Problem-Based learning: Case Discussion

Hany El-zahabyAin Shams University

2011

Case 1You have been called to anesthetize 6h old,

3.1kg male born at 36W by CS with Gastroschisis for primary closure.

What is Gastroschisis?

What are the differences between Gastroschisis and Omphalocele?

What are the main anesthetic problems:1- volume status2- thermal status3- induction techniques4- intra-abdominal pressure

preoperative assessment & preparationhistory

Apgar ScoreIV line & IVFNG aspirateUOP antibiotics anomalies

examination HR BpRR Spo2TempCapillary refillairway chest heart

investigationCBC S. electrolytesrenal function coagulation CBGCXR echocardiography

premedicationmonitoringthermal controlinduction

stomach aspirationrapid sequence

ventilationmuscle relaxation

Diagnosing hypovolemia under anesthesia:

Is the HR persistently increased (not with surgical stimulation)?

Is the BP reduced for age?Does BP vary with IPPV?Are the extremities cold?Is the capillary refill brisk?What about UOP?Core to skin temp. gradient?What is the response to 10-20ml/kg bolus of

isotonic crystalloid?

after reduction, the surgeon asked you if it is OK to continue closure, the PIP increased from 18 to 27cmH2O, how would you answer?

high intra-abdominal pressure:- decrease organ perfusion/function, prolonged drug effect- decrease diaphragmatic function & lower lobes atelectasis- decrease venous return- lower extremity venous congestion

measurement: intra-gastric or bladder pressures (20mmHg)gut & skin color lung compliancecv stability

after closure and removal of towels, moderate mottling of the lower limbs was noticed, how would you manage?

fluid bolusesvasopressorsoxygen

postoperative: ventilation (PEEP) sedation/analgesiarelaxation TPN

complications: cv collapse ileus

Silon patch

Case 2

7 years old, 14 kg male child with long history of cerebral palsy scheduled for laparoscopic Nissen fundoplication and gastrostomy tube insertion. History of URTI two weeks ago & he is now much better according to the mother. Patient has long standing spastic quadriplegia & underwent multiple orthopedic operations.

2:1000 live birthcranial nerve weakness, bulbar palsy, poor

coordination of laryngeal musclesgastro-esophageal reflux resistant to medication &

thickened feeds (Feeding video-fluroscopy)recurrent aspiration & decreased pulmonary

reserveimmobility, dehydration, poor diet, bowel stasis,

constipation, fecal impaction.common surgeries: orthopedic, scoliosis, ENT

(adeno-tonsillectomy/obstructive sleep apnea)

problems:muscle spasms seizures respiratory problemsmedicationslaparoscopy

preoperative assessment & preparationold filesneonatal historyprevious anesthesiarecent chest infectionmedications

examination: HR BpRR Spo2tempcapillary refillneurological status & posturehead & neckchest heartabdomen limbs

investigationsCBC S. electrolytesrenal function liver functioncoagulation ABGCXR Echocardiography?serum levels of antiepileptics

MedicationsAntiepileptics: Scheduling? IV forms? S. levels?Benzodiazepine- respiratory depression, sedation

(0.1mg/kg) Sodium valproate- weight gain, tremorsLamotrigine- rash, tremors, vomitingCarbamazepine- rash, sleep - > 8mg/LPhenobarbitone- (15mg/kg) - > 10mg/LPhenytoin- (15mg/kg) - > 10mg/L

Other medications included ranitidine, omeprazole, baclofen & salbutamol

Would you reserve an ICU bed?Premedication?

antacid-EMLA creamPosition?

modified Lloyed Davis- avoid force- good paddingInduction?Intubation/Ventilation?Maintenance?Pneumo-peritoniumAnalgesia?

Immediately after extubation, laryngeal spasm has occurred with gradual desaturation, what would you do?

10 minutes after arrival to PACU, the patient desaturated down to 88% on oxygen face mask 6l/m, how would you manage?

THANK YOU