Post Operative Edema

Laryng
Introduction
• Laryngeal edema is a common cause of airway obstruction
after extubation
• Arise from direct mechanical trauma to the larynx by the
endotracheal tube
• The severity of airway obstruction due to laryngeal edema
varies
• In more severe cases, the edema can lead to acute respiratory
compromise necessitating emergency reintubation
Etiology and pathogenesis
• Endotracheal intubation can cause damage to the oropharynx,
larynx and trachea
• Pressure and ischemia are thought to contribute to mucosal
edema, which may subsequently progress and present as
inspiratory stridor within hours of extubation
• Respiratory distress develops in those patients with >50%
narrowing of the tracheal lumen
• Factors contributing to the development of laryngeal edema :
- the use of an appropriately large tracheal tube
- occurrence of trauma at tracheal intubation
- prolonged intubation
- coughing on the tracheal tube
- change in position of the patient’s head and neck during
surgery
Incidence
• Laryngeal edema occurs in nearly all intubated patients, only
some of them develop clinical symptoms
• Laryngeal edema is therefore usually transient and self-limiting.
• Clinical signs associated with laryngeal edema develop rapidly
following extubation.
• About 15% of all reintubations are performed because of post-
extubation laryngeal edema
• Post-extubation stridor (PES) is accepted as a clinical marker of
laryngeal edema following extubation
• Stridor is commonly defined as a high-pitched sound produced
by airflow through a narrowed airway
Therapy
• Maintaining the airway, adequate oxygenation and relieving
distress associated with obstruction  primary treatment goals
• Several treatment modalities, including reintubation, are available
• Intubation in the presence of edema obstructing the airway is life-
saving, but may also prove difficult because of impediment of
vision
• Medical therapeutic strategies include systemic administration of
steroids
• Dose of 0.5 mg/kg prednisolone intravenously per day
 Child with Down Syndrome
• The trachea is smaller in children with DS than in children without DS
• This has important implications for clinicians who might intubate children with DS, and it is
recommended that a smaller endotracheal tube is used than would be expected for the
patient’s weight.
• Tracheal bronchus is a congenital anomaly seen in DS consisting of an aberrant or accessory
bronchus arising from the trachea.
• While this may be an incidental finding, it may also be associated with respiratory disease,
particularly recurrent right upper lobe pneumonia
Child with Down Syndrome
Size and Distance of insertion of ETT
OK GBPT 405
11
An. Takziyatul / 3 tahun / 13 kg / 12704567 MOS

Diagnosa MAR post PSARP + attention to sigmoidostomi

PS ASA PS ASA 2
- Kelainan kongenital
- Down syndrome
- Anemia (10,4)
- Slight hipoalbumin (3,3)
- TR ringan

Tindakan Tutup stoma

Anestesi GA caudal
Ruang Bedah H
Pasien riwayat tidak punya anus sejak lahir,
kemudian dilakukan stoma satu minggu setelah V : Tidak ada kelainan
lahir. Tahun 2020 dilakukan PSARP. Riwayat alergi A : Malformasi Anorectal
disangkal C : tidak terdengar murmur, tidak ada septal defek
T : tidak ada kelainan
R : Tidak ada kelainan renal
L : Tidak ada kelainan limb

18/05/2021

Hb 10,4 BUN 10 OT 34 Swab negati

PCR f

Hct 33,2 SK 0,5 PT 22

Wbc 5.470 Alb 3,3 Na 143

Plt 442.000 aPTT 24,1 K 4,3

GDA 84 PPT 11 Cl 112

13
Kondisi pre operatif di bedah H :
B1 : Jalan napas bebas, napas spontan, RR
22x/m mgg, SpO2 99%. Tidak ada rhonki
wheezing
B2 : Akral hangat, naadi 108x/menit,Bunyi
jantung reguler, tidak ada murmur
B3 : GCS 456, Gerak tangis cukup
B4 :BAK spontan via pampers
B5 Abdomen supel, terpasang stoma
B6 : edema tidak ada, suhu 36,6
18/05/2021 15.00
WIB
POC dengan Dr. dr. Christrijogo,
SpAn, KIC.KAR
Advis :
Acc dikerjakan dengan GA caudal
Keadaan saat di OK GBPT
B1 : Airway bebas, RR 22x/menit, SpO2 99%
dengan O2 ruangan
B2 : HR 110x/menit
B3 : gerak tangis cukup
B4 : BAK spontan via pampers
B5 : Abdomen supel, terpasang stoma
B6 : Oedema tidak ada, suhu 36,5C
18/05/2021 08.00 19/05/2021 08.15
WIB WIB
Induksi di OK:
- Insuflasi dengan sevoflurane
- Fentanyl 20 mcg
Dilakukan intubasi dengan ETT cuff
No 5,0 dengan batas bibir 15cm
Evaluasi suara napas kanan kiri
simetri
14
Ditemukan Balans Cairan Durante op
- Stoma
Input
RL 260ml
Dilakukan
- Pembebasan stoma Output
- Tutup stoma Urin 40ml

19/05/2021 19/05/2021
09.00 – 13.00 WIB 09.00 – 13.00 WIB

Hemodinamik durante
operasi:
- Nadi 110 - 115
- etCO2 33 - 35

15
Keadaan saat di RR Evaluasi oleh timped
B1 : Airway bebas, RR 22x/menit, SpO2 99% B1 airway bebas, RR 28x/m SpO2
dengan O2 ruangan, tidak ada rhonki wheezing 95-96% dengan O2 SM 4lpm,
B2 : akral hangat HR 107x/menit didapatkan rhonki di kedua
B3 : GCS 456, gerak tangis cukup lapang paru
B4 : BAK via kateter
B5 : Abdomen supel Tidak tersedia masker dan JR
B6 : suhu 36,4 C pediatri di bedah H

19/05/2021 13.30
21/05/21 03.30 WIB 21/05/21 06.30 WIB
WIB

Pesanan Post Op
Planning Dx : Cek DL
Diruangan Bedah H, didapatkan
Planning Terapi :
Infus D5 1/4NS 65ml/jam sampai intake oral stridor inspirasi.
●
adekuat Airway bebas, RR 28x/m SpO2
● Paracetamol 200mg/8jam IV 95-96% dengan O2 SM 4 lpm.
Terdengar rhonki
Planning Mx = Evaluasi Tanda Vital, Tanda obstruksi
jalan nafas, balans cairan, Kesadaran

16
 Keadaan saat di RES
Melaporkan pasien ke konsultan B1 : Airway bebas, RR 28x/menit, SpO2 B1 : Airway bebas, support ventilator
bidang minat Dr. dr. Arie Utariani, 96% dengan O2 ruangan, rhonki +/+ mode PSIMV, SpO2 99%
SpAn, KIC.KAP B2 : HR 120x/menit B2 : HR 116x/menit
Advis : B3 : GCS 456 B3 : GCS sedasi
Bantu oksigenasi, jika perlu B4 : BAK via kateter, B4 : BAK via kateter,
lakukan intubasi, pasien dorong B5 : Abdomen supel B5 : Abdomen supel
ke RES B6 : suhu 37 C B6 : suhu 37 C

21/05/2021 06.45
07.00 WIB 07.30 WIB
WIB

Dilakukan intubasi dengan

menggunakan Fentanyl 20mcg,
Propofol 20 mg, Atracurium 6
mg
Dengan ETT cuff no 4,5, batas
bibir 15 cm,

Evaluasi suara napas kanan kiri

simetris

17
 Keadaan saat di ICU :
B1 : Airway bebas, support ventilator B1 : Airway bebas, support ventilator
mode PSIMV, FiO2 50% SpO2 100% mode PSIMV, SpO2 99%
B2 : HR 116x/menit B2 : HR 120x/menit
B3 : GCS sedasi B3 : GCS sedasi
B4 : BAK via kateter, B4 : BAK via kateter,
B5 : Abdomen supel B5 : Abdomen supel
B6 : suhu 37 C B6 : suhu 37 C

07.30 WIB 10.30 WIB

pH 7,262
pCO2 36,9 Terapi :
Dexa 2,5mg tiap 8jam
pO2 309 Paracetamol 200mg tiap 8 jam
Infus D5 1/4NS 65ml/jam
Nebul Pulmicort tiap 8 jam
HCO 16,7
3
BE -10
19
SO2 100%
ICU H-2 pH 7,394 ICU H-3
B1 : Airway bebas, support ventilator B1 : Airway bebas, support ventilator
mode CPAP Ps 8, PEEP 3 FiO2 30%
tercapai MV 2,0 TV 130 Ppeak 11 Ftot
pCO2 30,5 mode CPAP Ps 5, PEEP 3 FiO2 30%
tercapai MV 2,8 TV 148 Ppeak 8 Ftot
14-16 , SpO2 99%, ves/ves/ rhonki -/- 22 , SpO2 99%, ves/ves/ rhonki -/-
B2 : perfusi HKM, tensi 112/65HR pO2 151,8 B2 : perfusi HKM, tensi 95/54HR 120x/
120x/menit menit
B3 : GCS sedasi HCO 18,8 B3 : GCS sedasi
B4 : BAK via kateter
B4 : BAK via kateter
B5 : Abdomen supel 3 B5 : Abdomen supel
B6 : suhu 37 C B6 : suhu 37 C
BE -4,5
22/05/2021 07.00 SO2 99, 23/05/2021 07.00
WIB WIB
7%
A : Post tutup stoma H-3 pf 506 A : Post tutup stoma H-4
Terapi : Terapi :
Paracetamol 200mg tiap 8 jam Paracetamol 200mg tiap 8 jam
Sp dexmedetomidine 0,65ml/ Sp dexmedetomidine 0,65ml/
jam jam
Sp midazolam 1ml/jam Sp midazolam 1ml/jam
Infus D5 1/4NS 65ml/jam Infus D5 1/4NS 65ml/jam
Sonde D5 8x15ml Sonde Peptamen Jr 8x15ml
Nebul Pulmicort tiap 8 jam Nebul Ventolin+PZ tiap 8 jam

20
 Conclusion
• Endotracheal intubations may lead to chronic inflammation and scarring of
the subglottic airway
• Laryngeal edema is a common cause of airway obstruction after extubation
• Post-extubation stridor (PES) is accepted as a clinical marker of laryngeal
edema following extubation
• Patients with Downs’s syndrome should be intubated with an endotracheal
tube 0.5–1.0 mm diameter smaller than the standard age-appropriate
endotracheal tube size.
• There are the likely components of both congenital and iatrogenic stenosis
contributing to subglottic pathology in these patients
TERIMA KASIH