Appendix XIb
UAB Nurse Anesthesia Program
School of Health Related Profession
Anesthesia Management Plan
Date: August 6, 2002
Student Name:
__Prospective
x _Retrospective
Patient DX: Prolonged Respiratory Insufficiency
Proposed Procedure: Tracheostomy
Age: 56
Sex: F
Height: 5’2”
Weight: 146kg
Allergies: NKDA
Medications: Lopressor, NTG Paste, Zyprexa, Dilantin, sliding scale insulin
ASA Status: 4
Medical/Surgical History
Significant Review of Systems
Med. Hx: S/P CVA 11/97, HTN, CHF,
Asthma, GERD, IDDM x 17 years
Surgical Hx: PEG placement 3 weeks ago,
Right BKA with GETA with NAC
Social Hx: Remote h/o smoking and has been
abstinent since stroke.
Dental: Poor dental hygiene, several rotten teeth upper
and lower. One loose tooth lower left molar
Neuro: Pt. is unable to communicate in any way due to
CVA.
Resp: Some wheezing bilaterally.
CV: NSR on ECG, S1 and S2 without ectopy or murmers
Very poor exercise tolerance and pt has been
bedridden since her stroke
Airway: Class 3 airway but the pt. is already intubated.
Her neck and face are very edemetous as is the rest
Of her and reintubation could be difficult.
Lab Values
Na: 153
Hgb: 9.7
Cl: 122
BUN: 16
Ca:8.0
K: 4.6
HCT: 28.9
Plt: 256
CO2: 21.3 Glu: 157
Cr: 0.9
Mg:1.6
Phos:2.7
PT/PTT: 11/32
Fluid Management
Maint: 290 cc/hr
Deficit: None, the pt is in house and on maintenance
Fluids
3rd Space: minimal
ABL: 100-250cc
Evaluation Anesthetic Management
All anesthetics minimally titrated for effect. Pretty good control of BP and HR intraop and adequate level
of anesthesia obtained. Muscle relaxation required to avoid a dangerous depth of anesthesia for the pt. and
reversal was not required as the pt. resumed mechanical ventilation post-op. No difficulty with transfer to
tracheostomy ventilation.
Postoperative Evaluation
Returned to ICU on monitors and 100% ambu O2 via trach. No complication with transfer and mechanical
ventilation resumed upon entering. VSS.
- Sample -
Scheduled Procedure: Tracheostomy
Position: Supine with head in the sniffing position
Exposure: Entire anterior neck down to sternum
Incision: Transverse skin crease between thyroid and suprasternal notches.
Blood bank: Type & screen usually but this pt. was typed and crossmatched for one unit pre-op.
EBL: 5-25cc
Surgical time: 3-20 minutes
Nerves: Recurrent Laryngeal Nerve and the Transverse Cervical Nerves.
Overview
In this case the tracheostomy was performed due to prolonged ventilatory assisstance and inability to ween.
A horizontal incision is made about 1 cm below the cricoid cartilage and the strap muscles are separated to
expose the thyroid gland. The center of the thyroid gland is excised and the fascia overlying the trachea is
removed. At about the second or third tracheal ring the trachea is entered with a horizontal incision and a
tracheal tube is placed into the trachea as the ETT is pulled back slowly. Then the ventilator circuit is
reconnected to the tracheal tube and ventilation is resumed.
Pre-op Assessment
.
Resp: Assess breath sounds while mechanically ventilated. Obesity predisposes to premature airway
closure. Check out what the PIP’s run at normally. A lower TV with higher respiratory rate may be needed.
CV: Cardiovascular risk factors may be present in this population. Check all studies such as
echocardiogram to assimilate what the CV reserve is. 12 lead ECG is a necessity.
Neuro: In this pt. degree of neurological compromise is important to assess so that proper anxiolytics,
sedation, and pain relief may be given.
GI: Assess PO status and in this pt, how long has the peg tube feeding been off. Pretx. With reglan and
pepcid IV may be indicated.
Labs: CBC, Chem 7, PT/PTT
PreMeds: 10mg Reglan and 20 mg Pepcid IV
Anesthesia Implications
Since this pt. was already intubated anticipation of airway difficulties was minimal, however the ETT
should not be completely backed out from the vocal cords until you are sure that the tracheostomy tube is in
the right plane per BBS and + CO2 return, Chest rise etc.
This pt. has significant respiratory insufficiency and may require PEEP for transfer from ICU.
Positioning is critical to the exposure of the surgical site. Place a roll under the shoulders to allow for
maximum extension of the head. Do not allow the head to dangle freely though.
Muscle relaxation may be required to assure a quite surgical field during critical moments of the procedure.
Avoid placing monitors in the surgical prep field.
Pneumothorax is a complication of low neck dissection and is manifested by decreased BP, increased CVP,
wheezing, increased RR, decreased O2 saturation and decreased breath sounds. Monitor closely.
Anesthetic Management
This pt. was given 100mcg of Fentanyl upon entering the room and 70mg Propofol titrated to effect for
induction. Muscle relaxation was achieved with Zemuron in small boluses and reversal was not provided.
Isoflurane/air and O2 were used for maintenance.
The pt. was transported to and from ICU on the monitor and with 100% O2 via ambu.
Mechanical ventilation was resumed upon entering the OR and returning to ICU.