Wednesday, June 17, 2015
Saturday, June 13, 2015
Diabetes a nightmàre for anaesthesiologists
Type II DM is quite common in patients undergoing surgical procedure. Some times in quite a sizable no of patients it is detected at the time of screeing for operation. However insignificant it may be , it can cause havoc even death . Here are some case reports.
CASE 1
In earlier years of my anaesthesia practice, A relative young man of 35 yrs old was posted for Laparotomy and proceed for suspected peptic perforation. An emergency proicedure. There was no History of Diabetes from clinical examination. He was induced with Thiopentone , Scholine sequence of intubation followed by N2O+ O2 and ether anaesthesia with spontaneous respiratiobn with a boyles machine and Maggils semi open circuit was used.Additional Intra operative relaxation was provided with small doses of scholine and a deeper levels of ether anaesthesia.The intra operative monitors were BP, Pulse,Resp, Pupil and reflexes. At the end of surgery patient was extubated and sent to ward to recover slowly .The patient had gradually deeper levels of Comma and died finally. A blood sample taken and sent while comatose for blood sugar. The report received after death showed to be more than 600 mg%.
CASE 2.
A 62 yr old man underwent TURP under Spinal anaesthesia. He was mildly diabetic and received 6-4-6 units of insulin pre operatively. At the end of surgery it was observed on the table that there was still bleeding from the prostatic fossa. Surgeon wanted to inspect it again. As the effect of anaesthesia was still there , the surgeon proceeded and started to look for the bleed. And tried to remove some more prostatic t8ssue. As it took some time the pt started to be restless, So a GA was instituted with thio-Pentazocin-Midazolam and Vecuronium combination. After about 1 hr of GA there was delay in return of resp activity and fluctuations of BP, tachycardia . The patient was put on ionotropic support and ventilator. There was no facility to do bed side blood sugar estimation but with each dextrose containing solution 5 units of insulin was given. By next 4 hours pts condition detoriated , unresponsive , hypotensive and died. A blood sample collected before death for blood sugar showed the value to be 368.
CASE 3.
A 58 yr old lady relative of a doctor was posted for Lap Cholecystectomy. During preop screening she was found to be diabetic witha a random blood sugar of 230mg.
She was put on an insulin subcutaneoußly at a titrating doses of insulin by evening her blood sugar was 98. As planned she underwent Lap Chol with pre op blood sugar of 135. The operation was uneventful so also recovery. Normal protocol for fluid therapy analgesic was followed. Post op blood sugar control was not veŕy rigid. 8 hrs post operative the patient became restless then tachycardia and hypotension. All support was given by the doctor relative . By next 6 hrs the pt became unresponsive , slowly collapsed and died at mid night.
CASE 4.
A 42 yr old man suffer3d from pelcic fracture. He was type II mildly diabetic . Was converted to insulin before surgery with a dose of 8-8-10 units. The surgery 2as supposed to last for 6 to 8 hrs. An combined spi al epidural was planned and adminstered. During the course of surgery bedside blood sugar was monitored and insulin was being given into the i v drip which varied from 6 to 10 units. The patient was sedàt2d with Midazolam of 5 mg1Inspite of insulin the blood sugar remained above 200mg. It was also observed the patient is developing tachycardia and mild hypotension around 90~100 mmHg. There was no significant blood loss. A combination of RL, DNS , Ns was being aďminstered. It was a matter of concern when the heart rate increased beyond 160. At this point an ABG (arterial blood gas) analysis was done It showed metabolic acidosis with a pH of 7.24 and a blood sugar of 285 and K 3.1. Now the patient was tretaed in line with diabetic keto acidosis. With 1.5 litres of NS. 40 mEq K and 50 ml of Sodi bicarbonate and 30 u its of insulin over the nexþ hour brought things under contŕol. The patient slowly revovered with reďuced heart rate and stable CVStatus IN NEXT 8 HRS TIME.
CASE 5
A 50 yeaŕ old man was undergoing lumber disecþomy/ root decompression for radicular pain in left limb. He was hefty with a body wt of 95 kg . Had a slightly raised blood sugar which is detected during screeing. He was converted to insulin therapy before opn and received 8-6-10 units of insulin regular and mixtard combination. Pre op blood sugar on the morning od surgery was 112 mg. The patient was induced with Midazolam 5mg Propofol 130 mg Pentazocin 30 mg and intubated with scholine and veron 6 mg aded to continue ventilation. Pt was positioned prone and operation started. Abour 20 mins through operation pt started sweating. There was no apparent reason. No hypoxia, Sodalime canister was warn. There was not much tachycardia. Hypoglycemia was thought of and a 5% DNS started . A blood sample for HGT showed to be 168. The blood was taken when the Glucose containing solution was on. There fore the next bottle was added with 8 units of soluble insulin . An injecgtion of atropine was given I/v. In next 20 mins or so the sweating decreased slowly and the patient was continued to be given NS 1000 ml to compensate for profuse sweating estimated to be not less than 1.5 lit.
The procedure was completed with release of pr on root and the patient was repositioned and reversed with prostigmine and atropine. The pt recovered completely.
CASE 6
A 68 YR OLD MAN WAS POSTED FOR cabg FOR DIFFUSE CORONARY ARTERY DISEASE .
He was diabetic but mild with daily insulin requirement of 16 units on;y
Immidiate post op period was stormy with diabetic keto acidosis and was treated accordingly. The cardio vascular instability during that period was finally diagnosed when an ABG was done and metabolic acidosis detected , which was treated accordingly wirth 1500 ml of NS, Sodi bicarb, Pottasium.and insulin infusion.
CASE 1
In earlier years of my anaesthesia practice, A relative young man of 35 yrs old was posted for Laparotomy and proceed for suspected peptic perforation. An emergency proicedure. There was no History of Diabetes from clinical examination. He was induced with Thiopentone , Scholine sequence of intubation followed by N2O+ O2 and ether anaesthesia with spontaneous respiratiobn with a boyles machine and Maggils semi open circuit was used.Additional Intra operative relaxation was provided with small doses of scholine and a deeper levels of ether anaesthesia.The intra operative monitors were BP, Pulse,Resp, Pupil and reflexes. At the end of surgery patient was extubated and sent to ward to recover slowly .The patient had gradually deeper levels of Comma and died finally. A blood sample taken and sent while comatose for blood sugar. The report received after death showed to be more than 600 mg%.
CASE 2.
A 62 yr old man underwent TURP under Spinal anaesthesia. He was mildly diabetic and received 6-4-6 units of insulin pre operatively. At the end of surgery it was observed on the table that there was still bleeding from the prostatic fossa. Surgeon wanted to inspect it again. As the effect of anaesthesia was still there , the surgeon proceeded and started to look for the bleed. And tried to remove some more prostatic t8ssue. As it took some time the pt started to be restless, So a GA was instituted with thio-Pentazocin-Midazolam and Vecuronium combination. After about 1 hr of GA there was delay in return of resp activity and fluctuations of BP, tachycardia . The patient was put on ionotropic support and ventilator. There was no facility to do bed side blood sugar estimation but with each dextrose containing solution 5 units of insulin was given. By next 4 hours pts condition detoriated , unresponsive , hypotensive and died. A blood sample collected before death for blood sugar showed the value to be 368.
CASE 3.
A 58 yr old lady relative of a doctor was posted for Lap Cholecystectomy. During preop screening she was found to be diabetic witha a random blood sugar of 230mg.
She was put on an insulin subcutaneoußly at a titrating doses of insulin by evening her blood sugar was 98. As planned she underwent Lap Chol with pre op blood sugar of 135. The operation was uneventful so also recovery. Normal protocol for fluid therapy analgesic was followed. Post op blood sugar control was not veŕy rigid. 8 hrs post operative the patient became restless then tachycardia and hypotension. All support was given by the doctor relative . By next 6 hrs the pt became unresponsive , slowly collapsed and died at mid night.
CASE 4.
A 42 yr old man suffer3d from pelcic fracture. He was type II mildly diabetic . Was converted to insulin before surgery with a dose of 8-8-10 units. The surgery 2as supposed to last for 6 to 8 hrs. An combined spi al epidural was planned and adminstered. During the course of surgery bedside blood sugar was monitored and insulin was being given into the i v drip which varied from 6 to 10 units. The patient was sedàt2d with Midazolam of 5 mg1Inspite of insulin the blood sugar remained above 200mg. It was also observed the patient is developing tachycardia and mild hypotension around 90~100 mmHg. There was no significant blood loss. A combination of RL, DNS , Ns was being aďminstered. It was a matter of concern when the heart rate increased beyond 160. At this point an ABG (arterial blood gas) analysis was done It showed metabolic acidosis with a pH of 7.24 and a blood sugar of 285 and K 3.1. Now the patient was tretaed in line with diabetic keto acidosis. With 1.5 litres of NS. 40 mEq K and 50 ml of Sodi bicarbonate and 30 u its of insulin over the nexþ hour brought things under contŕol. The patient slowly revovered with reďuced heart rate and stable CVStatus IN NEXT 8 HRS TIME.
CASE 5
A 50 yeaŕ old man was undergoing lumber disecþomy/ root decompression for radicular pain in left limb. He was hefty with a body wt of 95 kg . Had a slightly raised blood sugar which is detected during screeing. He was converted to insulin therapy before opn and received 8-6-10 units of insulin regular and mixtard combination. Pre op blood sugar on the morning od surgery was 112 mg. The patient was induced with Midazolam 5mg Propofol 130 mg Pentazocin 30 mg and intubated with scholine and veron 6 mg aded to continue ventilation. Pt was positioned prone and operation started. Abour 20 mins through operation pt started sweating. There was no apparent reason. No hypoxia, Sodalime canister was warn. There was not much tachycardia. Hypoglycemia was thought of and a 5% DNS started . A blood sample for HGT showed to be 168. The blood was taken when the Glucose containing solution was on. There fore the next bottle was added with 8 units of soluble insulin . An injecgtion of atropine was given I/v. In next 20 mins or so the sweating decreased slowly and the patient was continued to be given NS 1000 ml to compensate for profuse sweating estimated to be not less than 1.5 lit.
The procedure was completed with release of pr on root and the patient was repositioned and reversed with prostigmine and atropine. The pt recovered completely.
CASE 6
A 68 YR OLD MAN WAS POSTED FOR cabg FOR DIFFUSE CORONARY ARTERY DISEASE .
He was diabetic but mild with daily insulin requirement of 16 units on;y
Immidiate post op period was stormy with diabetic keto acidosis and was treated accordingly. The cardio vascular instability during that period was finally diagnosed when an ABG was done and metabolic acidosis detected , which was treated accordingly wirth 1500 ml of NS, Sodi bicarb, Pottasium.and insulin infusion.
Saturday, May 16, 2015
A HURRIED SURGEON CAN HARM A PATIENT
A 16 year old boy was posted for removal of ureteric stone on his left side . A patient of ASA—I without any known problem. The stone was of small size was said to be close to ureteric opening to bladder.
The patient was given spinal anaesthesia in sitting position with a 25 G needle a dose of 2 ml ( 10 mg ) bupivicaine Heavy with the idea that the procedure will be over quickly.
The patient was positioned lithotomy and the surgeon proceeded after 10 mins of anaesthesia after sterilization draping the legs etc etc .
Some how the procedure was difficult . The ureteric orifice could not be located and identified. After what was thought to be ureteric orricie the instrument could not be negotiated . The surgeon was struggling there for more than 90 mins when he decided to remove the stone by oprn method.
The patient was repositioned .
While I was preparing the drugs for induction of anaesthesia and setting up the Laryngoscope tube etc, surgeon hurried applied betadine antiseptic and draping . Without any check put an incision slightly obliquely above the inguinal region for an extraperitonial approach.
Suddenly the patient gave a cry and moved all his body with a convulsive movement for anout 10—15 seconds. The drape the pulse oxymetre probe came off and the saline stand fell down. While we were looking at those things and fixing the ECG leads and probe etc the patient was found to be quite and unresponsive . The pulse in oxymetre probe was absent . When radial pulse was palpated , there was nopulse. Cardiac arrest has occurred. The assistant was asked to prepare an adrenaline injection diluted to 10 ml. Cardiac massage was started with a thump on his chest.
Simultaneously Obygen mask was applied to face and two breaths was delivered. With that the heart beat returned and radial pulae was felt. Afetr about another 10 seconds the respiratory activity returned when the patient was intubated with a small dose of Midazolam 2 mg . After observing the vital parameters for next 15 mins. Aditional doses of Ketamine 25 mg, Analgesic fortwin 15 mg was administered followed by muscle relaxant Nitrous oxide was added and the surgeon was asked to proceed .
The surgeon now proceeded more carefully and it was all over in another 45 mins.
The patient was reversed as usual and had a complete recovery without any neurologic problem
FB in trachea
A 20 year old male son of a doctor presented with #nasal bone for fixation. Or of ASA-I the procedure was completed with GA with atropin thiopentone scholine vecuron. Elevation of #pieces done with with an external application of plaster. A nasal pack was given to both nostrils individually. Tongue tie was applied to prevent fall of tongue and easy mouth breathing. Anesth was reversed and after satisfactory recovery , sent to ward. 15-20 mins later emergency call was given for the patient had difficulty in breathing and cyanosis.
The patient was attended within minutes .The pattern of respiration indicated acute airway obstruction with severe indrawing of chest wall. The pt was cyanotic and unresponsive. The patient was intubated on the ward bed. While trying to ventilate with an Ambu there was much resistance and not knowing what to do brought the patient to OT . Connected to anaesthesia machine but still not possible to ventilated. The pulse oxymeter could not show any pulse.. I could feel the patient has arrested and lying flaccid. The ET tube wasRemoved and tried to visualise what was in trachea. With flaccid and wide open glottic opening, I could see something whitish deep down the trachea. That object was beyond the reach of Maggils forceps. Fortunately a long foreign body forceps was available with that I could catch the whitish object. Lo it was one of the nasal pack.. (picture below). The father a doctor who was present in OT collapsed on the floor with vasovagal attack Pt was reintubated a few cardiac massage and a thump on the chest wall the heart activity returned and within 20 mins the patient regained full consciousness.Pt was treated for possible hypoxic brain injury. The patient recovered completely without any residual damage.
pICTURE OF FOREIGN BODY
Monday, March 23, 2015
Hypothyroidism should not be under estimated
Two cases of hypothyroidism is describedhaving different outcome
CASE-1
Mrs N D, 67 yrs female was posted for rt sided knee replacement.. She was somewhat hefty 75 kg. No h/o hypertension, asthma. allergy, She was diabetic which is wel controlled.She was hypothyroid on medication for long time. All routine investigations were within normal limits and had a stable cardio Vascular status. There was a small rise in TSH 9.8. A repeat test showed TSH .6.7 Such a trivial thyroid dysfunction was taken very seriously. As planned she was given an epidural injection.
The operation went on well. Pt was resting well without any complaints with repeated doses of epidural. By 24 hours she had a renal suppression with very low urine output inspite of normal if fluid. She had not any episodes of unusual hypotension.
Whilre re evaluating the case she was found to be unusually more sedated with a single dose of tramadol.and from other clinical features like edema, lethergy,weakness etc. was noticed. With addition of thyroxin 150mcg by oral route her condition very quickly improved.
CASE-1
Mrs N D, 67 yrs female was posted for rt sided knee replacement.. She was somewhat hefty 75 kg. No h/o hypertension, asthma. allergy, She was diabetic which is wel controlled.She was hypothyroid on medication for long time. All routine investigations were within normal limits and had a stable cardio Vascular status. There was a small rise in TSH 9.8. A repeat test showed TSH .6.7 Such a trivial thyroid dysfunction was taken very seriously. As planned she was given an epidural injection.
The operation went on well. Pt was resting well without any complaints with repeated doses of epidural. By 24 hours she had a renal suppression with very low urine output inspite of normal if fluid. She had not any episodes of unusual hypotension.
Whilre re evaluating the case she was found to be unusually more sedated with a single dose of tramadol.and from other clinical features like edema, lethergy,weakness etc. was noticed. With addition of thyroxin 150mcg by oral route her condition very quickly improved.
CASE-II
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