Looking for some input from practicing anesthesia providers.
We have a panniculectomy scheduled for this week for non-cosmetic indications. Pt is mid-30's, with trisomy 21 and NIDDM. Pt has fairly high level mental function, and is able to understand the procedure, instructions, and implications, and can sign own consents for surgery.
Mallampati II airway, pt is scheduled for EKG, CXR, CBC, ABG, coags, and comprehensive metabolic profile, all of which will be reviewed prior to surgery. Anesthetic plan is for sedated awake intubation, followed by general anesthesia. Triple lumen central line will be placed with CVP monitored. We are also going to place an arterial line to monitor BP and intra op and post op ABG's. We are crossmatching for four units of blood, with two to be in the room at induction.
Post operative plan includes at least one night in ICU. Pain management will be with PCA MS. Pt is aware that they must be out of bed within 2-4 hours post op. Surgeon is planning for post op heparin therapy as well.
We are planning for both CRNA's to be in the room on induction, and will probably have one manage anesthetic and one manage fluids during the case (it's nice to be at a small hospital where we can do this). We have discussed the anesthetic plan with the surgeon, and told him that we will have a fairly low threshhold to cancel the case. If we are unable to get a tube in or if there are other complications at induction, we are planning to cancel.
patients with down's syndrome typically have large tounges, small mandibles, and an increase in subglottic stenosis. other than just safety of cspine in someone obese with a probable short neck i'm at a loss. please follow up.
down's patients have the tendency to sublux at C1-C2.... so you have to be careful not to rip their head off their neck???
how did i do kevin?!?!?
This is correct. There is a potential for Down's patients to have congenital malformation of the atlato-occipital joint. There have been cases of neck fractures resulting from overzealous neck extension.
The patient is now in ICU and doing well. Yoga, your idea of a post op epidural had a great deal of merit, and I considered it. However, ours is a small hospital, and generally epidurals frighten nurses outside of the OR or OB. Additionally, the patient would likely have refused. So, PCA MS it is, and she isn't really using much.
Kevin McHugh
Kevin, did you leave her intubated overnight? Just curious. What about pre-op Decadron for airway edema?
Does anybody use topical intranasal Cocaine anymore, and do awake fiberoptic nasal intubations? I used to see this all the time, during the '80s and '90s--can't remember the last time I saw it, now--
thanks for the followup, i didnt know about c1-c2 in downs patients. i saw an awake fiber optic just last week. transtracheal lidocaine injection. arosolized lidocaine down the back of the throat. plus cetacaine spray. fiberoptic bite block and she passed the tube right down. pretty cool.
gaspassah
457 Posts
patients with down's syndrome typically have large tounges, small mandibles, and an increase in subglottic stenosis. other than just safety of cspine in someone obese with a probable short neck i'm at a loss. please follow up.
thanks
d