- Joined
- Sep 19, 2018
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Dear Fellows,
I hope you are doing well; as you know, I am always (hopefully will continue), like to write and discuss our unique cases with you, and as you know me!
Today's case is kind of interesting, and now is 0315 AM Iraq Local Time and we just finished an hour ago an emergency case of laparotomy for an old age patient with a pacemaker (Question brought up - Anesthetic consideration and guidelines to deal with patient with pacemaker?) !
Let's start:
65+ Years old, male patient, 80+ Kg, presented with Acute abdomen (NG tube was in).
Past Medical History : Hypertension, Diabetes II [10 years ago, survived from a cardiac standstill and successful CPR was done, ended up to get a Pacemaker and was done in a nearby country - last time was programmed 9 months ago - the patient told us he had slowing of his heart rate and illness of the electrical bundles of his heart, and that was the reason his Physician install a pacemaker / per patient knowledge]
He is taking a list of Antihypertensive medication (was not available at the time of presentation), and also two other medication for DM + recently adding Insulin.
His Vital Signs : PR 110+/min - RR 16/min - BP 155/95 mmgh - SPO2 96%
Due to the emergency setting, and the availability of necessary medication, we (my Attending and me were discussing the plan of Anesthesia, to avoid sympathomimetics, really it was a challenge, because only Pethidine was available as an opioid, beside our regular anesthesia medications, and unfortunately no thiopental available too, or vecuronium as a choice of muscle relaxants or isoprenaline - just in case; addressing to avoid using unipolar cautery by the surgeon, although Medicine team was consulted and assured us, but still), we were planning to fight with the following medications:
Pre-Medication and Induction :
- Pethidine 50 mg IV
- Ketamine 30 mg (very cautious)
- Propofol 100 mg, then followed by 50 mg
- Rocuronium 30 mg
Monitoring: EKG on Lead II showing Tachycardia with wide spikey rhythm (almost like this image) - Credit :ECGpedia https://en.ecgpedia.org/images/0/0b/Pacemaker_mediated_tachycardia.svg
Difficult intubation (one of the most difficult one for me), myself I had to use stylet (honestly blindly, with even shoulders elevation and neck manipulation - extension !
Maintenance:
- Isoflurane 1.2%
- Ringer IV fluid
Machine set : On Volume Control, FGF=7 Lt (previously discussed, it is a semi-closed circuit, to wash out the gases with such high FGF and no Soda Lime nor scavenging system), Tidal Volume was set per lean body weight 550, rate was 16, then 12/ min, Peep 4, I:R = 1:2
Events:
- SPO2 didn't change and was in very good shape (no Capnography - was broken) : 98 - 100 %
- Two separate doses of muscle relaxants were given, because surgeon was in need of ms. relaxants, beside it ended up with colostomy.
- Blood Pressure, we experienced during the mid time, a rapid drop in the blood pressure and had reached to 75/35 mmgh, I addressed the use of Normal Saline (Glucose Saline was available and was given), then I changed the RR to 10 then to 12, the blood pressure get elevated gradually to reach 155/90, then suddenly before they closed the abdomen peaked to 205/120 mmgh, here I addressed to give another bolus of Propofol 30 mg to deepen the anesthesia, blood pressure then came back 135/85 mmgh and the pulse rate was fluctuating between 110 - 130 b/min
Operation Done.
Extubation:
- Done smoothly, patient fully recovered and his vital signs were almost the same pre-operatively despite the SPO2 was 92% , his BP was 150/85, his PR 110/min
Patient was sent to the Surgery ward - no ICU bed available - but instruction was give to get Oxygen by cannula 2 Lt and to get hourly charting of his vital signs!
--------------------------------------
Thanks for reading me
Your comments are valuable, your consideration, your way to manage the case vs alternatives ?
Love and Peace
Amir
I hope you are doing well; as you know, I am always (hopefully will continue), like to write and discuss our unique cases with you, and as you know me!
Today's case is kind of interesting, and now is 0315 AM Iraq Local Time and we just finished an hour ago an emergency case of laparotomy for an old age patient with a pacemaker (Question brought up - Anesthetic consideration and guidelines to deal with patient with pacemaker?) !
Let's start:
65+ Years old, male patient, 80+ Kg, presented with Acute abdomen (NG tube was in).
Past Medical History : Hypertension, Diabetes II [10 years ago, survived from a cardiac standstill and successful CPR was done, ended up to get a Pacemaker and was done in a nearby country - last time was programmed 9 months ago - the patient told us he had slowing of his heart rate and illness of the electrical bundles of his heart, and that was the reason his Physician install a pacemaker / per patient knowledge]
He is taking a list of Antihypertensive medication (was not available at the time of presentation), and also two other medication for DM + recently adding Insulin.
His Vital Signs : PR 110+/min - RR 16/min - BP 155/95 mmgh - SPO2 96%
Due to the emergency setting, and the availability of necessary medication, we (my Attending and me were discussing the plan of Anesthesia, to avoid sympathomimetics, really it was a challenge, because only Pethidine was available as an opioid, beside our regular anesthesia medications, and unfortunately no thiopental available too, or vecuronium as a choice of muscle relaxants or isoprenaline - just in case; addressing to avoid using unipolar cautery by the surgeon, although Medicine team was consulted and assured us, but still), we were planning to fight with the following medications:
Pre-Medication and Induction :
- Pethidine 50 mg IV
- Ketamine 30 mg (very cautious)
- Propofol 100 mg, then followed by 50 mg
- Rocuronium 30 mg
Monitoring: EKG on Lead II showing Tachycardia with wide spikey rhythm (almost like this image) - Credit :ECGpedia https://en.ecgpedia.org/images/0/0b/Pacemaker_mediated_tachycardia.svg
Difficult intubation (one of the most difficult one for me), myself I had to use stylet (honestly blindly, with even shoulders elevation and neck manipulation - extension !
Maintenance:
- Isoflurane 1.2%
- Ringer IV fluid
Machine set : On Volume Control, FGF=7 Lt (previously discussed, it is a semi-closed circuit, to wash out the gases with such high FGF and no Soda Lime nor scavenging system), Tidal Volume was set per lean body weight 550, rate was 16, then 12/ min, Peep 4, I:R = 1:2
Events:
- SPO2 didn't change and was in very good shape (no Capnography - was broken) : 98 - 100 %
- Two separate doses of muscle relaxants were given, because surgeon was in need of ms. relaxants, beside it ended up with colostomy.
- Blood Pressure, we experienced during the mid time, a rapid drop in the blood pressure and had reached to 75/35 mmgh, I addressed the use of Normal Saline (Glucose Saline was available and was given), then I changed the RR to 10 then to 12, the blood pressure get elevated gradually to reach 155/90, then suddenly before they closed the abdomen peaked to 205/120 mmgh, here I addressed to give another bolus of Propofol 30 mg to deepen the anesthesia, blood pressure then came back 135/85 mmgh and the pulse rate was fluctuating between 110 - 130 b/min
Operation Done.
Extubation:
- Done smoothly, patient fully recovered and his vital signs were almost the same pre-operatively despite the SPO2 was 92% , his BP was 150/85, his PR 110/min
Patient was sent to the Surgery ward - no ICU bed available - but instruction was give to get Oxygen by cannula 2 Lt and to get hourly charting of his vital signs!
--------------------------------------
Thanks for reading me
Your comments are valuable, your consideration, your way to manage the case vs alternatives ?
Love and Peace
Amir
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