26 Y F WITH 36 WEEK PREGNANCY KNOWN CASE OF RHEUMATIC HEART DISEASE WITH MITRAL STENOSIS POSTED FOR ELECTIVE LSCS

PATHOPHYSIOLOGY OF MITRAL STENOSIS

ANESTHESIA PLAN 

PATHOPHYSIOLOGY OF MITRAL STENOSIS

  

Mitral valve stenosis is reduced valve area < 2 cm ²

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Reduced valve area causes impediment in blood flow across the valve

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Reduced left ventricular diastolic filing becomes dependent on atrial kick

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As Transvalvular Pressure increases the transmitted Left Atrial    Pressure rises

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Left Atrial enlargement leading to Atrial fibrillation

                                          

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Increased pulmonary artery Pressure, and Pulmonary Artery Hypertension

                                           

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Reduced cardiac output and Congestive Heart Failure        

         

 ANESTHESIA PLAN

Preoperative concerns 

Symptoms of breathlessness, fatigue,lower respiratory tract infection

Evidence of right heart failure- raised Jugular Pulse, pedal oedema

Left atrial enlargement prone to atrial fibrillation

If on warfarin to be bridged to heparin 

Investigations

Ecg has P mitrale

2D ECHO  PASP is a vital indicator

Perioperative management

• Fixed cardiac condition-Sinus Rhythm to be maintained
•  Rate low (<70/min) avoid tachycardia
•  Preload maintenance ,overload to avoid 
•  Afterload maintenance, it can reduce with  decreased systemic vascular resistance
•  Pulmonary vascular pressure to be maintained by avoiding hypoxia, hypercapnia and acidosis

Regional anaesthesia in form of epidural and continuous spinal has emerged as a safe technique has the advantage of titrated and incremental dose. The onset of anaesthesia is gradual allows for  cardiovascular compensation is  for sympathetic blockade is and decreases reduced uteroplacental perfusion

 

                                                           

Define functional residual capacity and closing volume, what is there importance in anaesthesia practice?enumerate factors affecting FRC and CV

Functional Residual Capacity is the lung volume at the end of a normal exhalation. This is the volume which  balances the outward pull of the structures of the thoracic cage and the inward elastic recoil of the lung parenchyma 

Importance in anaesthesia practice

Factors affecting the FRC and closing capacity

Closing capacity is the volume at which the small airways which lack the cartilaginous structures and depend on traction caused by the elastic recoil of the adjacent tissue for patency start to close especially in the dependent part of the lungs.

Induction with general anaesthesia reduces the FRC and closing capacity, this decrease is due to cephalic movement of the diaphragm.Other factors affecting the lung volume and compliance is the position of the patient, steep head down .The closing capping reduction can increase the intrapulmonary shunting which is more in elderly, obese and patients with lung diseases.

1) Body Habitus : FRC is directly proportional to height

2) Sex: FRC is less in females as compared to males

3) Postures:FRC is reduced in supine position 

4) Lung Disease: Restrictive lung diseases reduces the FRC and compliance of the lung

5) Diaphragmatic tone: affects the FRC

 What are the indications of transversus abdominis plane block? With the help of a diagram describe the block?

 The transversus abdominis plane block is the technique of deposition of LA agent in the fascial plane between transversus abdominis muscle and internal oblique which is done either with ultrasound guided technology or anatomical landmark guided .

Indication

unilateral block: 

• Cholecystectomy
• Appendicectomy
• Nephrectomy
• Renal transplant

bilateral block

• Ventral hernia repair
• Lower section caesarian section
• Hysterectomy
• Inguinal hernia repair
• Bariatric surgery
• Colostomy closure

Technique of the block

Equipment:

1) Ultrasound machine with linear transducer ,

curvilinear may be needful in obese pt

2) Sterile cover and gel

3) Skin disinfectant like chlorhexidine 2%

4) Block needle with tubing (50 to 100mm and    

    20 to 21 G)

5) LA agent bupivacaine,ropovacaine

6) 2 20ml syringes containing the LA

Preparation

Informed consent is obtained

Iv cannula is placed

Position

The patient generally lies supine

Monitoring

the basic monitoring of HR,SPO2,BP

High frequency linear probe with gel in sterile transparent cover is placed on the anatomical site corresponding to subcostal ,lateral or posterior TAP block

The probe is moved up and down or rotated to bring the right image

The first layer is Skin and subcutaneous tissue 

The next three are muscle layers External Oblique, internal oblique and traversus abdomens,int oblique being the thickest

As the needle tip enters the block compartment,hydrodissction done

with normal saline and when the plane within the internal oblique and transversus abdominis is separated the LA agent of around 15 to 20ml is injected slowly after negative aspiration for blood

Complications

bowel injury, hematoma, intravascular injection of LA, intraperitonal injection.

                                               

Preoperative evaluation and anaesthetic management of a 35 year-old female patient with a prosthetic mitral valve scheduled
for MTP with laparoscopic tubal ligation

Preoperative Assessment and optimisation

In patients with mechanical heart valve the anesthetic management addresses the following areas of concern

assessment of cardiac function 

• residual pathology

• infective endocarditis

• anticoagulation status

• preparation for reversal of anticoagulation if needful

• neurological evaluation for detection of microthrombi

The cardiac function is assessed with history of dyspnea,orthopnea and easy fatiguability, rhythm abnormality, chest rales, and distended jugular vein.
the labs needed would be ECG,CHEST RADIOGRAPH AND 2D ECHO
CARDIAC CATHETERISATION may provide additional information
the prosthetic valve can br mechanical or bioprosthetic
The prosthetic valve can be heterograft composed of porcine or bovine tissues mounted on metal supports or homografts which are preserved human aortic valves
they last less than the mechanical valve for 10 to 15 years and have less thrombogenic potential so long term anticoagulation is not necessary

Assessment of prosthetic heart valve with 2D ECHO for ring stability and leaflet motion while TEE provides higher resolution images.MRI for prosthetic valve regurgitation or paravalvular leak. CAG can be done for transvalvular pressure gradients and prosthetic valve area.

COMPLICATIONS WITH PROSTHETIC VALVE

• VALVE THROMBOSIS
• SYSTEMIC EMBOLISATION
• STRUCTURAL FAILURE
• HEMOLYSIS
• PARAVALVULAR LEAK
• ENDOCARDITIS

MANAGEMENT OF ANTICOAGULATION

           ANTICOAGULATION BEFORE SURGERY
                                      
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INCREASED RISK OF VENOUS AND ARTERIAL THROMBOEMBOLISM

                                                             

⬇                                                               ⬇
              MINOR SURGERY.                                                                        MAJORSURGERY
                  ⬇
        CONTINUE ANTICOAGULATION IF    MINIMAL BLOOD LOSS                                                                                                                                                                                                           

                                                                                                                                                                                                            

                                                        

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                                           WARFARIN or clopidogrel or any of the newer anticoagulants are discontinued 1 to 5 DAYS prior to surgery

                                                                                   

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      REPLACED WITH IV  UNFRACTIONATED  

                             HEPARIN OR LMWH

                                                                                         

                                                                 ⬇         
                                           TILL 1 DAY BEFORE   

                                             SURGERY 
                                                                                            
 RESTARTED  1 DAY POST SURGERY IF RISK OF BLEEDING IS REDUCED

ELECTIVE SURGERY IS AVOIDED IN THE FIRST MONTH AFTER AN ACUTE EPISODE OF THROMBOEMBOLISM

ANTICOAGULATION IS IMPORTANT IN PARTURIENTS IN VIEW OF HYPERCOAGULABLE STATE BUT WARFARIN IS AVOIDED AND LMWH IS CONTINUED TILL DELIVERY 

DOSE ASPIRIN THERAPY CAN BE GIVEN IN CONJUCTION WITH HEPARIN THERAPY

What is the role of kidney in acid base balance? What are the anaesthetic considerations in a dialysis patient?

The role of kidney in acid base homeostasis

Renal compensation in Metabolic Acidosis

1) Increased Reabsorption of HCO₃

2) Increased excretion of titrable Acids

3) Increased production of ammonia

Increased Reabsorption of HCO₃

almost 70-80% of all HCO₃ filtered by the kidneys is reabsorbed in proximal convoluted tubules

H⁺ is titrated into the tubular fluid and carbonic anhydrase catalyses the production of H₂O and CO₂which is rapidly reabsorbed and carbonic anhydrase within the cell converts CO₂ back into HCO₃which exits into the peritubular blood

Increased Excretion of Titratable Acids

The H⁺ that was secreted into the tubular fluid to recover the HCO₃⁻ combines with urinary buffers as HPO₄²⁻ to form H² PO⁴ which due to its charge can't be absorbed back and is excreted from body 

Increased production of Ammonia

The Deamination of Glutamine in the proximal convoluted tubules is the principle source of NH₃ production in the kidneys which is secreted into the tubular fluid as a buffer and combines with H⁺ to form NH₄⁺ which is readily not absorbed back and excretion of NH₄ in urine effectively eliminates H⁺

Renal compensation in Metabolic Alkalosis: The kidneys have good capacities of reabsorption or excretion of HCO₃which protects against metabolic alkalosis per se hence metabolic alkalosis  generally occurs in association with sodium depletion or mineralocorticoid excess. Sodium depletion enhances the Na⁺ reabsorption into the tubular blood  which is coupled with Cl⁻ to maintain neutrality which again causes H⁺ secretion and HCO³reabsorption causing metabolic alkalosis

The anaesthetic concerns in dialysis patients

1. Hypervolumia
2. Acidemia
3. hyperkalemia
4. Cardiac : Hypertension is most common
5. Pulmonary congestion and edema 
6. Hematological : Anemia due to insufficiente production of erythropoietin,platelet dysfunction leading to prolonged bleeding and clotting time
7. Hypoalbuminemia; due to hemodilution, impaired synthesis and increased loss leading to alterations in drug effect of high protein binding drugs like diazepam, warfarin and phenytoin but anaesthetic drugs are less albumin binding and free fraction of drug increases modulation needful in drug dosage
8. Patients weight need to be recorded so dry weight can guide to dialysis
9. Last dialysis time as immediately patients are hypovolumic with increased risk of hypotension
10. Use of Heparin in dialysis can potentiate blood loss during surgery so titres need to be done and antagonist used if more
11. Care of AV fistula 
12. Fluid therapy should be guarded on intra and post operative periods 

Anesthesia for total laryngectomy

Total laryngectomy is the removal one or more of the laryngeal structures including the epiglottis,hyoid,and a variable amount of upper trachea with selective neck dissection which aims to remove a portion of nodes most at risk of metastasis.
PREOPERATIVE ASSESSEMENT
Standard preliminary investigations with stress on Hb levels, anaemia if present should be optimised.Most patients may require grouping and saving of blood but pre-op transfusion is rare.
Comorbid health conditions: 1) Ischaemic Heart Disease is a frequent comorbidity and cardiology opinion has to be sought if unstable angina,recent stenting,decompensated heart failure or severe aortic stenosis.
2) Respiratory Disease Laryngectomy patients are frequent smokers.Thorough evaluation of the respiratory system with associated imaging studies, if laryngeal narrowing is significant then Pulmonary Function Tests are not very reliable If Pulmonary Hypertension and Right Heart Failure are associated then serious consideration to optimise as they fall under high risk category.
Dynamic assessment of the functional status of the cardiopulmonary status of the patient can be evaluated with the estimation of METS score if < 4 then associated with increased risk
Preoperative Optimisation Majority patients are chronic alcoholics and smokers, careful planning and optimisation to proceed  1 to 2 weeks ahead of surgery is warranted.Hospital admission and controlled alcohol withdrawal with NG feeding to improve nutrition.Smoking cessation.
Risk Stratification Discussion about risk and consent to be obtained on individual needs
Planning of airway Management
Airway Assessment
History Taking in detail with emphasis on voice change, dysphagia,breathlessness and stridor . if the patient can lie flat? and if he get"s up in sleep due to breathlessness?
Bedside examination: The patients natural resting position is to be noted.
 Airway assessment usual mouth opening, tongue protrusion, mallampati scoring, thyro-mental distance, neck movement is done
Neck Examination  For neck masses, any previous radiotherapy, tracheal deviation, previous scars.
Any anticipated difficulty with front of neck access should be noted
Imaging CT and MRI are the mainstay of preoperative imaging, The axial sections can be used to see the narrowing of airways and the coronal sections are used to estimate the length of narrowing.
Nasendoscopy imaging can be done prior to the airway management with the surgical team to note any points of narrowing, rigidity or fragility of tissue, or the presence of tumour which may obscure the laryngoscopic view.
Thorough evaluation is done in view of the following steps
Preoxygenation
Positioning the patient in the most restful position
High Flow Nasal Oxygenation (HFNO) as a means to pre oxygenate and apnoiec ventilation until definitive airway is obtained has been highlighted  in the Transnasal Humidified Rapid-insufflation ventilator exchange(THRIVE) study and is widely used. It can provide CPAP. If conventional Nasal prongs are used than can be augmented with face mask (NODESAT) technique
Preinduction 
These patients are always induced in OT table in presence of consultant surgeon
A anaesthesia and surgical briefing is done and planA,B,C and D is discussed, prepared and written on white board so all members of the team are prepared.
Awake intubation or conventional induction depends on the ease of attaining a definitive airway
Video-laryngoscopy has been the first line of choice in DAS guidelines for laryngoscopy
Awake Fibre-Optic intubation (AFOI) is the method of choice in supraglottic obstruction as in epiglottis and tongue base obstuction
In patients with critical narrowing of laryngeal inlet the AFOI is of lesser use as because of

• Topicalisation is difficult and there is Copious Secretion 
• Sedation has be used very judiciously as maintenance of spontaneous ventilation is needful
• "Cork in the Bottle" analogy as the critical narrowing is completely closed with the introduction of the FOB scope and the airway is lost.

FONA Front of neck access is ideal in the above conditions. Trantracheal cannulation for jet ventilation which can later be converted to tracheostomy if needful.Prior assessment of neck for FONA with landmarking and LA infiltration and prior ascertaining of who will perform FONA  can buy time in hour of need.The choice of cricothyroidectomy or tracheostomy is a individualised.

Perioperative Management

Monitoring

Standard monitors with invasive blood pressure monitors to assess the fluid and blood chemistry as the surgery is usually long and blood loss is anticipated.

Urinary Catheter and temperature probe.

Short acting agents are preferred due to long duration to allow early emergence

TIVA is preferred as there is loss of volatile anaesthetic during surgery

Meticulous care in positioning to avoid pressure points

Post operative care

Admission into HDU with team handlingl aryngectomy patients

Pain management with judicious use of opioids and NSAIDS and Patient controlled Analgesia

Patients are stepped down to specialist wards in the next 48hrs.

what are the adjuncts in anaesthesia

Histamine receptor Antagonists

H₁Receptor Antagonists 

H1 antagonist also have antimuscarinic or antiserotonergic which can be used for a multitude of therapeutic purposes

• suppression of allergic symptoms, cough, nausea and vomiting.
• sedation

Used as premedicaton because of antiemetic and mild hypnotic 

They maintain the ventilatory drive during sedation and their sedative effects can potentiate other CNS depressants such as Benzodiazepines,barbiturates and opioids.

H₂ Receptor antagonists

• Reduce gastric acid output ad raise gastric pH
• As a premedication to reduce peri operative risk of aspiration pneumonia
• Dosage is at bedtime and again at least 2hr before in the morning of surgery
• Rapid iv injection rarely associated with hypotension and arrhythmia
• Mild dose reduction in signifiant kidney impairment as renal elimination
• Weak inhibitor of Cytochrome P-450 hence no significant drug interaction

Antacids

• Neutralize the gastric acidity by giving  base to react with hydrogen ion to form water
• Unlike H2 blockers have an immediate effect
• Present in 2 forms- Particulate and Non-Particulate
• Non particulate are widely used as less damaging to heart 
• Dosage is 0.3M solution of Sodium Citrate 15-30ml orally 30min prior to induction
• Drug interaction by alteration in gastric pH like slowing absorption and elimination of Digoxin,Rantidine whereas phenobarbital elimination s prolonged

Metoclopramide

It is a Prokinetic Drug and increases the Lower Esophageal Sphincter tone, speeds gastric emptying and lowers gastric fluid volume

• It is cholinomimetic at intestinal smooth muscles and dopamine antagonist in CNS
• It is a antiemetic 
• Rapid injection may cause abdominal cramping and hypertensive crisis with pheochromocytoma 
• Sedation, nervousness and extra pyramidal signs with dopamine antagonism
• Concurrent usage with phenothiazines can increase extrapyramidal S/E

Proton Pump Inhibitor

• Pantoprazole inhibit the secretion of hydrogen ions and reduce gastric volume 
• Dosage 40mg 2hr prior to induction 
• Interferes with P-450 enzymes and decreases the clearance of diazepam, warfarin and phenytoin
• Repeat doses with caution in severe liver impairment as liver elimination

5-HT₃ Receptor Antagonists

Ondansetron is a antiemetic  due to blocking of serotonin 5HT3receptors at CTZ 

• Effective antiemetic in post op nausea and vomiting
• Prophylaxix in high incidence of N/V in Laparoscopy Surgery, Neurosurgeries
• Can Slightly prolong QT interval in ECG
• Given either prior to induction or at the end of the surgery

NSAIDS

Ketorolac and Diclofenac provide analgesia by inhibiting prostaglandin synthesis

• alternative to opioids in post operative pain management as they do not cause sedation, respiratory depression or N/V
• Inhibit platelet aggregation and prolong bleeding time cautious use in post op haemorrhage
• Dose reduction in renal impairment 
• Contraindicated in patients allergic to aspirin and NSAIDS

Clonidine

Alpha adrenergic agonist which  decreases sympathetic activity, enhance parasympathetic tone and reduce catecholamines

• Used as anti hypertensive
• Adjunct to Local anaesthetic agents in Epidural anaesthesia 
• As a premedication 
• Side effects sedation, bradycardia, dizziness, dry mouth
• Dose reduction in renal impairment

Dexmedetomedine

• Alpha agonist with selective activity
• Dose dependent sedation,anxiolysis and some analgesia
• Opioid Sparing role with no significant respiratory depression
• Side effects are bradycardia hypotension