A female patient 60 years of age was posted for Lap Cholecystectomy.
On evaluation the patient had GI problem 2 weeks back with
acute cholecystitis, distention , vomiting etc for which she was treated
conservatively and was seent back home with advice for early surgery of Gall
bladder.
She
was slightly plum with big tummy weighing 68kg. No h/o HTN, but DM type II with
blood sugar at 130 mg% was given glucose
and 5 units of Insulin. Her Hb was 11.2gm% TLC 12400, Amylase, LFT, Urea
and creatinine , Sodium and Pottasium were within normal limits. During PAC she
had more complain about back ache and sciatica type pain than Gall bladder
discomfort or pain. Her ECG and cardiac
reserve appeared to be OK clinically with good air entry to both lungs.
She
was given an Injection Diclofenac aqua before surgery so that sciatica pain
will diminish and her anxiety will be resolved. She was premedicated with Midazolam 3 mg. Nalbuphine 20 mg after 10 mins induced withPropofol 100 mg and
intubated with ease with 7.5 mmET tube after succynyl chiline injection of
100mg. Connected to ventilator with low tidal volume of 375mg and resp rate of
20 /min . Injection of Vecuronium initially 3 mg . As a routine pre incision
procedure takes about 15 mins so another
2mg Vecuronium was added at this time a total of 5mg. And Halothane 0.8 % was
added. To the FGFlow mixture of O2 nd N2O going at 1.5l to 3.0 L/min
The procedure was uneventful
with minimal fluctuation of Vital
parameters of HR, BP, and SpO2. The skin to skin procedure lasted 22 mins. As
displayed on the timer clock on the wall of the OT.
As the surgery was over so soon
we were waiting for the muscle elaxant to wear off. With O2 and N2O mixture
running at 50:50. There was no respiratory effort till next 15 mins. We tried
to stimulate the resp with under ventilation and accumulation of CO2 to some
extent but not more tham 50 mmHg as shown in ETCO2 monitor. There was no CO2 in expired gas.
At this stage the surgeon wanted
to take up another case and finish his OT list and go to OPD.
But all my effort to stop N2O and stop ventilation for sometime did not help. With much hesitation
half of the mixture of Prostigmine 2.5mg and atropine1.2 mg ( diluted to 10 ml)
was given IV. Slowly. In next 5 mins there was a flicker of resp movement in
Bag and small CO2 curve appeared and being encouraged with that the rest of the
mixture was injected. By this time the next patient was standing by the OT for
spinal anaesthesia . More movement of resp
was noticed but still with a high expired CO2 of 60mm. But the coughed
on the tube and there was fall in Spo2 even with 100 % oxygen. So the patient
was extubated assuming that her respiration will be quiet and will improve over
next 5-10 mins. As soon as she was extubated the patient was shifted to trolley
and taken to Recovery room to accommodate the next surgical case.
In the recovery room the
patients breathing appeared to be inadequate with SpO2 less than 90%. An air
way was given respiration was watched . It was found that the patient was
showing signs of incomplete reversal
with jerky muscular movement of limbs and
inadequate respiratory movement. A second dose of Neostigmine atropine mixture
was given IV . Still there was no improvement. The big abdomen caused more embarrassment to respiratory
function. It was intermittently supported with Ambu bag and mask ventilation.
When ever there was some fall in Spo2 a little ambu bagging helped to regain
Spo2 to 100 %. In the process it was suspected that there is a stomach is
inflated with air and we tried to remove
the air introducuing a feeding tube
and were not sure how much was removed. The presence of feeding tube
made the bag mask ventilation difficult and therefore the patient was intubated
with a 7.5 mm tube on the recovery trolley as such with out any drug or
additional muscle relaxant. As such she resisted a little and intubation was
completed with ease .
As we tried several times with a
T –piece connection to maintain resp
,But the respiratory drive and
ventilation did not improve more Ambu
bagging support was needed to main Oxygen saturation and avoid CO2 retention
and sweating. Some secretion appeared in
the Et tube at this time it was felt probably the patient has aspirated with
some Gastric content during Ambu and
mask ventilation. So the patient was shifted to ICU for full and controlled
ventilation.
The patient was initially put on
Pressure control with SIMV FiO2 0.5 Pr
20cm Peep of 5 and SIMV rate of 12. IE ratio of 1:2 but spO2 was still low and
Ambu ventilation showed better SpO2. So the setting was changed to Pure pressure control Pr of 20cmH2O PEEP of
10 . f=15 I;E ratio of 1:1.5 FiO2 =0.6.
Over the next 15-20 mins patient was stabilized for SpO2, HR. BP was low
because of high Intrathoracic pressure and a rapid fluid and a small dose of
nor adrenaline helped. A small dose of
Lasix. Change of Antibiotics wasdone. By
next 4 hrs the pt was better with stable vitals and patient looking up.
Gradually Fi)2, PEEP and Pressure was reduced after overnight ventilation the
patient was extubated and transferred to
Ward with out any hassle.
Analysis:
1.
Fundamentally the process of reversal
should have been initiated after some respiratory activity is seen.
2.
The patient should not have been extubated just because started bucking on the
tube.
3.
Re intubation should have been planned earlier
4.
What ever way one ventilate with Ambu bag and mask. There is always chance of
air going to stomach.
5.
Chance of Aspiration regurgitation is
highest during this period and can not be ruled out.
6.
Persistent Hypoxic episode could lead to
pulmonary edema.
7. In this case development of pulm
edema could be either of the factors as mentioned above.
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| Lady who suffered |
