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Anesthetic management of a patient requiring placement of a Y- stent

Anesthetic management of a patient requiring placement of a Y- stent. Presented by 林起翎 蔡鵠遠 戴家煌. Brief History. 呂 xx, 61 y/o, male Persistent dry cough since 3 yrs ago. Dyspnea and wheezing on left side down.

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Anesthetic management of a patient requiring placement of a Y- stent

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  1. Anesthetic management of a patient requiring placement of a Y- stent Presented by 林起翎 蔡鵠遠 戴家煌

  2. 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.

  3. 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.

  4. 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.

  5. 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

  6. 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(+)

  7. 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

  8. 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

  9. 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

  10. ALP:196 Na:138 • AST:21 K:3.65 • ALT:111 Cl:96 • BUN:10.9 Ca:2.31 • Creatinine:0.96 • Glucose AC:105

  11. EKG: normal sinus rhythm, Q wave at V1~3 • CXR: left apical fibrotic change

  12. Anesthesia IVA

  13. Monitor EKG , BP , A line , 2 IV line end-tidal CO2 , pulse oxymeter Urinary output

  14. Induction: Fentanyl: 1ml Pentothal: 250mg Atracurium: 25mg Xylocaine: 100mg Robinul: 0.2mg Nitroderm: 1TTS Vitacal: 1amp Maintenance: IV propofol infusion: 50~100 mg/h

  15. Problem • Tube without seal air leakage • no gas anesthesia • ventilation efficiency SaO2 PaCO2 • Left bronchial stenosis

  16. procedure • dilated the left main bronchus • check the lesion of left main bronchus with flexible scope • measure the length to insert Y stent

  17. Problem • Tube without seal air leakage • no gas anesthesia • ventilation efficiency SaO2 PaCO2 • Irritation of airway • laryngospasm, bronchospasm • HR BP

  18. procedure • 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

  19. Problem • 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

  20. Problem • Blood clot and debris: lower airway • obstruction

  21. Major Problems • 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

  22. Discussion • Airway management • ventilation • laryngospasm and bronchospasm • bleeding due to surgical manipulation • Tuberculosis

  23. Ventilation • Intermittent ventilation • Closely monitor • Avoid continuous positive pressure ventilation • increased intrathoracic pressure

  24. Laryngospasm • Anesthetic depth should be adjusted • If laryngospasm occurs • Remove the offending stimulus • Give 100% oxygen • Increase anesthetic depth • Succinylcholine

  25. Bronchospasm • Intravenous aminophylline or salbutamol • Volatile anesthetic agents and ketamine are also effective bronchodilators • Epinephrine is indicated in life-threatening situations

  26. Bleeding during surgery • Suction • One lung intubation

  27. 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

  28. Place bacterial filters on the exhalation limb of the anesthesia delivery circuit • Use a dedicated mechanical ventilator • Postoperative care in an isolation room

  29. Conclusion • O2 saturation • Anesthetic depth

  30. Thank you for your attention!

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