CASE PRESENTATION

1
CASE PRESENTATION

• PRESENTER Dr. UMAKANTH

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
2
HISTORY

• 35 yrs / F
• 50 kgs
• h/o swelling in front of the neck since 12 yrs

3
HISTORY OF PRESENT ILLNESS

• Apparently well 12 yrs back
• Noticed a small swelling in left lower part of
  the neck which was the size of about 2 x 2 cm
• It progressively increased in size to the present
  size of about 10 x 11 cm
• Filling the left side of the neck, crossing the
  midline

4
HOPI CONTD

• No history of
• pain, fever or breathlessness
• sudden increase in size
• change in voice
• Dysphagia or odynophagia
• Stridor
• h/s/o hypo/hyperthyroidism

5
PAST MEDICAL HISTORY

• No history of
• HT
• DM
• TB
• Bronchial Asthma
• Epilepsy

6
PAST SURGICAL HISTORY

• History of surgery for diminished vision in Right
  eye 4 years back at AIIMS under local
  anesthesia (No records available)

7
MENSTRUAL HISTORY

• Normal, regular menstrual cycles
• LMP 15 days back
• Married
• 4 children normal delivery
• Last child birth 10 yrs back

8
PERSONAL HISTORY

• Sound sleep
• Normal appetite
• Regular bowel and bladder habits
• No history of tobacco chewing / smoking
• No history of alcohol intake

9
PHYSICAL EXAMINATION

• Comfortable
• Conscious and oriented
• Pulse 88/ min, regular, adequate volume, all
  peripheral pulses felt, no radio radial or radio
  femoral delay
• BP 138/76 mm of Hg
• Corneal opacity R eye
• No pallor / edema / clubbing / cyanosis / icterus
  / lymphadenopathy
• No voice change / stridor

10
RESPIRATORY SYSTEM

• Normal vesicular breath sounds heard bilaterally
• No rhonchi / crepts

11
CARDIO VASCULAR SYSTEM

• S1 and S2 normal
• No murmurs

12
LOCAL EXAMINATION

• INSPECTION
• Situation - Front of the neck extending
  vertically from the mandible to the sternal notch
  and horizontally from the post. border of the
  left SCM to the anterior border of the right SCM
• Shape irregular
• Size - about 10 x 11 cm
• Edge clearly defined and distinct
• Number single swelling

13
INSPECTION .

• Pulsation nonpulsatile
• Coughing no impulse
• Deglutition MOVES UP
• No movement with protrusion of the tongue
• Skin over the swelling normal
• Pressure effects no visible engorged veins in
  the neck

14
PALPATION

• Temperature
• Tenderness
• Size, shape and extent
• Surface
• Edge
• Consistency
• Fluctuation
• Fluid thrill

15
PALPATION

• Translucency
• Impulse on coughing
• Reducibility
• Compressibility
• Pulsatility
• Fixity to overlying skin
• Relations to surrounding structures

16
REGIONAL LYMPH NODES

• Not palpable

17
AUSCULTATION

• No Bruit

18
EXAMINATION FOR PRESSURE EFFECT

• Arterial pulse distal to the swelling
• Veins
• Nerves wasting of muscles
• Tracheal displacement to the Right

19
INVESTIGATIONS

• Hb, TLC, DLC, platelets, ESR
• Urine Albumin, Sugar and microscopy
• Blood Sugar
• RFT
• LFT
• Thyroid Function Tests

20
INVESTIGATIONS

• ECG
• CT

21
CXR
22
X RAY NECK AP LAT
23
USG
24
IDL

• B/L Vocal Cord Mobility

25
DIFFERENTIAL DIAGNOSIS

• MULTINODULAR GOITRE

26
CASE SUMMARY

1. 35 yrs female, with ?MNG, is scheduled for
   Subtotal Thyroidectomy
2. Pre-op preparation
3. Intra-op concerns

27
PREMEDICATION GOALS

• NPO gt 10 pm
• Informed Written Consent
• Anxiety relief T. Diazepam 5 mg previous night
  10 pm and morning 630 am of surgery
• Reduce gastric pH T. Rantac 150 mg HS / CM

28
PREMEDICATION GOALS

• Antisialagogue Inj.Glycopyrrolate 0.2 mg IV in
  pre anesthesia room
• Xylocaine gargle
• Xylocaine spray
• Xylometazoline nose drops

29
OT PREPARATION

• EMERGENCY RESUSCITATION EQUIPMENT

30
OT PREPARATION

• Oxygen pipeline source and its backup (cylinder)

31

• Anesthesia Machine
• Suction wall vacuum suction and its backup
  (mobile suction device)

32
DIFFICULT AIRWAY TROLLEY
33
OT PREPARATION

• DRUGS
• Atropine
• Induction agent
• Muscle relaxant
• Analgesic
• Stand by Adrenaline, SNP, NTG, Esmolol

34
INTRAVENOUS ACCESS

• Two large bore cannulae
• RL

35
MONITORING
36
MONITORING
37
INDUCTION

• Pre Oxygenation
• Fentanyl
• Propofol
• Vecuronium
• IPPV ( O2 N2O ISO)
• 7.0 mm ETT

38
MAINTENANCE

• O2 / N2O / ISO
• VEC, FENT
• CIRCUIT CLOSED
• VENTILATOR Datex Ohmeda
• TV 400 ml
• RR 10 / min
• Aw Pr 12 14 cm H2O

39
INTRAOP

• BP 110 130 / 70 86 mm of Hg
• Pulse 60 80 / min
• Spo2 99
• Et CO2 34 38 mm Hg
• Temperature
• Urine output
• Neuromuscular function monitoring

40
INTRAOP

• Blood loss - 250 ml
• Total IV Fluids transfused 1500 ml

41
POST OP

• NEOSTIGMINE
• ATROPINE

42
LARYNGOSCOPY AT THE END OF SURGERY
43
POSTOPERATIVE CARE

• Monitored environment
• O2 by face mask
• Fluids
• Urine output monitoring
• Regular analgesia regimen
• Investigations
• CBC, electrolytes, blood sugar, urea, CXR and ECG

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om