factors ; genetic , biochemical, metabolic , mechanical and hemodynamic • Major pathologic cause is atherosclerosis • Rare cause of AAA include trauma, mycotic infection, syphilis, Marfan syndrome

  21. The diameter and rate of expansion of AAA AAA 4 to 5 cm. In diameter is not well defined , and significant controversy exists regarding surgical repair Surgical repair is recommened if such aneurysms become symptomatic , expand more than 0.5 cm. In a 6-month period , diameter 5 cm. or greater

  22. Aortic cross- clamping • Most abdominal aortic reconstruction require clamping at the infrarenal level • Ischemic complication may result in renal failure , hepatic ischemic and coagulopathy • Thoracic and supraceliac cross-clamping may increase left ventricular wall stress ( resultant acute left ventricular dysfunction and/or myocardial ischemia )

  23. ภาพ systemic hemodynamic response to aortic cross-clamping

  24. Physiologic changes (cross-clamping ) • Hemodynamic changes ; increase arterial blood pressure increase left ventricular wall tension and segmental wall motion abnormalities increase pulmonary artery occlusion pressure increase central venous pressure increase coronary blood flow decrease cardiac output and ejection fraction decrease renal blood flow

  25. Metabolic changes decrease total body oxygen consumption decrease total body carbon dioxide production decrease total body oxygen extraction increase mixed venous oxygen saturation increase epinephrine and norepinephrine respiratory alkalosis metabolic acidosis

  26. Therapeutic interventions (cross-clamping) • Afterload reduction ; sodium nitroprusside , inhalation anesthetics , amrinone • Preload reduction ; nitroglycerine , shunts and left heart bypass • Renal protection ; Mannitol , low dose dopamine , fluid administration • Other ; decrease minute ventilation , sodium bicarbonate

  27. Aortic unclamping • The hemodynamic responses to unclamping depend on the level of aortic occlusion, the total occlusion time, the use of diverting support and the intravascular volume • Humoral factors and mediators which may also play a role in organ dysfunction after aortic occlusion include lactic acid, renin-angiotensin, oxygen free-radicals, neutrophil, prostaglandins, activated complement, cytokines and myocardial-depressant factors

  28. ภาพ aortic unclamping

  29. Physiologic changes ( aortic unclamping ) • Hemodynamics changes ; decrease myocardial contractility decrease arterial blood pressure decrease central venous pressure decrease venous return decrease cardiac output

  30. Metabolic changes ; increase total body oxygen consumption increase lactate, prostaglandins, activated complement , myocardial-depressant factors decrease mixed venous oxygen saturation metabolic acidosis

  31. Therapeutic interventions (aortic unclamping ) decrease inhalation anesthetics decrease vasodilator increase fluid administration increase vasoconstrictor drugs reapply cross-clamp for severe hypotension

  32. Anesthetic management • Preoperative considerations High incidence of coexistent cardiac, renal, pulmonary disease, hypertension, diabetes Severe hypertension, myocardial ischemia, aortic valve regurgitation, left ventricular failure may be precipitated The location of the lesion The procedure of complicated by the potential for large intraoperative blood losses

  33. Intraoperative monitoring central venous or pulmonary artery catheter direct arterial blood pressure and NIBP two-lead ECG or modified V5 ECG temperature I/O pulse oximetry two-dimensional TEE

  34. Anesthetic drugs and techniques • Combined techniques most commonly employ a lumbar or low thoracic epidural catheter • Induction of general anesthesia should controll such that stable hemodynamics are maintained during loss of conciousness, laryngoscopy and intubation , the immediate postinduction period

  35. Induction, intravenous hypnotic agents ( thiopentone , etomidate, propofol ) or a short-acting potent opioid ( such as fentanyl 3-8 microgram/kg) and halogenated agents may be administered in low concentration before intubation • Esmolol (10-25 mg), sodium nitroprusside (5-25 microgram), nitroglycerine (50-100 microgram), and phenylephrine(50-100 microgram) should be available for bolus administration during induction • Anesthetic maintenance may be accomplished with a combination of a potent opioid and an inhaled anesthetic

  36. Epidural local anesthetics are used the same balanced technique and reduce the opioid dose ( but avoiding significant hypotension at the time of aortic unclamping) • Extubation of the trachea is generally not attempted in patients with supraceliac aortic cross-clamp times greater than 30 minutes, patients with poor baseline pulmonary function , or patients requiring large volumes of blood or crystalloid during surgery

  37. Routine use nasal airway after induction but before systemic heparinization in all patients for whom extubation is planned • Hypertension and tachycardia are aggressively controlled during emergence by use of short-acting agents , such as esmolol, nitroglycerine, and sodium nitroprusside

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