Dear All,
I hope you are doing well, it has been a year since my last post where I told you about passing my 1st year residency exam (like ABA) here in Iraq where I am now a third year resident in Anesthesia and Intensive Care / Iraqi Board. It has been a tough year for all of us, and for me since Covid hits Iraq, we worked very hard to contain the crisis especially with a weak and devastated health system, it wasn't easy at all, we have lost so many doctors in Iraq and well known Anesthesiologists too unfortunately, because of covid, and for me I had contracted the infection last August, and it wasn't that severe too.
I started my third year residency back in October in another teaching center in Baghdad, and day after day, I am realizing how different my approach in dealing with the cases, and as you remember, I had shared my cases especially in late 2018 and through 2019; and I hope I can say I am back with my backpack of interested cases to me at least, and looking always for an answer from a different perspective.
My New Case - I believe case #5 on SDN:
10 days ago, I had a shift to run the ORs of the emergency cases - not OBGYN (it is usually a 24 hour shift at our medical city), anyway - a neuro team approached me to tell me about a case they need to replace her VP shunt because of blocking issue, and they request to have a reserved OR room, because it was full house, and I asked them about the case and here is the summary from the neurosurgeon : 30 years old female with a current GCS of 10, had an OP of VP shunt 2 weeks ago, because of a brain tumor, and she was kept at the ward for observation.
The patient arrived to the OR to examine her, she was skinny like 55 Kg, (x 2.2 = 121 Ib), and yes, she was GCS of 10 - 11, with barely closed mouth, like contracted jaw and neck muscles, and I couldn't even open her mouth and wouldn't try the jaw thrust, and I got the consent for the anesthesia (consent of death complications), her vitals was upper normal, except a bit tachycardia.
Interestingly, I had with me a PGY1 resident and she was in her first weeks of residency and you know they keep ask valuable questions and sometime those questions based on logical prediction while I believe Anesthesia is unpredictable and sometime Logic means Guidelines !
I anticipated difficult intubation scenario, and I was ready, I had some Sevoflurane, and I started preoxygenation for 5 minutes, then I opened Sevo for another 3 minutes with a tight mask, and gave her propofol a sleeping dose and it was around 100 mg (10 ml slowly) and the jaw relaxed a bit, and I came with my laryngoscope and I saw the vocal cords shining like a star, and the resident said "did you see them?", I said "yes", she said "Lets give her muscle relaxants", I said "Okay, we may but (started to think about this logic, since you have seen the vocal cord proceed with MR as usual, and my heart was aching I don't know why) - Okay give her MR doctor", we only have rocuronium (C/I succinylcholine because of ICP).
Well, after 1 minute, she became very relaxed and I opened her mouth, her tongue disappeared - fallen down in her throat like, and I don't have Magill forceps handy, but with my fingers and laryngoscope manipulation was able to see the field and intubated her, I was relieved guys to be honest!
The operation went smooth and another problem was how to awake a GCS of 10 like?, and the patient at the end of the operation was taking full breath (end Tv was great) and she was like biting on the ETT (she had excised premolars and fortunately was creating a nice gap for the ETT - without it she was biting the ETT for sure) - and her eye muscles and especially the corrugator supercilii was functioning to tell me "EXTUBATE", and I did honestly and tried to do suction and barely from the premolars area. The patient was well and the same voice of mumbling like, and just like I received her prior!
I maintained the Operation with Isoflurane, analgesics and set the RR 16 (for ICP), and at the end of the operation, I shifted her to SIMV-PC and then PSPro modes !
My question, what is your opinion about the whole process? Any comment? Will you do an inhalational technique?
Love to hear from you friends !
Sincerely,
Amir
I hope you are doing well, it has been a year since my last post where I told you about passing my 1st year residency exam (like ABA) here in Iraq where I am now a third year resident in Anesthesia and Intensive Care / Iraqi Board. It has been a tough year for all of us, and for me since Covid hits Iraq, we worked very hard to contain the crisis especially with a weak and devastated health system, it wasn't easy at all, we have lost so many doctors in Iraq and well known Anesthesiologists too unfortunately, because of covid, and for me I had contracted the infection last August, and it wasn't that severe too.
I started my third year residency back in October in another teaching center in Baghdad, and day after day, I am realizing how different my approach in dealing with the cases, and as you remember, I had shared my cases especially in late 2018 and through 2019; and I hope I can say I am back with my backpack of interested cases to me at least, and looking always for an answer from a different perspective.
My New Case - I believe case #5 on SDN:
10 days ago, I had a shift to run the ORs of the emergency cases - not OBGYN (it is usually a 24 hour shift at our medical city), anyway - a neuro team approached me to tell me about a case they need to replace her VP shunt because of blocking issue, and they request to have a reserved OR room, because it was full house, and I asked them about the case and here is the summary from the neurosurgeon : 30 years old female with a current GCS of 10, had an OP of VP shunt 2 weeks ago, because of a brain tumor, and she was kept at the ward for observation.
The patient arrived to the OR to examine her, she was skinny like 55 Kg, (x 2.2 = 121 Ib), and yes, she was GCS of 10 - 11, with barely closed mouth, like contracted jaw and neck muscles, and I couldn't even open her mouth and wouldn't try the jaw thrust, and I got the consent for the anesthesia (consent of death complications), her vitals was upper normal, except a bit tachycardia.
Interestingly, I had with me a PGY1 resident and she was in her first weeks of residency and you know they keep ask valuable questions and sometime those questions based on logical prediction while I believe Anesthesia is unpredictable and sometime Logic means Guidelines !
I anticipated difficult intubation scenario, and I was ready, I had some Sevoflurane, and I started preoxygenation for 5 minutes, then I opened Sevo for another 3 minutes with a tight mask, and gave her propofol a sleeping dose and it was around 100 mg (10 ml slowly) and the jaw relaxed a bit, and I came with my laryngoscope and I saw the vocal cords shining like a star, and the resident said "did you see them?", I said "yes", she said "Lets give her muscle relaxants", I said "Okay, we may but (started to think about this logic, since you have seen the vocal cord proceed with MR as usual, and my heart was aching I don't know why) - Okay give her MR doctor", we only have rocuronium (C/I succinylcholine because of ICP).
Well, after 1 minute, she became very relaxed and I opened her mouth, her tongue disappeared - fallen down in her throat like, and I don't have Magill forceps handy, but with my fingers and laryngoscope manipulation was able to see the field and intubated her, I was relieved guys to be honest!
The operation went smooth and another problem was how to awake a GCS of 10 like?, and the patient at the end of the operation was taking full breath (end Tv was great) and she was like biting on the ETT (she had excised premolars and fortunately was creating a nice gap for the ETT - without it she was biting the ETT for sure) - and her eye muscles and especially the corrugator supercilii was functioning to tell me "EXTUBATE", and I did honestly and tried to do suction and barely from the premolars area. The patient was well and the same voice of mumbling like, and just like I received her prior!
I maintained the Operation with Isoflurane, analgesics and set the RR 16 (for ICP), and at the end of the operation, I shifted her to SIMV-PC and then PSPro modes !
My question, what is your opinion about the whole process? Any comment? Will you do an inhalational technique?
Love to hear from you friends !
Sincerely,
Amir
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