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- Sep 19, 2018
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Dear SDN Anesthesiologists,
I hope you are doing well, yesterday night, I had a tough 24 hours emergency surgeries’ shift, my call then started at 0530 PM with Knee injury and the vascular team required to do popliteal veins exploration and this operation lasts 4 hours plus orthopedic intervention, the total cases I gave anesthesia with the help of my PGY1 and our team leader (CA3) were 8 cases, 3 appendectomies (20 male one with history of epilepsy, 16 years heavy smoker, and one child 11 years old with a weight of 125 Ibs), two other perianal abscesses (one child 11 months old, one female heavy smoker 30 years old), last case was posterior hip dislocation – pregnant 7 miss periods – this case ended up my shift at 0200 AM.
The case I am talking about was obstructed umbilical vs para umbilical hernia, 55 years old female, weight around 300 Ibs if not more) with a past medical history of diabetes and hypertension. Patient obesity was more central, on examination in the operating theatre, once supine her sat O2 was less than 95%, her Bp was 177/104 mmhg, her pulse was like 90s. The bed elevated from her head side about 30 degrees, her sat became 97%, clear chest no added sounds.
After getting the consent till (death) from their family, I called my CA3 Senior resident – the team leader, to come and to provide me with opioids, you know we have shortages.
Induction:
Patient placed head – bed up, preoxygenated with Nasal Cannula 6 Lt, and Ventilator mask for more than 3 minutes, the induction done with multimodal analgesia as follows (with anesthetics):
Patient woke up from scoline around 10 minutes later, with high Peak Pressure 40 cmH2O, then given atracurium 30 mg (long operation), patient relaxed, but blood pressure went up to 180s/110s mmhg, then given another Fentanyl 50 mcg with Pethidine 25 mcg.
Fluid was given 2 liters during the operation, but the Bp kept up, I tried to give her Angisid (GTN) 10 mcg, but she desaturated to 92% briefly, then went up to 95%, I didn’t have good emergent Beta blockers unfortunately except Metoprolol, but I decided to give her 1 mg of it prior to extubation and I did.
Prior to closure of the subcutaneous tissue after removing 3 pounds of fat and omentum stuck with the sac plus skin (they did lower umbilical transverse incision – wide enough like over 10 inches, could’ve more, same as the incision of pfannenstiel incision), I prepared my Lidocaine in two syringes, each one with 10 ml, 2% diluted to 12 ml (>1.5%) and gave her TAP petit triangle block, using regular needle and could manage the depth with skin stretching and feeling the first pop of the skin (I blunted out the tip) and the second pop of external oblique.
Operation finished, and I woke her up with SIMV/PC Ventilation, then PSVPro mode, and did suction, the patient with her ETT in, was able to protrude her tongue out and elevate her neck, beside opening her eyes. I extubated her and put her on Nasal Cannula 6 Liter and saturation was 98% and didn’t drop, the patient was amazingly saying “did you do the operation”, I tried to touch the wound dressing and without pain noticed, she was able to speak, elevate her head and she moved herself to the next stretcher without pain, I sent her with face mask 10 Lt oxygen to the surgical ward, and semi stting position 45 degrees, patient in the morning is well, feeling better.
What should’ve done more according to the limited resources I have, rate my approach 0 – 10 😊, did I pass this challenging case? Were something needs to be addressed? This is my first multimodal analgesia - surgical anesthesia!
Love and Peace,
Dr Amir Al Shimmarii, PGY3 aka CA2
Iraqi Board in Anesthesia and Intensive Care,
Al Imamain Al Kadhimain Medical City
North of Baghdad / Iraq
I hope you are doing well, yesterday night, I had a tough 24 hours emergency surgeries’ shift, my call then started at 0530 PM with Knee injury and the vascular team required to do popliteal veins exploration and this operation lasts 4 hours plus orthopedic intervention, the total cases I gave anesthesia with the help of my PGY1 and our team leader (CA3) were 8 cases, 3 appendectomies (20 male one with history of epilepsy, 16 years heavy smoker, and one child 11 years old with a weight of 125 Ibs), two other perianal abscesses (one child 11 months old, one female heavy smoker 30 years old), last case was posterior hip dislocation – pregnant 7 miss periods – this case ended up my shift at 0200 AM.
The case I am talking about was obstructed umbilical vs para umbilical hernia, 55 years old female, weight around 300 Ibs if not more) with a past medical history of diabetes and hypertension. Patient obesity was more central, on examination in the operating theatre, once supine her sat O2 was less than 95%, her Bp was 177/104 mmhg, her pulse was like 90s. The bed elevated from her head side about 30 degrees, her sat became 97%, clear chest no added sounds.
After getting the consent till (death) from their family, I called my CA3 Senior resident – the team leader, to come and to provide me with opioids, you know we have shortages.
Induction:
Patient placed head – bed up, preoxygenated with Nasal Cannula 6 Lt, and Ventilator mask for more than 3 minutes, the induction done with multimodal analgesia as follows (with anesthetics):
- Lidocaine 100 mg
- Fentanyl 50 mcg
- Pethidine 25 mcg
- Paracetamol 1000 mg with Nefopam (infusion)
- Dexamethasone 8 mg
- Ketamine 50 mg
- Propofol with sleeping dose 125 mg
- Another dose of Fentanyl 50 mcg
- Scoline 200 mg RSI procedure (crush like induction)
Patient woke up from scoline around 10 minutes later, with high Peak Pressure 40 cmH2O, then given atracurium 30 mg (long operation), patient relaxed, but blood pressure went up to 180s/110s mmhg, then given another Fentanyl 50 mcg with Pethidine 25 mcg.
Fluid was given 2 liters during the operation, but the Bp kept up, I tried to give her Angisid (GTN) 10 mcg, but she desaturated to 92% briefly, then went up to 95%, I didn’t have good emergent Beta blockers unfortunately except Metoprolol, but I decided to give her 1 mg of it prior to extubation and I did.
Prior to closure of the subcutaneous tissue after removing 3 pounds of fat and omentum stuck with the sac plus skin (they did lower umbilical transverse incision – wide enough like over 10 inches, could’ve more, same as the incision of pfannenstiel incision), I prepared my Lidocaine in two syringes, each one with 10 ml, 2% diluted to 12 ml (>1.5%) and gave her TAP petit triangle block, using regular needle and could manage the depth with skin stretching and feeling the first pop of the skin (I blunted out the tip) and the second pop of external oblique.
Operation finished, and I woke her up with SIMV/PC Ventilation, then PSVPro mode, and did suction, the patient with her ETT in, was able to protrude her tongue out and elevate her neck, beside opening her eyes. I extubated her and put her on Nasal Cannula 6 Liter and saturation was 98% and didn’t drop, the patient was amazingly saying “did you do the operation”, I tried to touch the wound dressing and without pain noticed, she was able to speak, elevate her head and she moved herself to the next stretcher without pain, I sent her with face mask 10 Lt oxygen to the surgical ward, and semi stting position 45 degrees, patient in the morning is well, feeling better.
What should’ve done more according to the limited resources I have, rate my approach 0 – 10 😊, did I pass this challenging case? Were something needs to be addressed? This is my first multimodal analgesia - surgical anesthesia!
Love and Peace,
Dr Amir Al Shimmarii, PGY3 aka CA2
Iraqi Board in Anesthesia and Intensive Care,
Al Imamain Al Kadhimain Medical City
North of Baghdad / Iraq
