PHILIPPINE SOCIETY OF ANESTHESILOGISTS, INC.
CLINICAL CASE CONFERENCE
Date: April 22, 2008 ( Tuesday)
Time: 4:00 P.M.
Venue: EMG Auditorium 2nd F/ Lung Center of the Philippines
Presenting Hospital: University of Perpetual Help Rizal Medical Center
Discussant: Amellie D.S. Manahan, M.D.
Reactor: Merle F Dela Cruz-Odi, MD, DPBA
Moderator: Ma. Lilybeth R. Tanchoco, MD, DPBA
General Data:
This is a case of G.F. 60 y/o female, married, Filipino, Catholic, residing at Las Pinas City. Admitted at UPHRMC on May 23, 2005.
Chief Complaint: Anterior neck mass
History of Present Illness:
Three years prior to admission, patient experienced occasional palpitations at rest and on exertion, weight loss of approximately 20%, tremors, easy fatigability, intermittent chest pains at rest and on exertion lasting for approximately 1-3 mins, non-radiating and stabbing in character. She also noticed bulging of her eyes. Patient sought consult with an endocrinologist, work up was done, and she was diagnosed with hyperthyroidism. She was treated with propylthiouracil 50mg tab OD for 6 months and methimazole 5 mg tab every 8 hours for 6 months. Patient had good compliance with treatment and had regular follow ups with her endocrinologist.
Two years prior to admission, patient still had exopthalmos, experienced the same character of intermittent chest pains, occasional palpitations and occasional difficulty of breathing on exertion. She noticed her daily movements to be at a slower pace. She again consulted with her endocrinologist and thyroid function test revealed hypothyroidism. She was treated with Anhydrous thyroxine Na (Eltroxin) 50 mcg/tab, one tab every other day for 4 months. Patient was compliant with treatment.
One year prior to admission, patient was euthyroid, with no more medications, but still experienced the same character of chest pains and occasional palpitations and difficulty of breathing with bulging of eyes. She noticed an anterior neck mass, approximately 5x2cms, doughy, movable. No consult was done.
One month prior to admission patient still with the same signs and symptoms, noted a 50% increase in size of anterior neck mass. She sought consult, further evaluation done and was advised total thyroidectomy. Hence admission.
Past Medical History:
?(+)HPN with incidental finding of cardiomegaly - 10 years ago
- Metoprolol tab 100mg BID
- Imidapril Hcl 10 mg + Hydrochlorothiazide 12.5 mg tab OD
- Lercanidipine HCl 10mg tab OD
- poorly compliant
(+) Dyslipidemia – no medications
(-) DM
(-) Asthma,
No allergies to food or medications
Past Surgical History: Patient denies any previous surgical procedures.
Family History:
(+) Hypertension – maternal and paternal side
No other heredofamilial disease in the family
No other family member with the same illness
Personal And Social History:
Patient is a business woman, college graduate, smoker for 30 pack years, non- alcoholic beverage drinker and no history of illicit drug use.
Menstrual History:
Menarche at 13 y/o, regular monthly cycle (28-30) days for 3-4 days, moderate flow with no dysmenorrhea, no dyspareunia or post coital bleeding.
Obstetrical History:
Patient is a G3P3 (3003), All term live births via NSD without any fetomaternal complications noted.
Review of Systems:
SHEENT:
(-) rashes, (-) discoloration, (-) headache, (-) dizziness, (-) dysphagia,
(-) hoarseness of voice, (+) anterior neck mass
Lungs: (-) cough (-) difficulty of breathing
Cardiovascular system: (+) chest pain (+) palpitation (+) occasional dyspnea (+) easy fatigability
Gastrointestinal: (-)nausea (-) vomiting (- ) changes in bowel movements
Genitourinary: (-) dysuria (-) hematuria (-) urinary frequency
Endocrinologic: (+) tremors, (+) weight loss, (+) palpitation, (+) easy fatigability
Neurological: (-) weakness, (-) sensory deficit
Hematologic: (-) easy bleeding (-) easy bruising
Physical Examination:
General Survey:
Patient was conscious, coherent, oriented to time, place and person, ambulatory, not in cardio-respiratory distress.
Vital signs:
BP= 130/ 90 mmHg wt = 60 kgs
PR= 76 bpm ht = 157 cms
RR= 20 cpm temp= 36.5 C
SHEENT:
- warm to touch, good skin turgor, pink palpebral conjunctivae, (+) exophthalmos,
no nasal septal deviation, no tonsillopharyngeal congestion (+) anterior neck mass,
10 x 4 cms, doughy, non tender, moves with deglutition, no bruits, no cervical
lymphadenopathy
Chest/Lungs:
Symmetrical chest expansion, (-) gross deformities, (-)wheezes, (-) crackles, resonant
on percussion
Cardiovascular:
Adynamic precordium, normal rate regular rhythm, PMI at 5th intercostal space left
midclavicular line, (-) heaves, (-) thrills, (-) murmurs
Abdomen:
Flabby, normoactive bowel sounds, soft, (-) mass, (-) tenderness
Extremities:
(-) gross deformities, full and equal pulse, (-) edema
Pre Operative Course:
Patient was seen and examined. Pre operative laboratory examinations requested and reviewed. She was instructed nothing per orem for 8 hours prior to procedure. Venoclysis with D5LR 1L at 30gtts/min once on NPO was started. Premedications ordered were Metoprolol tab 100mg PO with sips of water two hours prior to the procedure and Nalbuphine 10 mg and Promethazine 50 mg intramuscularly one hour prior to the procedure. Anesthetic type, procedure, possible complications explained to patient.
Cardiopulmonary clearance noted with the following recommendations: May give nitroglycerine IV intraoperatively if needed.
Surgical Impression:
Non-toxic Goiter
Hypertension I, controlled
ASA 2 MAL 2
Surgical Plan: Total Thyroidectomy
Anesthetic Plan: General Endotracheal Anesthesia
Perioperative Course:
Patient was wheeled into the OR stretcher-borne, sedated, not in cardiorespiratory distress. Intravenous fluid was infusing well : D5LR 1 L at30 gtts/min. Patient was hooked to cardiac monitor, pulse oximeter and initial vital signs were as follows: BP=120/80 PR=82 RR=20 T=37C O2 sat=100%.
Intraoperative Course:
Preoxygenation was done at 4-5 lpm for 5 mins, Patient was induced with Midazolam 5 mg IV, Atracurium 2.5 mg IV, Fentanyl 50 mcg slow IV push, slow gas induction via face mask with Sevoflurane at 4%, and Succinylcholine 60 mg IV. Smooth intubation was done under direct vision using Mac blade 3, ETT 7.5, cuffed, equal chest expansion and breath sounds, secured up to 20 cms. Vital signs were as follows: BP=130/80 mmHg PR=86 RR=20 O2 sat=100%, controlled ventilation done at 16 cpm with tidal volume 500. Patient was maintained on Sevoflurane at Mac 4, oxygen at 3 liters and atracurium 10 mg.
Operative procedure was uneventful lasting approximately 3 hours, with an estimated blood loss of 50 cc. Total fluids infused was estimated at 700 cc. Patient was extubated with the following vital signs: BP: 120/70, CR 76 bpm, RR 20 cpm, O2 sat 100%. At the end of procedure patient responds to name calling, and obeying simple commands.
Patient was transferred to PACU sedated but arousable, hooked to vital signs monitor,
O2 inhalation via face mask at 4-5 lpm started. Initial vital signs: BP: 120/70 mmHg CR: 72 bpm RR: 20 cpm O2 Sat: 98% and temp: 36.5C. Medications were Ketorolac 30 mg IV q8 ANST ( ) x 3 doses, Nalbuphine 5 mg IV q6 x 2 doses, Ranitidine 50mg IV q12 x 2 doses, and Cefuroxime capsule 500mg per cap q12 once on diet.
One hour post op, patient asleep but opens eyes upon calling her name. Vital signs were BP at 150 / 100, PR 80’s, RR 20’s O2 sat at 96%. Analgesics were already started.
Patient was placed on lateral decubitus position.
Three hours post op, patient was awake, vital signs BP: 150/90 mmHg, PR 80’s, RR 20’s, O2 sat at 98%. Change of dressing done with minimal blood noted.
Four hours post-op patient was noted to be ashen colored from neck up and drowsy to stuporous. Vital signs BP palpatory 30’s and heart rate at 120’s, O2 saturation at 40’s. Breathing was labored, patient was noted to have cold, clammy skin. Dressing was removed and a bull neck appearance was noted. Patient was immediately brought back to operating room.
In the operating room mask ventilation with positive pressure for approximately 2 minutes was done. Intubation was immediately done but with difficulty using Mac 3, ET size 7 inserted, cuffed, equal chest expansion and breath sounds, secured to level 21. She Simultaneously given the ff medications: Ephedrine 10 mg, Dopamine side drip: D5W 250cc + Dopamine 400mg (microdrip) titrated accordingly, Fentanyl 50 ug IV, and BT line inserted, Haesteril 10% 500cc started.
Vital signs at that time was BP palpatory at 50s, HR 100s, O2 sat 80%. Emergency evacuation of hematoma, exploration and ligation of bleeders were done. Blood pressure went up to 90/60 mmHg with HR at 112, O2 saturation maintained at 97%. Dopamine was discontinued. Patient was then maintained on Sevoflurane Mac 2 with oxygen at 2 lpm, and Fentanly 50 ug iv. Estimated blood clots evacuated approximately amounting to about 600cc. Operation lasted for 45 minutes.
Vital signs after operation were: BP: 90/60 mmHg CR: 112 bpm, ventilation controlled. Patient was transferred to ICCU intubated.
Post Operative Course:
At ICCU, patient was hooked to vital signs monitor. Hooked to mechanical ventilator with the following settings TV: 500 cc, FiO2: 45%, RR: 16, PEEP: 2.5 cmsH2O, Mode: A/C. Patient was referred to IM for co-management. NGT and IFC inserted, 1unit PRBC properly typed and crossed matched for transfusion ordered. Other medications started: Cefuroxime 750 mg iv q 8, Metoprolol 100mg tab per NGT q 12, Metronidazole 500 mg iv q 6, Clonidine 75 mcg SL prn for BP > 150/100mmHg. Diagnostics ordered were CT/BT and post transfusion Hgb/Hct, serum Ca2+ and K+ requested.
Five hours post-op patient was awake, coherent, noted with weakness/numbness right lower extremity. No neck hematoma, (-) Chovstek’s sign, (-) spasms, serum electrolytes, ABG ordered.
Nine hours post-op, patient was awake and coherent. ABG results reviewed, FiO2 decreased to 40%, RR to 12 bpm. Patient tolerated well, no desaturation.
Sixteen hours post-op, weaning started. Patient hooked to T piece at FiO2 60%, nebulization done, (-) Chovstek’s sign, (-) paresthesia of extremities. Serum calcium results – 2.06mmol/L (2.10-2.55), so CaCO3 500mg tab per tab TID started.
First post-op day, patient was awake, coherent, GCS – 15. Her BP well controlled, stable vital signs, no difficulty of breathing, (-) chest pain, (-) fever, with minimal yellowish secretions per ET, chest auscultation revealed crackles - bilateral at the base. O2 sat 98-99% with T piece set up. ABG, CXR, and repeat CBC revealed normal results.
Patient was extubated, O2 via facemask at 6 lpm, O2 sat 99% - Incentive spirometry was done every 2 hours. NGT was removed, soft to full diet ordered.
Second to third post-op day, patient’s vital signs were stable, was transferred to room. Rest of hospital stay was uneventful. Patient was discharged on 4th post-op day. Home Meds: Cefuroxime 500 mg q 12, nifedipine 100 mg q 12, Lercanidipine Hcl 10mg tab OD, and Imidapril Hcl 10 mg combined with Hydrochlorothiazide 12.5 mg tab OD.
Discharge Diagnosis:
Non-Toxic Goiter, HPN I, controlled
S/P Total Thyroidectomy
S/P Exploration, evacuation of hematoma, exploration and ligation of bleeders
Laboratory Examinations:
CBC
Pre op
05/24/05
05/25/05
Hgb
124
118
133
Hct
.36
.35
.40
RBC
4.39
4.66
WBC
9.8
15.2
Neutrophil
.68
.68
Lymphocytes
.23
.23
Eosinophil
.03
.01
Monocytes
.06
.08
Platelet count
adequate
adequate
Blood Chemistry
Pre op 05/25/05
BUN
2.9
Creatinine
93
Sodium
140
136.1 mmol/L
Potassium
3.8
3.5 mmol/L
Calcium
2.06 mol/L
SGPT
34
SGOT
Uric Acid
05/24/05:
CT: 4 minutes 15 seconds
BT: 1 minute 30 seconds
ABG
05/24/05
05/25/05
PH
7.47
7.60
PCO2
42.4 mmHg
26.2 mmHg
PO2
143.6 mmHg
156.0 mmHg
SpO2
100%
100%
BE-EC
+7.4
+4.0
BE-B
+7.5
+5.6
SBC
31.3 mmol/L
29.7 mmol/L
HCO3
31.2 mmol/L
26.8 mmol/L
TCO2
32.5 mmol/L
26.6 mmol/L
Chest Xray:
Pre Op:
Cardiomegaly
Both lungs are clear
Atheromatous aorta
May 25, 2005:
Both lungs are clear. Heart is magnified.
Atherosclerotic aorta.
The rest of the visualized structures are unremarkable.
EDT tip at T4 level.
Impression: Atherosclerotic Aorta
ECG:
Pre op:
Non specific ST waves changes
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