Interesting case

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Interesting case
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Chief complaint ???????? 1 ?? ????????.
Present illness 1 ??????????.???????????????
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Past History - ???????????????
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G6PD deficiency Family History -
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Physical Examination Vital Signs PR 108 , BP
100/55, T 37c,RR32 BW 23.5,Height 97 cm.
General appearance A Thai boy look
obesity mild dyspnea ,no cyanosis,noisy
breathing HEENT not pale conjunctiva,no
icteric sclera no cyanosis,no neck vein
engorged tonsil Rt. gr.3 , Lt. gr.4
LN not palpable Heart PMI at 5th
intercostal space,MCL regular
rhythm,normal s1,s2,no murmur
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Lungs inspiratory stridor
rhonchi and wheezing both lungs Abdomen
fatty contour,active bowel sound
no hepatosplenomegaly,not tender Extremities
no edema Airway evaluation Interincisor
gap 3 cm Thyromental distance 5 cm
Mallapati class III
no craniofacial anormally
no micronagthia
no retronagthia
no loose of teeth
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Lab Investigation 1. CBC Hb 11.9 , Hct
35.2 , WBC 9,700 Plt.
460,000 2. U/A pH 7, sp.gr.
1.015,alb.-ve,sugar -ve WBC -ve, RBC
-ve 3. BUN 19, cr 0.6, Na 140, K 4.0,
Cl 104, Total CO2 24 , BS 75 4. PT 9.8
( 11.3) , PTT 30.8 (33.8)
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5. LFT Total protein 7.9 gm/dL
Albumin 4.7 gm/dL Globulin 3.2
gm/dL Alkaline Phosphatase 155 U/L
Cholesterol 196 mg/dL AST 43 U/L ALT
59 U/L 6. Lipid Profiles Triglyceride
98 mg/dL Choresteral 195 mg/dL HDL
67 mg/dL LDL 112 mg/dL VLDL 20
mg/dL Chylomicron -ve
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7. CXR 8. Film lateral neck 9. EKG
Operation Adrenotonsillectomy

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Obstructive sleep apnea syndrome
Definitions Sleep apnea cessation of
air flow at the mouth and nose for at
least 10 s during sleep Central
sleep apnea no airflow at the nose
and mouth occurs and there is no
respiratory movement Obstructive sleep
apnea absence of airflow at the mouth
and nose despite respiratory movement
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Hypopnea partial upper airway obstruction
during sleep causing at least a 50
reduction in airflow with respiratory
movement Mixed sleep apnea a period of
central apnea followed by an obstructive
apnea episode Epidemiology of SAS - Sleep apnea
syndrome is a common disorder, the estimate
prevalence in middle-aged adult population
1-4 - In children 0.7-2 ,Thailand 0.69
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- Most common in children age 2-5 years
old. Pathogenesis Pathophysiology - During
normal respiration--gtgenioglossus geniohyoid
muscles act as the main muscle groups in
maintainina pharyngeal airway patency. -
During inspiration--gttone in these muscles
counteracting intraluminal pharyngeal pressure
generate by the respiratory pump muscles.
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- During sleep--gt Force of dilatory muscles
negative intraluminal
pressure exceeding
inspiratory collapse
of the upper airway
- Obstructive sleep apnea results from a
narrowing of the airway and occurs as a
consequence of an anatomical reduction in the
upper airway or incoordination of upper airway
dilatory muscle activity.
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- When OSA occurs,the site of the obstruction
can be anywhere from the nasopharynx to the
supraglottis 1. Anterioposterior
displacement of the tongue against the
posterior pharynx 2. Posterior
displacement of the soft palate by the
tongue against the posterior pharynx
3. Opposition of the lateral pharyngeal wall
4. Circular closure of the pharynx
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Predisposing factors to OSA Anatomic factors
that narrow the upper airway Adenotonsillar
hypertrophy Trisomy 21 Other genetic or
crainofacial syndromes associated with
- Midface hypoplasia -
Small nasopharynx - Micrognathia or
retrognathia - Choanal atresia or
stenosis - Macroglossia
- Cleft palate Obesity Nasal
obstruction
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Laryngomalacia Sickle cell disease
Velopharyngeal flap repair Neurologic
factors that decrease pharyngeal muscle dilator
activity Medications--gt sedatives or
general anesth. Brain stem disorder--gt
Chiari malformation,
birth asphyxia
Neuromuscular disease
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Clinical features of sleep apnea
syndromes Symptoms Nocturnal events
- Snoring - Restless sleep with frequent
movements - Sudden arousals with choking
or shortness of breath -
Nocturnal awakenings and insomnia -
Nocturnal enuresis or frequent nocturia -
Nocturnal sweating Diurnal history -
Excessive daytime sleepiness -
personality changes - Morning headaches
- Morning dry throat - Sexual dysfunction
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Signs - Reduced sleep latency by EEG -
Obesity - Hypertension - Cardiac
dysrhythmias - Upper airway abnormalities
- Pulmonary hypertension - RV hypertrophy
- Cardiomegaly - Peripheral edema -
Polycythemia
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Diagnosis 1. CBC ---gt polycythemia 2. ABG ---gt
respiratory acidosis met.alkalosis 3. EKG,CXR
--gt RV hypertrophy 4. Film lateral neck --gt
narrowing upper airway 5. Polysomnography ( PSG
) Apnea Index ??????????????????????????
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Treatment 1. Avoid alcohol,sedatives,sleep
deprivation and supine sleep posture--gt
induce or worsen
symptom 2. Weight reduction 3.
Treat underlying --gt surgical correction 4.
Application of CPAP 5. Intra-oral appliance
--gt Tongue-retaining device 6.
Tracheostomy
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Plan of anesthesia 1. Preanesthetic period
- evaluation - preparation -
premedication 2. Intraoperative management
- induction - intubation -
maintenance of anesthesia - recovery 3.
Post anesthetic care
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Preanesthetic evaluation 1.Patients history
physical examination --gt to detemine the ease
of mask ventilation and tracheal
intubation 2.Lab investigation --gt CBC
Coagulation parameter --gt CXR --gt
EKG 3.Medication --gt antibiotic,diuretic
--gt premedication - sedative
drug - antisialagogue
- preemptive drug -
prophylactic antiemetic
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Monitoring - pulse oximeter - precordial
chest piece - capnograph - EKG - Peek
airway pressure
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Induction 1. Inhalation induction -
smooth transition from spontaneous to
assist ventilation--gtease to management
of a difficult airway - effects of
anesthesia reversible if difficult in
maintaining airway - The use of
inhalational agents in patient with
pulmonary hypertension has been
reported to lower pulmonary arterial
pressure - un pleasant for the child and
result in coughing
laryngospasm,especially if
anticholinergic premedication has not been
given
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- Most inhalation agents have a myocardial
depressant effect in the high concentrations
required for induction - Sevoflurane has
smoother and more rapid inhalational induction
and faster emergence compare with halothane -
Nitrous oxide has been reported to produce a
rise in pulmonary artery pressure
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Intravenous induction - rapid,does not produce
an excitation phase and reduces the likelihood
of vomiting and laryngospasm - may be
complete loss of upper airway with an inability
to ventilate the lungs - if the upper airway
becomes obstruct during induction can relieve
by jaw manipulation, the use of an oral or
nasal pharygeal airway or the use of CPAP - All
anesthetic drug should be titrated to just the
desire effect,prefer using short acting
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Intubation - Tracheal intubation is the prefer
option for adenotonsillectomy and in children
with associate craniofacial abnormalities this
can proove difficult - Intubation can be
facilitated by using high concentrations of
inhalation agents in the spontaneously breathing
child. - Alternatively,a muscle relaxant can
be used to facilitate intubation
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_at_ suxamethonium gt short acting
gt cardiac
arrhythmias _at_ nondepo. gt longer
onset,duration
gtprolong ventilategtregur.
gt if complete airway obstruct.
Difficult to reverse -
Awake intubation may be difficult in
uncooperative child. - Blind nasal intubation is
an alternative technique in skill hands.
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- The laryngeal mask airway has been used
successfully in many cases of failed intubation
and its elective use in ENT surgery is becoming
widespread. LMA ---gt no aspiration
of blood --gt one study found
recovery to be
significant better,with less
airway obstruction when
compare with tracheal tube
--gt extra vigilance because of the
danger if it dislodge
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Maintenance anesthesia - Spontaneous or
controlled ventilation should be used for
adenotonsillectomy is controversial - In the USA
advocate control ventilation. - In the UK
advocate spontaneous ventilation -
Nondepolarising Muscle relaxant should be used
intermediate acting than longer acting - The
use of opioids during anethesia may result in
respiratory depression,especially in the
postoperative period. ---gt should be
limited and short-acting
opioids use
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- The use of nitrous oxide and volatile agents
may be beneficial to decrease the amount
of opioids required to maintain anesthesia. -
When pulmonary hypertension is present, nitrous
oxide may cause a marked increase in pulmonary
vascular resistance and pulmonary arterial
pressure Extubation - Perform only in the fully
awake alert patient. - Respiratory monitoring is
imperative after extubation,and all equipment
and personnel necessary for airway management
must be immediately available.
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- Extubation in the lateral position,with slight
head down tilt,will ensure safe drainage of
blood if rebleeding should occur Postoperative
management -Positioning--gt sitting posture in
OSASobesity --gt tonsil
position in tonsillectomy -Oxygen therapy
prevent early episode desat.--gtadd 28 O2
concern that O2 may increase apnea duration
---gt CO2 retention -Pain -systemic opioids
use with extreme caution -NSAIDs ---gt caution
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CPAP therapy - Nasal CPAP may also be used to
maintain pharyngeal patency in patients
demonstrating recurrent apnea after
extubation. Bleeding Postoperative nausea and
vomiting Acute postoperative pulmonary edema