Intraoperative management

MMDx: CA Prostate s/p Laparoscopic radicalProstatectomy c Bilateral ureter injuryOp: Explore lap c Bilateral Uretero-IleoneocystostomyMM : Reintubation

Case• ผ้ปู ่ วยชายไทยอายุ 69 ปี นดั มาผา่ ตดั มะเร็งตอ่ มลกู หมากวนั ที่ 15/6/58 Op:Laparoscopic radical prostatectomy c explore lap for repair rectum• Post-op มีปัญหาปัสสาวะไมอ่ อกสงสยั Bilateral Ureteric injury 18/6/58 Op : Abdominal toilet for re- anastamosis• 19/6/58 Post-op ยงั มีปัญหาปัสสาวะไมอ่ อกจงึ ตดั สนิ ใจเข้าไป Re- explore อีกครัง้• คนไข้ตน่ื รู้ตวั ดที ําตามสง่ั ไมม่ ีอาการหอบเหน่ือยแนน่ หน้าอก นอนราบได้ดี

CasePast history – HT • Amlodipine (5) 1*1 – No history of drugs or foods allergy – No history of smoking – No history of alcohol drinking• No history of any problems related to GA• Functional class 2

Case• Physical ExaminationBP 125/51 mmHg PR 72 bpmT 37.2 °c RR 18 breaths/min• GA : An old-aged Thai man, good consciousness, well-cooperated, not pale, no jaundice• BW 60 kg, Height 165 cm (BMI 22.05 kg/m2)

Case• HEENT : mild dry lips & tongue, no sunken eye balls• Airway : full neck flexion & head extension , thyromental distance 5 cm, Mallampatti gr.2 mouth opening 5 cm• Pulmonary : Normal breath sounds, no adventitious sounds

Case• CVS : Pulse regular, full, normal S1, S2, no murmurs• Abdomen : Soft, not tender• Ext. : No pitting edema, no ecchymosis,• Neuro : E4V5M6, pupil 3 mm2 RTLBE, sensory intact, normal DTR

CaseLab investigations• CBC : Hct 38.5%, Plt. 185,000/mm3• Electrolytes : Na 138, K 4.44, Cl 112, CO2 22• BUN/Cr : 49.1/6.3 mg/dL (CrCl=9.39)• CXR : WNL• EKG : WNL





Case• Problem list1. An old-aged Thai man with.. – CA prostate s/p Laparoscopic radical prostatectomy c eaxnpalsotaremloapsisfor repair rectum and Abdominal toilet for re- – AKI – HT2. Operation : Re-explore with Abdominal Toilet

CasePreparation & Premedication• NPO, Inform consent• Intravenous fluids – NSS 1,000 ml iv 60 ml/hr – Prepare warmed IV fluid : 0.9% NaCl 1,000 ml IV• Plan postop : ICU• Keep warm• On CRRT ก่อนมา OR

Case• Choice of anesthesia – GA with ETT• Monitoring – EKG, ETCO2, NIBP, O2 Sat – PPV , CVP

Intraoperative management



BP 185/102mmhg Blunt airway reflexP 102/min 2% Xylocaine 90 mg ivRR 16/min

Sedation Dormicum 1 mg , fentanyl 50 mcgInduction Propofol 80 mgIntubation SCH 100 mgMuscle relaxant Nimbex 8 mgMaintenance O2:Air:Des 0.5:0.5:6

BP 105/60mmhg On ETT No 8cmP 100/min Deep 20 cm

Total Operation time 4hr30minBleeding 300 mlTotal Fluid 2900 mlTotal Fentanyl 200 mcg last at 23:15Total Nimbex 16 mg last at 23:15

Progress(19/6/58)• S : ก่อน off ETT คนไข้หายใจ TV >300 ml คนไข้ดนิ ้ ไมอ่ ยนู่ ่ิง ไมท่ ําตามสงั่ ขยบั แขนไปมาได้ดี เลยตดั สนิ off ETT หลงั off ETT คนไข้มีหายใจเหนื่อยมากขนึ ้ Sat 90% (hold mask 98%)• O : BP 140/80 P 100/min RR 28/min Lung : Clear , no crepitation , Abdominal Paradox• A : Impending respiratory failure• P : Re-intubation

CaseLab investigations• CBC : Hct 27.5%, Plt. 185,000/mm3• Electrolytes : Na 138, K 4.44, Cl 112, CO2 22• At 01:22 BUN/Cr : 54.1/5.6 mg/dL (CrCl = 10.56)



Extubation Criteria in OR1. Adequate Oxygenation SpO2 > 92%, PaO2 > 60 mm Hg2. Adequate Ventilation VT > 5 ml/kg, spontaneous RR > 7 bpm, ETCO2 < 50 mm Hg, PaCO2 < 60 mm Hg3. Hemodynamically Stable4. Full Reversal of Muscle Relaxation Strong hand grip TOF ratio >0.9 (cannot be accurately assessed visually) Sustained 5-second head lift or hand grasp5. Neurologically Intact Follows verbal commands, Intact cough/gag reflex

Extubation Criteria in OR6. Appropriate Acid-Base Status pH > 7.37. Normal Metabolic Status Normal electrolytes Normovolemic8. Normothermic : Temp > 35.5˚9. Other Considerations Aspiration risk , Airway edema The postanesthesia care unit. In Miller RD (ed), Miller’s Anesthesia, 8th ed. Airway management. In Barash PG, Cullen BF, and Stoelting RK (eds), Clinical Anesthesia, 7th ed

Extubation Criteria Ram Roth, Faieja C. Anesthesiology News. Extubation : Making The Unpredictable Safer. 2012. 69-74.

Causes of HYPOXEMIA• Low FiO2• Hypoventilation• Diffusion defect• V/Q mismatch – Low V/Q • Pulmonary edema, Pneumonia, Bronchiolitis – High V/Q : PE – Respond to oxygen supplement• Shunt – ARDS, complete atelectasis, consolidation, One lungintubation – Not respond to oxygen

Causes of Ventilatory Compromise During Tracheal Extubation• Secretion obstruction• Residual anesthetic drugs – NMBA – Narcotics• Laryngospasm

Progress(20/6/58)• S : คนไข้ตน่ื รู้ตวั ดี ปัสสาวะออกได้ดี 50ml/hr pain score = 3-4• O : BP 140/80 P 100/min RR 16/min Lung : Clear , no crepitation• A : s/p Explore lap c Bilateral Uretero- Ileoneocystostomy day 1• P : pain control observe การหายใจ plan ย้ายกลบั ward

CaseLab investigations• At 01:22 BUN/Cr : 54.1/5.6 mg/dL ( CrCl =10.56 )• At 04:23 BUN/Cr : 56/4.5 mg/dL ( CrCl =13.14 )• At 15:50 BUN/Cr : 40.1/2.1 mg/dL ( CrCl =28.18 )• 21/6/58 BUN/Cr : 26.8/1 mg/dL ( CrCl =59.16 )• 22/6/58 BUN/Cr : 21.1/0.7 mg/dL ( CrCl =84.52 )

THANK YOU