Anesthetic management of a patient requiring placement of a Y- stent

Presented by 林起翎 蔡鵠遠 戴家煌

Brief History

呂 xx, 61 y/o, male

Persistent dry cough since 3 yrs ago. Dyspnea and wheezing on left side down.

Tuberculosis was diagnosed at 署立新竹H. He started to receive regular medical therapy.

CXR showed a granuloma at LUL on OPD follow-up in Aug. 2001.

He was transferred to Dr. 李元麒‘ s OPD in Oct. 2001.

Echo-guide biopsy was performed. Pathology report revealed tuberculosis.

Sputum culture yielded “Mycobacterium gordonae” in March, 2002.

Chest CT-scan showed persisted granuloma in May, 2002.

Left main bronchus stenosis was noted. Tracheostomy with left main bronchus dilation was done first on 10/3, 2002.

Stenting for left main bronchus was inserted on 10/21, 2002.

Productive cough with massive sputum was noted after he was discharged on 10/26.

He was admitted again and bronchoscope revealed granulation tissue over distal end of the stent on 11/8.

Arrange Y-stent on 11/11.

Past History

Old MI at 4 years ago

DM(-), HTN(-), other systemic dz.(-)

No known food or drug allergy

Smoking(+), quitted for 3 yrs

Alcohol(-), betel nut(-)

Family history ： non-contributory

Previous operation history ： tracheostomy and stenting

Physical Examination

Consciousness:clear, E4M6V5, easy-looking

Vital signs:BP=115/75mmHg, HR=68/min, RR=20/min, BTR=37.0℃HEENT:conjunctiva:not pale, sclera:anicteric, pupil:isocoric, prompt light reflex L/R:+/+

Neck:supple, JVE(-), LAP(-), carotid bruit(-), tracheostomy(+)

Chest:L’t side decreased breathing sound

Heart:Regular heart beat, murmur(-), thrill(-), heave(-)

Abdomen:soft and flat, tenderness(-)

Extremities:freely movable, pitting edema(-)

Peripheral pulsation:intact

51.6 kg, 156.4 cm

Laboratory data

Complete Blood Cell Count (91-11-07) RBC:4.09 Hb:12.7 Hct:36.3 HCV:88.8 MCHC:35 PLT:466 WBC:7360

Coagulation Profile (91-11-07) PT:11.8/11.5 PTT:39.8/35.5

Blood Biochemistry (91-11-07) Albumin:4.06 Globulin:3.63 Bilirubin(T):0.3 Bilirubin(D):<0.1

ALP:196 Na:138AST:21 K:3.65ALT:111 Cl:96BUN:10.9 Ca:2.31Creatinine:0.96 Glucose AC:105

EKG: normal sinus rhythm, Q wave at V1~3

CXR: left apical fibrotic change

Anesthesia

IVA

Monitor

EKG , BP , A line , 2 IV line

end-tidal CO2 , pulse oxymeter

Urinary output

Induction:Fentanyl: 1mlPentothal: 250mgAtracurium: 25mg

Xylocaine: 100mgRobinul: 0.2mg

Nitroderm: 1TTSVitacal: 1amp

 Maintenance:

IV propofol infusion: 50~100

mg/h

Tube without seal air leakage

no gas anesthesia

ventilation efficiency SaO2 PaCO2

Left bronchial stenosis

Problem

dilated the left main bronchus

check the lesion of left main bronchus

with flexible scope

measure the length to insert Y stent

procedure

Tube without seal air leakage

no gas anesthesia

ventilation efficiency SaO2 PaCO2

Irritation of airway laryngospasm, bronchospasm

HR BP

Problem

Remove the granulation tissue and

blood clot

13mm Y stent insertion by rigid

bronchoscope

Adjust Y stent position via tracheostomy tube under flexible

scope guide

procedure

Apnea: O2 supply via side hole of rigid

bronchoscope

SaO2: 99% 92% in about 5 mins

Irritation of airway laryngospasm, bronchospasm

HR BP : BP up to 180/110

Problem

Blood clot and debris: lower airway

obstruction

Problem

T.B. Poor ventilation efficiency

upper airway leakage lower airway obstruction

Apnea during procedure

Surgical airway manipulation is a strong stimulus resulting in bronchospasm

Blood clot and debris: lower airway obstruction

Major Problems

Discussion

Airway management ventilation laryngospasm and bronchospasm bleeding due to surgical manipulation

Tuberculosis

Ventilation

Intermittent ventilation

Closely monitor

Avoid continuous positive pressure ventilation increased intrathoracic pressure

Laryngospasm

Anesthetic depth should be adjusted

If laryngospasm occursRemove the offending stimulusGive 100% oxygen Increase anesthetic depthSuccinylcholine

Bronchospasm

Intravenous aminophylline or salbutamol

Volatile anesthetic agents and ketamine are also effective bronchodilators

Epinephrine is indicated in life-threatening situations

Bleeding during surgery

Suction

One lung intubation

Anesthesia in patients with TB

Delay elective surgical procedures until no longer considered infectious

Perform tracheal intubation in a negative pressure environment

Place a high efficiency particulate air filter between the Y-connector and mask or tracheal tube

Place bacterial filters on the exhalation limb of the anesthesia delivery circuit

Use a dedicated mechanical ventilator

Postoperative care in an isolation room

Conclusion

O2 saturation

Anesthetic depth

Thank you for your attention!