S.V.C. OBSTRUCTION -ANAESTHETIC MANAGEMENT FOR DCPFOR FRACTURE TIBIA

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S.V.C. OBSTRUCTION WITH TIBIAL FRACTURE ANAESTHETIC MANAGEMENT UNDER POPLITEAL BLOCK BY,, DR.S.SREENIVASARAO, ASST.PROFESSOR, M.D, DEPT. OF ANAESTHESIA, S.V.R.R.G.G.H.,S.V.MEDICAL COLLEGE, TIRUPATI.

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CASE DETAILS; B.MUNIKRISHNAIAH ,40 YRS MALE MET WITH ACCIDENT RESULTING #.MANDIBLE WITH # TIBIA UPPER AND LOWER ONE THIRDS,, WIRING FIXATION DONE FOR MANDIBLE ,, CASE POSTED FOR INTERLOCKING TIBIA

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ENGORGEMENT OF VEINS FROM NECK TO PUBIC SYMPHYSIS PRESENT SINCE 20 YRS , DEVELOPED GRADUALLY PT. IS NORMAL AT REST , PT. DEVELOPS BREATHLESSNESS,COUGH & SWELLING OF FACE WHEN HE BENDS FOR ANY WORK LONGER THAN 10Min SUBSIDES SLOWLY AFTER TAKING REST FOR 30 TO60 Min HE WENT TO CMC VELLORE 15YRS BACK & TOOK TREATMENT. STOPPED ABRUPTLY AFTER 2 YRS ,TREATMENT DETAILS NOT KNOWN AT PRESENT HE IS NOT ON ANY TREATMENT ON EXAMINATION

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VITAL DATA PULSE RATE :70/Min BLOOD PRESSURE :140/80 mmhg(sit) C.V.S :S1 ,S2 + R.S. :Bilateral Air Entry Normal J.V.P : WAVE FORM NOT SEEN

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HB :9.4 gm% B.T. :1’. 11” C.T. :2’.55” BLOOD GROUP :B +ve BLOOD SUGAR :140 mg% BLOOD UREA :26 mg% SERUM CREATININE : 0.8, SERUM THYROID T3 : 1.2 mg/ml T4 : 106 mg/ml T.S.H : 1.7 IU/ml INVESTIGATIONS

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E.C.G .

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C.T CHEST

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CT ABDOMEN

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ECHOCARDIOGRAPHY.

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I PLANNED TO DO THE CASE UNDER POPLITEAL BLOCK , BY BLOCKING THE SCIATIC NERVE AT THE POPLITEAL FOSSA & PERIPHERAL BRANCH OF FEMORAL NERVE – SAPHENOUS NERVE AT THE UPPER END OF KNEE SECURED THE I.V.LINE &CONNECTED THE N.I.B.P,, P.R.,,SPO2 MONITORS PREMEDICATED THE PATIENT WITH 1mg BUTORPHANOL HOW I DID THE CASE ???

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PATIENT POSITION -- PRONE NEEDLE SIZE -- A 22 GAUGE 50 MM INSULATED NEEDLE DRUG &VOLUME -- 30 CC OF O.5% LIDOCAINE WITH ADRENALINE ANATOMIC LAND MARKS BASE—POPLITEAL CREASE MEDIAL—SEMITENDINOSUS & SEMIMEMBRANOSUS LATERAL—BICEPS FEMORIS

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POPLITEAL TRIANGLE

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APPROACH &TECHNIQUE SCIATIC BLOCK POPLITEAL TRIANGLE WAS DRAWN AS THE BOUNDARIES MENTIONED ABOVE,, THIS WAS DIVIDED INTO TWO PARTS BY DRAWING A LINE FROM THE APEX , I cm DOWNWARDS AND LATERALLY TO THE APEX IS THE NEEDLE POINT OF ENTRY NEEDLE WAS INTRODUCED PERPENDICULAR TO THE SKIN IN SEARCH OF A MOTOR RESPONSE RELATED TO STIMULATION OF COMMON PERONEAL NERVE i.e, DORSIFLEXION OF THE FOOT

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NEEDLE POSITION WAS ADJUSTED TO MAINTAIN THE SAME MOTOR RESPONSE WITH A STIMULATING CURRENT OF 0.5 MA AFTER NEGATIVE ASPIRATION FOR BLOOD 15 CC OF LOCAL ANAESTHETIC WAS INJECTED NEEDLE WAS DIRECTED MORE MEDIALLY & 1 TO 1.5CM DEEPER IN SEARCH OF STIMULATION OF TIBIAL NERVE i.e,PLANTAR FLEXION WITH FLEXION OF TOES AFTER NEGATIVE ASPIRATION FOR BLOOD 15CC LOCAL ANAESTHETIC WAS GIVEN

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SAPHENOUS BLOCK SAPHENOUS NERVE IS THE TERMINAL BRANCH OF FEMORAL NERVE & IT SUPPLIES SENSORY SUPPLY TO MEDIAL ASPECT OF THE LOWER LEG TO COMPLETELY ANAESTHETIZE THE LOWER LEG WE HAVE TO BLOCK BOTH THE NERVES TECHNIQUE: 7 CC OF 0.5% LIDOCAINE WITH ADRENALINE WAS INFILTRATED SUBCUTANEOUSLY STARTING FROM THE TIBIAL TUBEROSITY DIRECTED MEDIALLY COMPLETING THE INFILTRATION NEAR THE POSTERIOR ASPECT OF THE LEG

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D I S C U S S I O N

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WHY I DIDN’T GO FOR GENERAL ANAESTHESIA ??? #MANDIBLE WITH WIRING FIXATION MADE THE MOUTH OPENING RESTRICTED IT IS VERY DIFFICULT TO INTUBATE THE PATIENT IN OUR SETUP “AIRWAY OBSTRUCTION & CARDIOVASCULAR COLLAPSE MAY FOLLOW THE INDUCTION OF GENERAL ANAESTHESIA WITH MEDIASTINAL MASSES –S.V.C OBSTRUCTION” ANAESTH..ANALG..2003;97;883-4

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A RIGID VENTILATING BRONCHOSCOPE SHOULD BE ONE HAND TO BYPASS DISTAL TRACHEAL &CARINAL OBSTRUCTIONS & THE APPROPRIATE PERSONNES & EQUIPMENT FOR CARDIOPULMONARY BYPASS SHOULD ALSO BE AVAILABLE” MILLER 6TH EDI,PAGE-1922

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AZZIZKHAN et all – EXAMINED ANAESTHETIC AND SURGICAL MANAGEMENT OF 50 CONSECUTIVE CASES IN CHILDREN WITH MEDIASTINAL MASSES--- 30---HAD RESPIRATORY SYMPTOMS 13 –HAD MARKED COMPRESSION OF THE AIRWAY, ON RADIOLOGICAL IMAGING TRACHEAL CROSS SECTION WAS DECREASED BY 35—93% IN THESE PATIENTS INDUCTION OF GA TENDS TO EXACERBATE EXTRINSIC AIRWAY COMPRESSION BY DECREASING LUNG VOLUMES AND RELAXING THE BRONCHIAL SMOOTH MUSCLE. FURTHER EXACERBATED BY NEUROMUSCULAR BLOCK & POSITIVE PRESSURE VENTILATION BY REDUCING THE NORMAL TRANSPLEURAL PRESSURE GRADIENTS CAUSING NARROWING OF LARGE CALIBRE AIRWAYS ANAESTH..ANALG..2003;97;883-4

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WHY I DIDN’T GO FOR SPINAL ANAESTHESIA ??? IN S.V.C OBSTRUCTION MOST PART OF THE PRELOAD IS MAINTAINED BY THE I.V.C. ,SVC CONTRIBUTION IS VERY MINIMAL IN SPINAL ANAESTHESIA MOST PART OF THE BLOOD IS POOLED IN LOWER LIMBS DUE TO INTENSE VASODILATION DUE AUTONOMIC BLOCKADE DUE TO DRASTIC DECREASE IN PRELOAD IT IS VERY DIFFICULT TO MAINTAIN ADEQUATE CARDIAC OUT PUT IN SPINAL ANAESTHESIA DECREASED SYSTEMIC VASCULAR RESISTANCE LEADS TO DECREASED AFTERLOAD SO DECRAESED PRELOAD & AFTERLOAD LEADS TO SEVERE CRDIAC COMPROMISE ANAESTH.ANALG—2004-98:1160-1163

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WHY I DID N’T GO FOR EPIDURAL ANAESTHESIA ??? IN SVC OBSTRUCTION VERTEBRAL VENOUS PLEXUSES ARE ENLARGED EPIDURAL SPACE VOLUME IS VERY MUCH DECREASED EPIDURAL PRESSURE IS INCREASED EPIDURAL CATHETERISATION IS MORE RISKY –INTRAVASCULAR ENTRY CHANCES ARE MORE EXTENT OF ANALGESIA INCREASES EFFECTS OF AUTONOMIC BLOCKADE ARE MORE INTENSE IF GRADED EPIDURALS ARE NOT GIVEN ANAESTH-ANALG-2004-98:1160-1163

WHY I CHOOSEN FOR POPLITEAL BLOCK ???:

WHY I CHOOSEN FOR POPLITEAL BLOCK ??? MILLER 6 th EDI-PAGE –PAGE-1921

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PROBLEM -1 BEFORE STARTING THE CASE ,SURGEON WANTED TO APPLY TOURNIQUIET ABOVE THE KNEE FOR TOLERATING THE TOURNIQUIET PAIN A RING BLOCK WAS GIVEN AT THE LOWER ONE THIRD OF THIGH I INFILTRATED 10CC OF 0.25% BUPIVACAINE AROUND THE THIGH FOR THE FIRST 30 Min PATIENT HAD NO COMPLAINTS AFTER 30 Min PATIENT COMPLAINED OF TOURNIQUIET PAIN WHICH SETTLED WITH A TOTAL OF 3mg OF BUTORPHANOL ,i.e, 0.5 mg INCREMENTS EVERY 15 TO 20 Min PROBLEMS I FACED DURING THS CASE

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PROBLEM-2 2Hrs LATER THE SURGERY WAS COMPLETED WITH PROXIMAL INTERLOCKING OF THE TIBIA THE SENIOR SURGEON WANTED TO DO THE DISTAL INTERLOCKING ALSO THE WOUND WAS AGAIN OPENED & NAIL RETRIEVED BACK & WITH ANOTHER NAIL BOTH THE PROXIMAL & DISTAL INTERLOCKING WERE DONE THE TIME WAS EXTENDED BY 40 Min MORE FOR WHICH THE PATIENT WAS MAINTAINED WITH A TOTAL OF 60mg OF KETAMINE IN INCREMENTS TOTAL DURATION OF SURGERY WAS 2Hrs 40 Min THE PATIENT WITHSTOOD THE PROCEDURE AND ANAESTHESIA WITHOUT ANY UNTOWARD EVENTS.

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REFERENCES TEXT BOOK OF REGIONAL ANAESTHESI BY P.PRITHVIRAJ TEXT BOOK OF PERIPHERAL NERVE BLOCKS BY CHELLY, JACQES E. TEXT BOOK OF CLINICAL ANAESTHESIA BY G.EDWARD MORGAN ANAESTH..ANALG..2003;97;883-4 ANAESTH-ANALG-2004-98:1160-1163 TEXT BOOK OF ANAESTHESIA BY MILLER-6 th EDI TEXT BOOK OF REGIONAL ANAESTHESIA BY COLLINS e-MEDICINE-SVC OBSTRUCTION

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