PROBLEM ORIENTED PROBLEM ORIENTED DISCUSSIONDISCUSSION

INNOVATIVE METHODS OF MANAGING OPEN CHOLECYSTECTOMY

Moderator - Dr.Vidushi Presenter -

Dr.Parameswaran

PRESENTING PRESENTING COMPLAINTSCOMPLAINTS80 year old lady presents to the

hospital with the complaints of

1.Right upper abdominal pain – 10 days

2.Nausea and vomiting - 3 days

PRESENTING PRESENTING COMPLAINTSCOMPLAINTS Pain - localized in right upper

abdomen , dull aching type aggravating on food intake.

Nausea and vomiting - Non bilious type, no haemetemesis.

No history of loss of weight , yellowish discoloration of eye, dysphagia.

PRESENTING PRESENTING COMPLAINTSCOMPLAINTS

No history of fever

Complains of dysuria.

No history of chest pain, breathlessness on lying down.

Patient has been bedridden since past 3 months due to lethargy and easy fatigability.

PRESENTING PRESENTING COMPLAINTSCOMPLAINTS

She requires support to move around the house.

Bystanders give history of excessive

day time somnolence with history of

snoring at night.

PAST historyPAST history

Apparently normal 4 months and actively mobile in the house when admitted for urinary tract infection.

Diagnosed as hypertensive, hypothyroidism , OSA , urinary tract infection and hyponatremia.

TREATMENT HITORY TREATMENT HITORY

Started on T.Amlodipine 5 mg B.D and T.Eltroxine 150 mcg O.D

Hyponatremia corrected.

Since then has been admitted for recurrent UTI and has been lethargic and bedridden since.

ON EXAMINATIONON EXAMINATIONWt - 85 Kg Ht – 153cms

BMI – 36.3

Patient sleepy difficult to arouse and goes back to sleep if no verbal communication maintained.

No pallor, icterus, pedal edema

ON EXAMINATIONON EXAMINATIONPulse rate 80/ min and regular.

Blood pressure 150/90 mm Hg

Breath holding time 12 sec

AIRWAY ◦ Mouth opening 2.5 cm◦ Mallampati – class IV◦ Neck extension limited to 40-50*◦ Anterior bulky neck◦ Protruding upper incisors

ON EXAMINATIONON EXAMINATIONCVS and RS : within normal

limits

SPINE –thoracic spinous process felt very vaguely and on deep palpation.

INVESTIGATIONSINVESTIGATIONSHb 9.4 gm%.

TC 8,900 N: 88 L: 10 E: 01

Urea 43 mg % creatinine 1.4 mg%

LIVER FUNCTION TEST◦ T. bilirubin 2.6 mg%◦ D. bilirubin 1.5 mg%◦ Albumin 3.0 gm%◦ Globulin 4.5 gm%◦ ALP 408 u/l

INVESTIGATIONSINVESTIGATIONSBT 1’ 40” CT 4’00”

PT 14 sec (12 sec ) INR 1.21

THYROID FUNCTION TEST◦T3 1.14◦T4 12.84◦TSH 0.73

ECG and CXR within normal limit.

INVESTIGATIONSINVESTIGATIONSUSG abdomen – enlarged gall

bladder with thickened wall with multiple calculi 10 – 18 mm . Suggestive of calculus cholecystitis

ABG ◦PH - 7.346◦Pco2 - 51.2◦Po2 - 59◦Spo2 - 88.2◦Hco3 - 28.0◦Tco2 - 29.6

SUMMARYSUMMARYAcute obstructive cholecystitisElderly ObesityHypertensiveHypothyroidismObstructive sleep apneaRecurrent UTI

Intra op management Intra op management NPO of 7hrs.No premedicationPlan – combined spinal epidural IV access – 16 G cannula in left

UL, Patient in lateral position 17G tuohy needle in T6-T7 space Space reached at 4.5cms

Intra op management Intra op management Needle through needle tech used – 27G

spinal needle used.Free flow of CSF confirmed – 1.8ml of

0.5% bupivacaine (heavy) administered in the subarachnoid space

20G epidural catheter threaded and fixed at 11cms.

Patient was repositioned Rt radial artery cannulated for

continuous BP monitoringInj. Dopamine 200mg in 50 ml started

as an infusion at 3-5mcg/kg/min.

Intra op management Intra op management Oxygen through face mask with a flow

of 5l/min Epidural infusion - 0.5% bupivacaine @

5ml/hr was started. The procedure lasted for 1hr and 30

minThe patient was hemodynamically

stable throughout the surgeryAt the end of surgery patient was

shifted to post – op ward with stable vitals.

POST op management POST op management Oxygen – flow of 5l/min Epidural infusion – 0.25%

bupivacaine + 2mcg/cc fentanyl at 5ml/hr

Dopamine infusion at 3ml/hr stopped in the evening of the same day

IV fluids RL @ 100ml/hr

First post op dayFirst post op daycentral line was putI/O was maintained – 2100/2017Na-139, K-3.2, Hb-9.2ABG

◦ PH - 7.4◦ Pco2 - 34◦ Po2 - 141◦ Spo2 - 99.2◦ Hco3 – 21.3◦ Tco2 -22.3◦ BE – 2.7

She was started on Inj. Fragmin 2500U S/C

Second post op daySecond post op dayPatient was hemodynamically

stable I/O – maintained 2650/1340Epidural infusion with

bupivacaine continued

Third post op dayThird post op dayArterial line removed Patient was comfortable No complaints of pain Epidural infusion continuedRBS-136Creat – 1.2Na – 150K – 3.6Hb – 8.2 Patient was shifted to the ward on

the third post op day after removing epidural catheter.