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vascularRingsSlingsThings-1 - Of Rings Slings and many...

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Unformatted text preview: Of Rings, Slings and many other things many Diego Gonzalez M.D. Gregory Gordon M.D. Metrohealth Medical Center November 26, 2002 Pre Op Pre 7 month old 8kg PMHx & PSHx: PMHx Former Premie intubated x 6 weeks in CCF NICU History of previous “asthma episode” admitted to History hospital 2-3 weeks prior hospital Double aortic arch repair Presenting for evaluation of stridor Procedure Procedure Mask induction Start IV and Change to TIVA Confirm Satisfactory bag/mask control Short acting muscle relaxant Reconfirm good bag mask ventilatory control Ventilation via bronchoscope inserted by Ventilation surgery surgery Physical Exam Physical Airway unable to assess Pt was noticed to have biphasic stridor Lungs with adventitious breath sounds Regular rate and rhythm Neurologically was awake and alert, acting Neurologically like a 7 month old. like Infant Airway Infant Differences from adult Larger tongue Larynx is higher in the Larynx neck neck Epiglottis is short and Epiglottis stubby and angled over the laryngeal inlet the Vocal cords are angled Infant airway is funnel Infant shaped narrowest portion shaped Causes of Stridor Causes Expiratory stridor: (also prolonged expiration) Bronchiolitis Asthma Intrathoracic foreign body Inspiratory stridor: Epiglotitis LTB Laryngeal foreign body Vascular rings Vascular Definition: when any Definition: anomalous configuration or vessel surrounds trachea or esophagus forming a ring around them, they can be complete or incomplete Vascular rings Vascular Frequency: 2 most common are (85-90% of cases) < 1% of congenital heart defects Equal in both sexes Double aortic arch Right aortic arch with left ligamentum aretriosum Other anomalies make like left pulmonary Other artery sling make 10%, incomplete ie sling artery Etiology of rings and slings Etiology Non-regression or incomplete regression of any of the Non-regression 6 embryonic branchial arches embryonic Normally what happens: 1 and 2 arches irrigate the face 3 arch forms carotids Dorsal aorta in 3 and 4 involutes 4 form aortic arch 5 arch involutes 6 becomes the proximal right pulmonary artery 7 distal right subclavian and left subclavian Intra Operative Course Intra Easy mask induction Easy to ventilate Difficult time getting IV in (probably from Difficult previous surgeries) previous Once IV started changed to TIVA pt paralyzed Once with Mivacron with Bag mask ventilatory control confirmed Surgeon unable to introduce bronchoscope Intra Op 2 Intra Pt desaturated into low 90’s Try to reventilate by mask. Unable to mask Sats dropping Repositioned and remasked Sats dropping Some air entry to stomach and lungs Sats dropping, cyanosis markedly increased DL glottis visualized unable to inserted styletted #3 OETT Unable to intubate, sats in the low 40s Slash trach performed by surgeon Intra op 3 Intra Unable to pass Shiley, Number 3ETT tube Unable passed and could not ventilate adequately. passed PALS started Atropine and Epi given for PALS bradycardia. Now WHAT???? Intra OP 4 Intra Shiley replaced with Shiley 3# cuffed Ventilation possible via right lung Tube pulled back able to ventilate both lungs Shiley # 3 replaced with Shiley #4 adequate Shiley ventilation of both lungs ventilation Follow Up Follow Followed up pt that same day. H/D stable purposeful neurologically. Pt consequently followed days 2,3,4,5 and 7 Round 2 Round 7 days later pt taken for rigid bronchoscope, days tracheoscopy possible flex bronchoscopy tracheoscopy Able to pass small rigid suction tube Pt noticed to have severe sub-glottic stenosis. Able to pass OETT 2.5 styleted with snug fit. Able Flex scope through trachea which showed Flex severe stenosis at the carina level. severe Pt transferred to CCF for further evaluation Pt possible surgery. possible Round 3? Round Pt transferred back to Metro Pt Plan? Stent? Outgrow stenosis? Surgical repair? Sub Glottic Stenosis Sub Congenital malformation of the cricoid Congenital cartilage cartilage Acquired- Pathophysiology Mucosal edema Hyperemia Pressure necrosis of mucosa Fibrosis Risk factors for SGS Risk ETT Duration of intubation Repeated intubation GERD Factors that affect healing Systemic illness Malnutrion Anemia Hypoxia SGS SGS Incidence 1-2% of graduated NICU patients Morbi-mortality Difficulty breathing Exercise intolerance Death Clinically Clinically Inspiratory stridor Expiratory stridor Supraglottic lesion Tracheal, bronchial, pulmonary lesion In SGS that is moderate to severe they may In have biphasic stridor have Staging Staging Percentage is evaluated Percentage by using ETT of different sizes the largest ETT that can be place with 20cm pressure is evaluated against a scale developed by Myers and Cotton Cotton Staging Staging Grade 1- Obstruction of Grade 0-50 % of the lumen 0-50 Grade 2- Obstruction of Grade 51-70% of the lumen 51-70% Grade 3- Obstruction of Grade 71-99% of the lumen 71-99% Grade 4- Obstruction of Grade 100% (no visible lumen) lumen) Treatment Treatment No medical treatment Surgery indicated with SGS + symptoms Surgery present present Residents hard at work!! Residents ...
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