just a biopsy sara is 19 yrs old girl, presented to the hospital with history of progressive sob,...
TRANSCRIPT
Just a Biopsy
Sara is 19 yrs old girl, Presented to the hospital with history of Progressive SOB, cough weight loss and fatigability for 6 weeks.
Dyspnoea occurs with minimal exertion and and associated with orthopnea.
Cough is productive of yellowish sputum with occasional hemoptysis.
Week before admission she started to have dysphagia.
She was admitted to Medical ward on 25/12/1427 for further investigations and management.
Routine investigations were done.
CXR showed huge mediastinal mass
Then, The patient was booked for urgent chest CT scan and CT guided biopsy but procedure was cancelled because the patient can not lie down (flat on the bed).
CT done in (semi) lateral position.
Pleural tap was done and there was no evidence of malignant cell.
Mediastinoscopic biopsy was taken But the result was not informative and TRUE CUT biopsy was suggested To reach the diagnosis.
On 5/1/28 the patient was booked for emergency mini thoracotomy and true cut Biopsy.
Preoperative Anesthetic Assessment
History: Clinical Examination: She was looking fair. Conciuos,alert and oreinted. She can lie comfortable only on right
lateral position. She was afebrile, with normal vital
signs. RR 18, HR 80 , BP 110/60, Spo2 98% on
RA.
Cont..PreOperative Anesthetic Assessment
CVS: NAD Resp: Good air entry Bilatrally with
harsh breath sounds. A.W: Mallampati 1, TMD >6.5cm She has dilated Neck Veins and
over the right side of the chest (SVC obstruction).
Cont..PreOperative Anesthetic Assessment
Biochemical analysis, normal
PFT: was done but the patient was not able to do it Properly.
Pred
Pre Pre/Pred
FVC 3.58
.95 26.7
FEV1
3.21
.81 25.1
FEV1/%fvc
89.2
84.3
94.5
PEF 6.96
2.07
29.8
Cont..PreOperative Anesthetic Assessment
Preoperative Orders
ECG,ABG were Requested. High Risk Consent. ICU bed.
Cont..PreOperative Anesthetic Assessment
ECG : Right Axis Deviaton. ABG : Normal. MICU bed was Available. So the patient was taken for the
O.R. on Wednesday 5/2/1428.
IntraOperative Course
Induction Routine monitors were attached. 18 G cannula was inserted. Inhalational induction with
Sevoflurane 8% with O2 while the patient in semi sitting position.
Sedating dose of propofol was used 40mg plus 50 mcg of fentanyl.
Cont..IntraOperative Course
Lidocaine 10% was sprayed on the base of the tongue and Pharynx.
2ml of 2%lidocaine was injected intratracheal.
By ordinary laryngoscope patient was intubated with 7.0 ETT, smooth intubation.
Another dose of fentanyl 50mcg was given.
Cont..IntraOperative Course
Then the patient was kept spontaneously Breathing with some assistance manually as needed.
A.W pressure was high during manual assistance of ventialtion, because the patient was almost flat during Surgical Procedure.
Cont..IntraOperative Course
The Procedure lasted almost 40 minutes during which the patient was hemodynamiclly stable.
SpO2 98-99%, EtCO2 60-85. Multiple Biopsies were taken After
aspiration from Anterior Mediastinal mass Through the left 2nd Intercostal Space and left ICT was inserted.
Cont..IntraOperative Course
Intraoperative Bronchoscopy was done which showed external compression on trachea and bronchi.
Cont..IntraOperative Course
At the end of The Procedure The patient was given A chance of Extubation But She did not gain consciousness and maintain good ventilatory parameter. So she was
Re Intubated and kept spontaneously breathing with CPAP and was transferred to MICU.
PostOperative Course
In MICU the patient was kept Intubated sedated and Ventilated for 7days.
In the first day she developed High Airway Pressure and desaturation which was solved by Changing the patient Positioning…(Positioning!)
PCV: FiO2 0.4, P:20Tv:600+ , R18.
Cont..PostOperative Course
On 6/1/28 the result of the Biopsy was revealed As:
NON-HODGKIN LYMPHOMAB-CELL TYPE.
Same day Chemotherapy was started.
On 9/1/28 , Bronchoscopy was done which showed external compression at carina almost complete during Expiration.
Cont..PostOperative Course
Five days after Chemotherapy the patint was extubated - (12/1/28). And she was kept for Four days in MICU.
On 16/12/28 the patient was discharged from MICU to the medical ward and She was able to lie flat without any respiratory compromise.
On 17/1/28, CT scan of the chest was repeated.
On 29/1/28 , the patient was discharged from the hospital with home medicines and appointments For investigations and follow up for further Chemotherapy cycles.
Before ChemoRx After ChemoRx
Before ChemoRx After ChemoRx
