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Anesthesiology: Case Report
1 PATIENT INFORMATION
K.A. is a 6 year old, Filipina, Roman Catholic from Taguig City who was admitted for the first time at The Medical City on July 11, 2013
2 SOURCE AND RELIABILITY
Information was obtained from the patient’s mother, with good reliability
3 CHIEF COMPLAINT
“luyloy sa kanan at kaliwa” (inguinal bulge, bilateral)
4 HISTORY OF PRESENT ILLNESS
Patient was apparently well until 3 months prior to admission when she was noted to have a right inguinal bulge with associated intermittent groin pain, characterized as pressing, non-radiating, 4/10 in severity. The right inguinal bulge was noted to be spontaneously reducible, and was observed to become more prominent during bouts of crying and during physical exertion. No swelling, no nausea, no vomiting, no changes in bowel movement. Patient was brought to a pediatrician who advised referral to a surgeon. Relatives of the patient opted to observe the bulge. 1 month prior to admission, still with right inguinal bulge, patient was noted to have a left inguinal bulge with associated intermittent groin pain, characterized as pressing, non-radiating, 4/10 in severity. The left inguinal bulge was noted to be spontaneously reducible, and was observed to become more prominent during bouts of crying and during physical exertion Patient was brought to another pediatrician for second opinion, and was advised to undergo surgery, hence this present admission.
5 PAST MEDICAL HISTORY
No previous history of pneumonia, no constipation, no asthma, no ear infections, no cardiac disease, no diabetes, no seizures, no cancer. No previous hospitalizations. No past surgeries. No previous history of trauma. No known allergies.
Mother undertook a pregnancy test. Of visits: 10 Trimestral History: First Trimester: Mother was regularly menstruating until nine months prior to admission when she noted of missed menses. Laboratory tests requested include complete blood count. No illnesses were incurred during this trimester. ABO and Rh typing. There were no exposure to radiation nor illnesses during this trimester. with adequate amniotic fluid volume. Birth weight was 3. Second Trimester: Regular prenatal check-ups were done in The Medical City. with good compliance of intake. Lunch: 1 cup of rice with chicken/pork/beef. Third Trimester: Mother had regular prenatal check-ups with her obstetrician. Transvaginal ultrasound showed single live pregnancy at 8 weeks. Mother was prescribed with folic acid 400 micrograms and multivitamins. On her 24th week of pregnancy. Solid foods were introduced at 6 months of age. where she tested positive. HepBsbAg and Rubella titer. cephalic. She was prescribed with multivitamins and ferrous sulfate. Her pregnancy course during the third trimester was unremarkable. which showed a single live intrauterine fetus. No food allergies.Birth History: Patient was born full term via normal spontaneous delivery to a G1P1 (1001) 29-year old mother at The Medical City by an obstetrician. She underwent an ultrasound exam during her 17th week of gestation. No perinatal complications noted. urinalysis. A 24-hour food recall was conducted on the patient.5 kilograms. Nutritional History: Infant feeding: Patient was breastfed from birth up to 1 year of age. with good compliance of intake. while birth length was unrecalled. revealing: Breakfast: 1 piece of bread and peanut butter spread. compatible with last menstrual period. Maternal History: Prenatal Care and Testing: The Medical City No. mother underwent 75-grams oral glucose tolerance test which showed normal result. Immunization History: BCG vaccine: 1 shot at birth DPT vaccine: 3 shots (unrecalled date) Oral polio vaccine: 3 shots (unrecalled date) Hepatitis B vaccine: 3 shots (unrecalled date) Measles vaccine: 2 shots (unrecalled date) . Dinner: 1 cup of rice with chicken/pork/beef No current feeding problems. VDRL. All revealed normal results. APGAR was not obtained but patient was noted to have good activity and cry upon delivery.
6 Mother. allergies.Developmental History: Patient is developmentally at par with age. Gross Motor: 3 months: pulls to sit. 35 No family history of hernia. asthma. voice 6 months: monosyllabic babble 12 months: Speaks first real word (mapa) Cognitive 4 months: stares at own hand 12 months: egocentric pretend play 6 FAMILY HISTORY The Family of K.A. hands together in midline 6 months: sits without support 12 months: walks alone 15 months: Able to run Fine Motor: 4 months: reaches for objects 6 months: transfers objects from hand to hand 12 months: scribbles Communication and Language: 3 months: smiles in response to face. diabetes. July 14. 2013 Grandfather 62 Grandmother 60 Grandfather 61 Grandmother 60 Father. heart disease. hypertension.. seizures. 37 K.A. . cancer.
old heart attack. Examples *ASA PS classifications from the American Society of Anesthesiologists ASA PS 1 Normal healthy patient No organic.7 PERSONAL AND SOCIAL HISTORY Patient lives in a 400 square meter lot with his parents. bronchospastic disease with intermittent symptoms Has at least one severe disease that is poorly controlled or at end stage.aspx Patient is classified as ASA I since the patient is healthy with with no systemic illness. has a well-controlled disease of one body system. imminent risk of death. stable angina. multiorgan failure. Electricity is obtained from Meralco. pollution. hypothermia. mild obesity. The family does not have any pets. Family uses a gas stove in cooking their food. physiologic. as described below. Ventilation in the household is reportedly good as the family has a lot of windows in their home. poorly controlled coagulopathy ASA PS 2 Patients with mild systemic disease ASA PS 3 Patients with severe systemic disease ASA PS 4 Patients with severe systemic disease that is a constant threat to life Moribund patients who are not expected to survive without the operation A declared brain-dead patient who organs are being removed for donor purposes ASA PS 5 ASA PS 6 Source: American Society of Anesthesiologists and http://my. Patient is not exposed to smoking. symptomatic COPD.clevelandclinic. with segregation of waste. cigarette smoking without chronic obstructive pulmonary disease (COPD). 8 ASA CLASSIFICATION ASA physical status classification is a grading system for gauging the physical state of a patient prior to surgery. unstable angina. healthy with good exercise tolerance No functional limitations. has a controlled disease of more than one body system or one major system. Describing patients’ preoperative physical status is used for recordkeeping for communication between colleagues and to create a uniform system for statistical analyses. the child’s water is boiled for 30 minutes before consumption. pregnancy Some functional limitation. chronic renal failure. possible risk of death. or psychiatric disturbance. controlled congestive heart failure (CHF). . controlled hypertension or diabetes without systemic effects. or toxins. Drinking water source is from Manila Water. poorly controlled hypertension. hepatorenal failure Not expected to survive > 24 hours without surgery. excludes the very young and very old. There is no pertinent history of travel in the family. morbid obesity. ASA PS Category Preoperative Health Status Comments. no immediate danger of death. The modern classification system consists of six categories. Patient’s father works as a businessman while his mother is a housewife. symptomatic CHF. Garbage disposal is conducted every day. sepsis syndrome with hemodynamic instability.org/services/anesthesia/hic_asa_physical_classification_system.
No dental caps. No dentures. base of uvula visible. the patient was scheduled for bilateral herniotomy. fauces. and asking the patient to hold the head in a neutral position. The wound will then be closed with dissolvable sutures which can take up to 6-8 weeks to dissolve. uvula. specifically. and protruding the tongue without phonating. the parents were informed of the guidelines for food and fluid intake before elective surgery. pillars visible. The anatomy of the oral cavity is visualized. A high Mallampati score (class 3 or 4) corresponds to more difficult intubation and higher incidence of sleep apnea. fauces visible. Class IV: Only hard palate visible The patient is classified as MAL I since the soft and hard palate. As such. Neck: Full range of motion. Toast and clear liquids). Class III: Soft palate. The operation is done under general anaesthetic and usually involves one incision in the groin. No bridges. 11 PREOPERATIVE MANAGEMENT Fasting: Adherence to fasting guidelines minimizes the risk of aspiration of gastric contents. faucial pillars). Since the patient’s operation was scheduled at 7 am. nonhuman milk Up to 4 hours (3 am of surgery day for patient) Breast milk Up to 2 hours (5 am of surgery day for patient) Clear liquids only During the 2 hours No solids . and is described as such: Class I: Soft palate. No loose teeth. The Modified Mallampati Scoring consists of four classes. 10 PLANNED SURGERY A surgical operation is required for our patient since there is a risk that a part of the bowel can become trapped in the inguinal hernia. Mouth: opening of at least 3 fingerbreadths between upper and lower incisors. infant formula. which is presented below: Time Before Surgery Food or Fluid Intake Up to 8 hours (11 pm. The Mallampati score is assessed with the observer at eye level. uvula. Teeth: good condition. of previous day for patient) Food and fluids as desired Up to 6 hours (1 am of surgery day for patient) Light meal (eg. fauces and tonsillar pillars are visible. no liquids .9 AIRWAY ASSESSMENT The Mallampati score is used to correlate the oropharyngeal space with the ease of direct laryngoscopy and tracheal intubation. soft and hard palate are visible. opening the mouth maximally. whether the base of the uvula. uvula. The surgeon will locate the hernial sac and tie this off. Class II: Soft palate.
D5NM solution was used for parenteral maintenance of routine daily fluid and electrolyte requirements with minimal carbohydrate calories from dextrose.Hydration: What fluid. The anesthesiologist also noted that general anesthesia results in a state where a patient would be unconscious and unable to feel pain . midazolam 1-2 mg IV can be given as premedication in the preoperative phase to reduce anxiety. inhaled anesthetics in the form of sevoflurane in oxygen was continued. Pre-operative hydration is instituted to help in maintaining intravascular fluid volume and thus renal function in the patient. Induction of anesthesia was facilitated by the use of midazolam 2 mg/IV. significant blood loss or fluid shifts and use of general anesthesia. benzodiazepines can be used a premedication as it provides anxiolysis and anterograde amnesia. Premedications In other patients. 1 day prior to surgery. Furthermore. started at 9:40 pm. premedications can be considered by the anesthesiologist to help ease the patient prior to surgery. A muscle relaxant was also given in the form of rocuronium 6 mg/IV. Furthermore. propofol 50 mg/IV. One should consider discontinuing aspirin if the risk of bleeding is greater than the risk of thrombosis. For maintenance. and for surgeries with serious risks for bleeding. General anesthesia was chosen for the patient since she might develop difficulty tolerating the procedure due to anxiety or discomfort owing to her young age. Why? Fluid: D5NM 1 liter to run at 60 cc / hour. the adequacy of arterial blood pressure control. fentanyl 40 micrograms/IV. For example. two puffs can help in preventing bronchospasm. intravenous hydration in the preoperative period will also help in decreasing both postoperative nausea and vomiting. and the anticipated anesthetic and intravascular volume concerns. Why? No maintenance drugs or premedications were given prior to surgery. as well as pain. albuterol. with sevoflurane in oxygen. the degree of cardiac dysfunction. when started. why? No drugs that needed to be discontinued in the patient. Pain on injection can be reduced by use of an opioid or coadministration with lidocaine. Medications to be taken prior to surgery including important maintenance drugs and premedication if any. Continuing or discontinuing medications depends on the intravascular volume and hemodynamic status of the patient. ACE inhibitors and ARBs can cause refractory hypotension especially with lengthy procedures. Meanwhile. 12 INTRAOPERATIVE MANAGEMENT Anesthetic Technique: Patient was placed under general anesthesia. Drugs that need to be discontinued if any.
transient apnea: maintain ventilation via bag mask ventilation or mechanical ventilation Drowsiness: flumazenil Pain during IV injection: can give premedication with tramadol or coadminstration with lidocaine. drowsiness. adverse effects. treatment for adverse effects): Medication Midazolam Site of Action Central nervous system and the spinal cord (for muscle relaxation) Mode of Action activation of the GABAA receptor complex and enhancement of GABA-mediated chloride currents. mitigating the transfer of painful sensations to the brain. transient apnea. The anesthesiologist cited the following factors for choosing general anesthesia in the patient: Reduced intraoperative patient awareness and recall Allows proper muscle relaxation for prolonged periods of time Facilitates complete control of airway. leading to hyperpolarization of neurons and reduced excitability Adverse Effects Decreased respiratory rate. bradycardia.during the medical procedure. producing effects that culminate in hyperpolarization of the cell and reduction of neuronal excitability. leading to activation of the G protein. nausea/vomiting. breathing and circulation Can be administered rapidly and is reversible Pharmacology of drugs used in anesthetic technique (site and mode of action. muscle rigidity. pain during IV injection Fentanyl Opioids exert their therapeutic effects at multiple sites. . urinary retention Treatment of Adverse Effects Decreased respiratory rate. which are typical of the G protein– coupled family of receptors. They inhibit the release of substance P from primary sensory neurons in the dorsal horn of the spinal cord. Respiratory depression. For respiratory depression: secure airway and control ventilation via bag mask or mechanical ventilation Bradycardia: use atropine Muscle rigidity: rocuronium (a nondepolarizing muscle relaxant) or naloxone Nausea and vomiting: maintain adequate . opioid-induced ileus. pupillary constriction. Opioid actions in the brainstem modulate interacts with opioid receptors.
Opioids probably change the affective response to pain through actions in the forebrain. Pupillary constriction and opioid-induced ileus: treat with naloxone potentiation of the chloride current mediated through the gaminobutyric acid type A (GABAA) receptor complex Hypotension. pruritus. bradycardia. nausea.Propofol nociceptive transmission in the dorsal horn of the spinal cord through descending inhibitory pathways. pain on injection site Hypotension: phenylephrine or ephedrine Bradycardia: atropine Pain on injection site: premedication with opioid or coadministration with lidocaine Respiratory depression: secure airway and control ventilation with bag mask ventilation or mechanical ventilation Transient hypotension: treat with phenylephrine or ephedrine Transient hypertension: provide adequate medications for pain during induction to reduce the risk of increased BP due to stress response as a result of Rocuronium Motor end plate Intermediateacting Nondepolarizing neuromuscular blocking agent that competes with acetylcholine for cholinergic receptors at the motor end plate. respiratory depression. transient hypertension. Transient hypotension. severe rash. vomiting . Central nervous system hydration and can give metoclopramide if with continued nausea and vomiting.
Sevoflurane Central Nervous System induces a reduction in junctional conductance by decreasing gap junction channel opening times and increasing gap junction channel closing times. Nausea and vomiting: maintain adequate hydration and provide metoclopramide or other antiemetics as needed (propofol also has antiemetic properties) Severe rash. Apnea: secure airway and control ventilation via bag mask or mechanical ventilation Nausea and vomiting: maintain adequate hydration and provide antiemetics such as metoclopramide as needed (propofol also has antiemetic properties). pruritus: treat with epinephrine Cough: Leaving the endotracheal tube cuff deﬂated after intubation until a patient reaches a deep level of anesthesia may be helpful in coughing. the large conductance Ca2+ activated potassium Apnea. Increased saliva: suction secretions . It also appears to bind the D subunit of ATP synthase and NADH dehydogenase and also binds to the GABA receptor. cough intubation. Sevoflurane also activates calcium dependent ATPase in the sarcoplasmic reticulum by increasing the fluidity of the lipid membrane.
Adverse Events if any. how were these managed? No adverse events noted during the course of the intraoperative procedure. increasing the pain threshold by inhibiting both isoforms of cyclooxygenase. COX-2. rash. and COX-3 enzymes involved in prostaglandin (PG) synthesis Adverse Effects Hepatotoxicity.why were these given? No adjuvants were given to the patient. the glutamate receptor.g metoclopramide) Anaphylaxis: discontinue drug and give epinephrine Adjuvants given if any. COX-1. vomiting. vomting: provide antiemetics (e. and the glycine receptor. nausea. . Medication Paracetamol Site of Action Primarily in CNS. pruritus anaphylaxis Treatment of Adverse Effects Hepatotoxicity: careful assessment of patient’s risk factors for possible liver disease Nausea.channel. Shivering: can treat with dexmedetomidine 13 POSTOPERATIVE MANAGEMENT Patient was given paracetamol 300 mg/IV as analgesic in the post-operative period. also in endothelial cells Mode of Action Act primarily in the CNS.
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