Harold Nathan Tan ASMPH Year Level 9

Anesthesiology: Case Report

1 PATIENT INFORMATION
K.A. is a 6 year old, Filipina, Roman Catholic from Taguig City who was admitted for the first time at The Medical City on July 11, 2013

2 SOURCE AND RELIABILITY

Information was obtained from the patients mother, with good reliability

3 CHIEF COMPLAINT
luyloy sa kanan at kaliwa (inguinal bulge, bilateral)

4 HISTORY OF PRESENT ILLNESS

Patient was apparently well until 3 months prior to admission when she was noted to have a right inguinal bulge with associated intermittent groin pain, characterized as pressing, non-radiating, 4/10 in severity. The right inguinal bulge was noted to be spontaneously reducible, and was observed to become more prominent during bouts of crying and during physical exertion. No swelling, no nausea, no vomiting, no changes in bowel movement. Patient was brought to a pediatrician who advised referral to a surgeon. Relatives of the patient opted to observe the bulge. 1 month prior to admission, still with right inguinal bulge, patient was noted to have a left inguinal bulge with associated intermittent groin pain, characterized as pressing, non-radiating, 4/10 in severity. The left inguinal bulge was noted to be spontaneously reducible, and was observed to become more prominent during bouts of crying and during physical exertion Patient was brought to another pediatrician for second opinion, and was advised to undergo surgery, hence this present admission.

5 PAST MEDICAL HISTORY

No previous history of pneumonia, no constipation, no asthma, no ear infections, no cardiac disease, no diabetes, no seizures, no cancer. No previous hospitalizations. No past surgeries. No previous history of trauma. No known allergies.

Birth History: Patient was born full term via normal spontaneous delivery to a G1P1 (1001) 29-year old mother at The Medical City by an obstetrician. Birth weight was 3.5 kilograms, while birth length was unrecalled. APGAR was not obtained but patient was noted to have good activity and cry upon delivery. No perinatal complications noted. Maternal History: Prenatal Care and Testing: The Medical City No. Of visits: 10 Trimestral History: First Trimester: Mother was regularly menstruating until nine months prior to admission when she noted of missed menses. Mother undertook a pregnancy test, where she tested positive. Laboratory tests requested include complete blood count, urinalysis, ABO and Rh typing, VDRL, HepBsbAg and Rubella titer. All revealed normal results. Transvaginal ultrasound showed single live pregnancy at 8 weeks, compatible with last menstrual period. Mother was prescribed with folic acid 400 micrograms and multivitamins, with good compliance of intake. There were no exposure to radiation nor illnesses during this trimester. Second Trimester: Regular prenatal check-ups were done in The Medical City. On her 24th week of pregnancy, mother underwent 75-grams oral glucose tolerance test which showed normal result. She underwent an ultrasound exam during her 17th week of gestation, which showed a single live intrauterine fetus, cephalic, with adequate amniotic fluid volume. She was prescribed with multivitamins and ferrous sulfate, with good compliance of intake. Third Trimester: Mother had regular prenatal check-ups with her obstetrician. Her pregnancy course during the third trimester was unremarkable. No illnesses were incurred during this trimester. Nutritional History: Infant feeding: Patient was breastfed from birth up to 1 year of age. Solid foods were introduced at 6 months of age. A 24-hour food recall was conducted on the patient, revealing: Breakfast: 1 piece of bread and peanut butter spread. Lunch: 1 cup of rice with chicken/pork/beef. Dinner: 1 cup of rice with chicken/pork/beef No current feeding problems. No food allergies. Immunization History: BCG vaccine: 1 shot at birth DPT vaccine: 3 shots (unrecalled date) Oral polio vaccine: 3 shots (unrecalled date) Hepatitis B vaccine: 3 shots (unrecalled date) Measles vaccine: 2 shots (unrecalled date)

Developmental History: Patient is developmentally at par with age. Gross Motor: 3 months: pulls to sit, hands together in midline 6 months: sits without support 12 months: walks alone 15 months: Able to run Fine Motor: 4 months: reaches for objects 6 months: transfers objects from hand to hand 12 months: scribbles Communication and Language: 3 months: smiles in response to face, voice 6 months: monosyllabic babble 12 months: Speaks first real word (mapa) Cognitive 4 months: stares at own hand 12 months: egocentric pretend play

6 FAMILY HISTORY
The Family of K.A. July 14, 2013

Grandfather 62

Grandmother 60

Grandfather 61

Grandmother 60

Father, 37 K.A., 6

Mother, 35

No family history of hernia, asthma, allergies, diabetes, hypertension, heart disease, seizures, cancer.

7 PERSONAL AND SOCIAL HISTORY

Patient lives in a 400 square meter lot with his parents. Patients father works as a businessman while his mother is a housewife. Patient is not exposed to smoking, pollution, or toxins. Ventilation in the household is reportedly good as the family has a lot of windows in their home. Electricity is obtained from Meralco. Drinking water source is from Manila Water, the childs water is boiled for 30 minutes before consumption. Family uses a gas stove in cooking their food. Garbage disposal is conducted every day, with segregation of waste. The family does not have any pets. There is no pertinent history of travel in the family.

8 ASA CLASSIFICATION
ASA physical status classification is a grading system for gauging the physical state of a patient prior to surgery. Describing patients preoperative physical status is used for recordkeeping for communication between colleagues and to create a uniform system for statistical analyses. The modern classification system consists of six categories, as described below.
ASA PS Category Preoperative Health Status Comments, Examples

*ASA PS classifications from the American Society of Anesthesiologists

ASA PS 1 Normal healthy patient No organic, physiologic, or psychiatric disturbance; excludes the very young and very old; healthy with good exercise tolerance No functional limitations; has a well-controlled disease of one body system; controlled hypertension or diabetes without systemic effects, cigarette smoking without chronic obstructive pulmonary disease (COPD); mild obesity, pregnancy Some functional limitation; has a controlled disease of more than one body system or one major system; no immediate danger of death; controlled congestive heart failure (CHF), stable angina, old heart attack, poorly controlled hypertension, morbid obesity, chronic renal failure; bronchospastic disease with intermittent symptoms Has at least one severe disease that is poorly controlled or at end stage; possible risk of death; unstable angina, symptomatic COPD, symptomatic CHF, hepatorenal failure Not expected to survive > 24 hours without surgery; imminent risk of death; multiorgan failure, sepsis syndrome with hemodynamic instability, hypothermia, poorly controlled coagulopathy

ASA PS 2

Patients with mild systemic disease

ASA PS 3

Patients with severe systemic disease

ASA PS 4

Patients with severe systemic disease that is a constant threat to life Moribund patients who are not expected to survive without the operation A declared brain-dead patient who organs are being removed for donor purposes

ASA PS 5

ASA PS 6

Source: American Society of Anesthesiologists and http://my.clevelandclinic.org/services/anesthesia/hic_asa_physical_classification_system.aspx

Patient is classified as ASA I since the patient is healthy with with no systemic illness.

9 AIRWAY ASSESSMENT
The Mallampati score is used to correlate the oropharyngeal space with the ease of direct laryngoscopy and tracheal intubation. A high Mallampati score (class 3 or 4) corresponds to more difficult intubation and higher incidence of sleep apnea. The Mallampati score is assessed with the observer at eye level, and asking the patient to hold the head in a neutral position, opening the mouth maximally, and protruding the tongue without phonating. The anatomy of the oral cavity is visualized; specifically, whether the base of the uvula, faucial pillars), soft and hard palate are visible. The Modified Mallampati Scoring consists of four classes, and is described as such:

Class I: Soft palate, uvula, fauces, pillars visible. Class II: Soft palate, uvula, fauces visible. Class III: Soft palate, base of uvula visible. Class IV: Only hard palate visible

The patient is classified as MAL I since the soft and hard palate, uvula, fauces and tonsillar pillars are visible. Neck: Full range of motion. Mouth: opening of at least 3 fingerbreadths between upper and lower incisors. Teeth: good condition. No loose teeth. No dentures. No bridges. No dental caps.

10 PLANNED SURGERY
A surgical operation is required for our patient since there is a risk that a part of the bowel can become trapped in the inguinal hernia. As such, the patient was scheduled for bilateral herniotomy. The operation is done under general anaesthetic and usually involves one incision in the groin. The surgeon will locate the hernial sac and tie this off. The wound will then be closed with dissolvable sutures which can take up to 6-8 weeks to dissolve.

11 PREOPERATIVE MANAGEMENT
Fasting: Adherence to fasting guidelines minimizes the risk of aspiration of gastric contents. Since the patients operation was scheduled at 7 am, the parents were informed of the guidelines for food and fluid intake before elective surgery, which is presented below: Time Before Surgery Food or Fluid Intake Up to 8 hours (11 pm, of previous day for patient) Food and fluids as desired Up to 6 hours (1 am of surgery day for patient) Light meal (eg. Toast and clear liquids), infant formula, nonhuman milk Up to 4 hours (3 am of surgery day for patient) Breast milk Up to 2 hours (5 am of surgery day for patient) Clear liquids only During the 2 hours No solids , no liquids

Hydration: What fluid, when started. Why? Fluid: D5NM 1 liter to run at 60 cc / hour, started at 9:40 pm, 1 day prior to surgery. D5NM solution was used for parenteral maintenance of routine daily fluid and electrolyte requirements with minimal carbohydrate calories from dextrose. Pre-operative hydration is instituted to help in maintaining intravascular fluid volume and thus renal function in the patient. Furthermore, intravenous hydration in the preoperative period will also help in decreasing both postoperative nausea and vomiting, as well as pain. Medications to be taken prior to surgery including important maintenance drugs and premedication if any. Why? No maintenance drugs or premedications were given prior to surgery. Premedications In other patients, premedications can be considered by the anesthesiologist to help ease the patient prior to surgery. For example, midazolam 1-2 mg IV can be given as premedication in the preoperative phase to reduce anxiety. Furthermore, albuterol, two puffs can help in preventing bronchospasm. Pain on injection can be reduced by use of an opioid or coadministration with lidocaine. Meanwhile, benzodiazepines can be used a premedication as it provides anxiolysis and anterograde amnesia. Drugs that need to be discontinued if any, why? No drugs that needed to be discontinued in the patient. Continuing or discontinuing medications depends on the intravascular volume and hemodynamic status of the patient, the degree of cardiac dysfunction, the adequacy of arterial blood pressure control, and the anticipated anesthetic and intravascular volume concerns. ACE inhibitors and ARBs can cause refractory hypotension especially with lengthy procedures, significant blood loss or fluid shifts and use of general anesthesia. One should consider discontinuing aspirin if the risk of bleeding is greater than the risk of thrombosis, and for surgeries with serious risks for bleeding.

12 INTRAOPERATIVE MANAGEMENT
Anesthetic Technique: Patient was placed under general anesthesia. Induction of anesthesia was facilitated by the use of midazolam 2 mg/IV, fentanyl 40 micrograms/IV, propofol 50 mg/IV, with sevoflurane in oxygen. A muscle relaxant was also given in the form of rocuronium 6 mg/IV. For maintenance, inhaled anesthetics in the form of sevoflurane in oxygen was continued. General anesthesia was chosen for the patient since she might develop difficulty tolerating the procedure due to anxiety or discomfort owing to her young age. The anesthesiologist also noted that general anesthesia results in a state where a patient would be unconscious and unable to feel pain

during the medical procedure. The anesthesiologist cited the following factors for choosing general anesthesia in the patient: Reduced intraoperative patient awareness and recall Allows proper muscle relaxation for prolonged periods of time Facilitates complete control of airway, breathing and circulation Can be administered rapidly and is reversible Pharmacology of drugs used in anesthetic technique (site and mode of action, , adverse effects, treatment for adverse effects):

Medication Midazolam

Site of Action Central nervous system and the spinal cord (for muscle relaxation)

Mode of Action
activation of the GABAA receptor complex and enhancement of GABA-mediated chloride currents, leading to hyperpolarization of neurons and reduced excitability

Adverse Effects Decreased respiratory rate, transient apnea, drowsiness, pain during IV injection

Fentanyl

Opioids exert their therapeutic effects at multiple sites. They inhibit the release of substance P from primary sensory neurons in the dorsal horn of the spinal cord, mitigating the transfer of painful sensations to the brain. Opioid actions in the brainstem modulate

interacts with opioid receptors, which are typical of the G protein coupled family of receptors, leading to activation of the G protein, producing effects that culminate in hyperpolarization of the cell and reduction of neuronal excitability.

Respiratory depression, bradycardia, muscle rigidity, nausea/vomiting, pupillary constriction, opioid-induced ileus, urinary retention

Treatment of Adverse Effects Decreased respiratory rate, transient apnea: maintain ventilation via bag mask ventilation or mechanical ventilation Drowsiness: flumazenil Pain during IV injection: can give premedication with tramadol or coadminstration with lidocaine. For respiratory depression: secure airway and control ventilation via bag mask or mechanical ventilation Bradycardia: use atropine Muscle rigidity: rocuronium (a nondepolarizing muscle relaxant) or naloxone Nausea and vomiting: maintain adequate

Propofol

nociceptive transmission in the dorsal horn of the spinal cord through descending inhibitory pathways. Opioids probably change the affective response to pain through actions in the forebrain. Central nervous system

hydration and can give metoclopramide if with continued nausea and vomiting. Pupillary constriction and opioid-induced ileus: treat with naloxone

potentiation of the chloride current mediated through the gaminobutyric acid type A (GABAA) receptor complex

Hypotension, bradycardia, respiratory depression, pain on injection site

Hypotension: phenylephrine or ephedrine Bradycardia: atropine Pain on injection site: premedication with opioid or coadministration with lidocaine Respiratory depression: secure airway and control ventilation with bag mask ventilation or mechanical ventilation Transient hypotension: treat with phenylephrine or ephedrine Transient hypertension: provide adequate medications for pain during induction to reduce the risk of increased BP due to stress response as a result of

Rocuronium

Motor end plate

Intermediateacting Nondepolarizing neuromuscular blocking agent that competes with acetylcholine for cholinergic receptors at the motor end plate.

Transient hypotension, transient hypertension, severe rash, pruritus, nausea, vomiting

Sevoflurane

Central Nervous System

induces a reduction in junctional conductance by decreasing gap junction channel opening times and increasing gap junction channel closing times. Sevoflurane also activates calcium dependent ATPase in the sarcoplasmic reticulum by increasing the fluidity of the lipid membrane. It also appears to bind the D subunit of ATP synthase and NADH dehydogenase and also binds to the GABA receptor, the large conductance Ca2+ activated potassium

Apnea, cough

intubation. Nausea and vomiting: maintain adequate hydration and provide metoclopramide or other antiemetics as needed (propofol also has antiemetic properties) Severe rash, pruritus: treat with epinephrine Cough: Leaving the endotracheal tube cuff deated after intubation until a patient reaches a deep level of anesthesia may be helpful in coughing. Apnea: secure airway and control ventilation via bag mask or mechanical ventilation Nausea and vomiting: maintain adequate hydration and provide antiemetics such as metoclopramide as needed (propofol also has antiemetic properties). Increased saliva: suction secretions

channel, the glutamate receptor, and the glycine receptor. Adverse Events if any, how were these managed? No adverse events noted during the course of the intraoperative procedure.

Shivering: can treat with dexmedetomidine

13 POSTOPERATIVE MANAGEMENT
Patient was given paracetamol 300 mg/IV as analgesic in the post-operative period. Medication Paracetamol Site of Action Primarily in CNS, also in endothelial cells Mode of Action Act primarily in the CNS, increasing the pain threshold by inhibiting both isoforms of cyclooxygenase, COX-1, COX-2, and COX-3 enzymes involved in prostaglandin (PG) synthesis Adverse Effects Hepatotoxicity, nausea, vomiting, rash, pruritus anaphylaxis Treatment of Adverse Effects Hepatotoxicity: careful assessment of patients risk factors for possible liver disease Nausea, vomting: provide antiemetics (e.g metoclopramide) Anaphylaxis: discontinue drug and give epinephrine

Adjuvants given if any- why were these given? No adjuvants were given to the patient.