investigations
DESCRIPTION
CASE REPORT – RIGHT HEPATECTOMY Dr.M.MuthuShenbagam,MD( Anes ),DA. Asst.Professor Dept.of Anaesthesia , Kanyakumari Govt.Medical College Hospital. - PowerPoint PPT PresentationTRANSCRIPT
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CASE REPORT – RIGHT CASE REPORT – RIGHT HEPATECTOMYHEPATECTOMY
Dr.M.MuthuShenbagam,MD(Anes),DA.Dr.M.MuthuShenbagam,MD(Anes),DA.Asst.ProfessorAsst.Professor
Dept.of Anaesthesia,Dept.of Anaesthesia,Kanyakumari Govt.Medical College Kanyakumari Govt.Medical College
Hospital.Hospital.
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•51yrs old Mr. Stephen from 51yrs old Mr. Stephen from Nagercoil,admitted at KGMCH Nagercoil,admitted at KGMCH with C/o. Abdominal pain > 6 with C/o. Abdominal pain > 6 months.months.Diagnosed by CT as Giant Diagnosed by CT as Giant Hemangioma (Rt) lobe of liver. Hemangioma (Rt) lobe of liver.
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INVESTIGATIONSINVESTIGATIONS
Hb Hb - 10 gms %- 10 gms %
LFTLFT- WNL- WNL
Coagulation profileCoagulation profile - WNL - WNL
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• Planned for Rt Hepatectomy.
• Assessed
• Procedure & risk explained to the patients and relatives.
• Adequate blood reserved.
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•Patient was shifted to OT.Patient was shifted to OT.
Started IV linesStarted IV lines 2 widebore 16G venflon – 2 widebore 16G venflon –
Rt&Lt arm.Rt&Lt arm. One 18G venflon in LL. One 18G venflon in LL.
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•Monitors.Monitors.- Pulse oximeter- Pulse oximeter- NIBP - NIBP - ECG- ECG- CVP- CVP-Urine output-Urine output
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ANAESTHESIA PLAN ANAESTHESIA PLAN
ETGA + Thoracic Epidural ETGA + Thoracic Epidural AnesthesiaAnesthesia
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Emergency drugs ,NTG, Emergency drugs ,NTG, Dopamine infusion kept ready.Dopamine infusion kept ready.Premed :Premed :
-Inj.Glycopyrolate 0.2mg IV -Inj.Glycopyrolate 0.2mg IV - Midazolam 2mg IV- Midazolam 2mg IV- Pethidine 50mg IV- Pethidine 50mg IV
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Under Asepsis Rt Internal Under Asepsis Rt Internal jugular vein cannulated &jugular vein cannulated &Triple lumen CVP catheter Triple lumen CVP catheter inserted under seldinger inserted under seldinger technique & distal port used for technique & distal port used for CVP measurement.CVP measurement.
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Under asepsis, RT lat-position, Under asepsis, RT lat-position, 18G Epidural Catheter inserted 18G Epidural Catheter inserted in T10-T11space& 5cm kept in T10-T11space& 5cm kept inside& 10ml of 0.2% inside& 10ml of 0.2% Ropivacaine + 25mcg Fentanyl Ropivacaine + 25mcg Fentanyl given through Epidural Catheter given through Epidural Catheter
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INDUCTION : Thiopentone 250mgINDUCTION : Thiopentone 250mg IV IV Scoline 75mg IV Scoline 75mg IV
INTUBATION INTUBATION : 8.0 ID Endo tracheal : 8.0 ID Endo tracheal tube & BAE checked tube & BAE checked
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MAINTENANCE MAINTENANCE – N – N22O/OO/O22
- Fentanyl - Fentanyl - Atracurium - AtracuriumLA supplementation thro LA supplementation thro Epidural.Epidural.
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Fluid- Maintenance with Fluid- Maintenance with Crystalloids& Colloids.Crystalloids& Colloids.
CVP was kept in the range of CVP was kept in the range of 4-6 cm water.4-6 cm water.
NTG infusion was used to NTG infusion was used to minimize blood loss.minimize blood loss.
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Vascular control was done with Vascular control was done with inflow clamping of Hepatic A / inflow clamping of Hepatic A / portal veinportal vein (Pringle maneuver)(Pringle maneuver)
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Intra operatively, during resection Intra operatively, during resection phase, huge blood loss from middle phase, huge blood loss from middle hepatic veins.hepatic veins.
BP to 60/40mmHgBP to 60/40mmHg
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MANAGEMENT:MANAGEMENT: - Mephentermine 12 mg Bolus - Mephentermine 12 mg Bolus - Colloids/Blood 2 units rushed - Colloids/Blood 2 units rushed - Dopamine drip - which was - Dopamine drip - which was stopped after control stopped after control
BP to 100/70mmHgBP to 100/70mmHg
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•Rest of the intraop period- uneventfulRest of the intraop period- uneventful
Surgery lasted for 6 hrs.Surgery lasted for 6 hrs.
Blood loss – app. 2 to 3 lit.Blood loss – app. 2 to 3 lit.
Intraoperativly 6 units of blood Intraoperativly 6 units of blood transfused & calcium supplement transfused & calcium supplement given.given.
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At the end of procedure – At the end of procedure – reversal with Neostigmine + reversal with Neostigmine + Glycopyrolate Glycopyrolate
Extubated awake.Extubated awake.
Postop period – Vitals – StablePostop period – Vitals – Stable
Shifted to ISCUShifted to ISCU..
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Problems in Liver ResectionProblems in Liver Resection
Long operation time Long operation time Fluid Shifts Fluid Shifts Sudden unexpected blood Sudden unexpected blood lossloss CoagulopathyCoagulopathy HypothermiaHypothermia
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Low CVP Technique – controversial
Aids surgery Minimise blood loss
But, increased risk of Airembolism Potential for Hemodynamic instability if
bleeding is sudden & significant
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THANK YOUTHANK YOU