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Jennifer A.

Macaraig NKTI

General Data
y H.P., 37 y/o male, known case of CKD 2o Diabetes

Mellitus x 7 yrs, on Insulin 1 yr admitted last June __

History of present illness

Past Medical History


y Chronic Kidney Disease 2o DM Nephropathy since Oct 2008, ,

on hemodialysis 2x/wk y Previously admitted last March 2009 s/p BKA (3/30/09) discharged as:
y y y y

CKD 2o DMN Gangrenous DM foot, R Delirium 2o general medical condition VS medications s/p BKA, R & AVF creation, L brachiocephalic

y (-) Hypertension (-)Bronchial asthma y (?) Peripheral artery occlusive disease y Coronary artery disease suspect y No known allergies

Family History

Personal & Social history


y (+) smoker y Occasional alcoholic beverage drinker

Review of Systems
(-) weight loss (-) cough, colds, fever (-) rashes, joint pains (-) chest pain (-) orthopnea (-) PND (-) palpitations (-) hemoptysis (-) easy bruisability (-) seizures (-) neurologic deficits (-) change in blower & bladder habits

Physical Examination
y Conscious, coherent, ambulatory, not in y y y y y

cardiorespiratory distress BP HR RR T 3C Pale palpebral conjunctiva, anicteric sclerae No palpable cervical LN Symmetrical chest expansion, no retractions, clear breath sounds Adynamic precordium, tachycardic, regular rhythm, AB at 5th LICS, MCL

Physical examination
Globular abdomen, normoactive bowel sounds, nontender, no massess Extremities: (+) stump, R leg w/ multiple necrotic abscess, L leg, hypopigmented, dry, no edema w/ multiple necrotic abscess, pulses decreased Neuroligic exam: y Conscious coherent, oriented to 3 spheres y Intact cranial nerves y No motor or sensory deficit y No nuchal rigidity y No babinski

Initial impression
y Non healing wound R, stump and left leg, s/p BKA,

right y Plan:
y Wound debridement R stump & L leg

Diagnostics
y Cbc : (6/9) Hb 9.1 Hct 28 wbc 10.78 plt 168 y (6/6) Crea = 4.8, K = 3.8, Na = 135 y ABGs =pH 7.5 pCo2 36 HCO3 28.1 PO2 66 SPO2 94%

Therapeutics
y Antibiotics --y Hemodialysis, last done 6/8/09 y (+) nephrology clearance

Preoperative evaluation
y Conscious, coherent, slightly anxious, weak looking y y y y y

not in CP distress Obese (-) dyspnea, orthopnea E/N chest & lung findings Mallampati --Plan: IV sedation or general anesthesia
y No premedications given

Intraoperative course
1:50 PM 1:55 PM

Patient received awake, with high back rest, anxious IVC g 24 @ RH w/ heplock, PNSS started Hooked to O2 @ 2-3 LPM per nasal cannula VS: BP 140/90 HR 95 RR 20 SPO2 99%

IV induction started Midazolam 1.5 mg, Fentanyl 75 ug, Propofol 40mg VS: BP 148/92 HR 100 SpO2 99%

2:00 PM

2:10 PM

2:20 PM

Operation started BP 148/92 HR 105 spO2 99%

BP 80/50 HR 40s Atropine 1mg/IV x3 Ephedrine 5mg/IV

Continued bradycardia & desaturation GAFM initiated

2:25PM

2:45 PM

End of operation ETT 8.0 UDV w/ MAC 3 w/o stylet x3 Development on ventricular fibrillation BP 0/0 HR 0/0 SpO2 0% CPR started

Defibrillation x3 @ 200J Epinephrine 1 amp x 5 Calcium gluconate 1 amp/IV NaHCO3 1amp

BP 80/30 HR 110 spO2 50-60% Dopamine drip started ABGs taken Ph 7.07 PO2 63 PCO2 68 HCO3 19.7 SpO2 80% FIO2 100

3:00PM

3:30PM

BP 130/100 HR 130s SPO2 60-70% Dopamine drip decreased to 10 cc/hr, Dobutamine drip started @ 20 cc/hr

BP 100/70 HR 90s Dopamine drip off Patient hooked to MV SPO2 gradually increased to 90s% GCS E1VTM1 Pupils fixed dilated

Lab post op: ABG 5pm pH 7.68 pO2 389 pCO2 19 HCO3 22.4 SpO2 100% ABG 8pm pH 7.54 pO2 123 pCO2 27 HCO3 23.1 SpO2 99%

Salient features
y CKD 2o DMN y t/c CAD y t/c PAOD y s/p CP arrest y Prolonged hypoxemia

Cardiac arrest
y Abrupt cessation of cardiac pump function which may

be reversible by prompt intervention but will lead to death in its absence y Primary cardiac arrest
y Those that occur in the absence of hemodynamic

instability

y Secondary cardiac arrest y Those that occur in whom abnormal hemodynamics predominate the clinical picture before cardiac arrest

Structural causes of cardiac arrest


y Coronary heart disesase y Coronary artery abnormalities y Myocardial Infarction y Myocardial hypertrophy y Secondary y Hypertrophic cardiomyopathy y Dilated cardiomyopathy y Inflammatory &

infiltrative disorders y Valvular heart disease y Electrophysiologic abnormalities


y Anomalous pathways in

WPW syndrome y Conducting system disease y Membrane channel structure

Functional contributing factors


y Alterations in coronary y Systemic metabolic

blood flow
y Transient ischemia y Reperfusion after

abnormalities
y Electrolyte imbalance y Hypoxemia, acidosis

ischemia

y Low cardiac output

y Neurophysiologic

states
y Heart failure y Shock

disturbance y Toxic responses

Cardiac arrest
y Cardiac disorders constitute the most common cause

of cardiac arrest y Ventricular fibrillation = most common electrical mechanism for true cardiac arrest y Death during hospitalization after resuscitation relates closely to the severity of CNS injury
y Anoxic encephalopathy y Infections susbsequent to prolonged respirator

dependence

Pulmonary arrest
y Sudden interruption of pulmonary-gas exchange y primary respiratory arrest y caused by airway obstruction, decreased respiratory drive, or respiratory muscle weakness y Secondary respiratory arrest y result of circulatory insufficiency

Causes of Apnea
y y y y y y y y y y

Asthma or other lung diseases Cardiac arrest Choking Drug overdose, especially due to alcohol, narcotic painkillers, barbiturates, anesthetics, and other depressants Obstructive sleep apnea Other causes of apnea include: Head or brain stem injury Irregular heartbeat Metabolic disorders Near drowning

Respiratory acidosis
y Can be due to: y Severe pulmonary disease, respiratory muscle fatigue or abnormalities in ventilatory control y Increased in PaCO2 and decrease in pH

Causes of respiratory acidosis


y Central y Drugs (anesthetics, morphine, sedatives) y Stroke y Infection y Airway y Obstruction y Asthma y Parenchyma y Emphysema y Pneumoconiosis y Bronchitis y ARDS y barotrauma y Neuromuscular disorders y Poliomyelitis y Kyphoscoliosis y Myasthenia y Muscular dystrophies y Miscellaneous y Obesity y Hypoventilation y Permissive hypercapnea