Anesthesizing a malnourished patient case.pptx

Anesthesia for malnourished patient is common in low resource set ups

1. Case presentation on Malnutrition Dr. Eyob Asefa, ACCPM R2 July 2022

2. Case presentation A 1yr and 3 months old male child admitted to pediatrics ward with the diagnosis 91 st POD after pull through done for Biopsy proven HSD 87 th POD after Ex-Lap + Barrel illeostomy done for SBO 2° to Post Op intussuception SAM( W/L < -3 Z Score, MUAC= 10.5cm) Hypoalbuminemia 7/4/2022 Eyob Asefa 2

3. History He is born from a Para IV ( 3 alive, 1 abortion) mother after 9 months of amenorrhea. Mother didn’t have Regular ANC follow up He suffered from abdominal distension and vomiting of injested milk since 2 nd day of his life, for which Colostomy was done + biopsy taken for ? HSD under GA without complications on his 5 th day of life at District Hospital. He had regular follow up and undewent pull through Under GA 3 months back without anesthetic complications. On his 3 rd POD he started suffering from vomiting and abdominal distension for which he was investigated and Diagnosed with SBO 2° to Post op intussuseption and undewent Ex- Lap + Barrel illeostomy 7/4/2022 Eyob Asefa 3

4. Continued He was exclusively breastfed for the 1 st six months of his life. And he started feeding complimentary feeding with gruel made of wheat , teff , barley and cow’s milk 3 to 5x per day. He was not adequately exposed to sunlight. He was diagnosed with SAM 02 weeks back and he is currently on 2 nd phase treatment He is fully vaccinated according to EPI schedule. He can stand by himself, has pincer grasp, waves bye bye. 7/4/2022 Eyob Asefa 4

5. Continued He has no history of: Recent cough, fever, fast breathing Feeding interruption or sweating during Feeding Chronic cough or contact with chronic cougher Recent vomiting or change in bowel habit Abnormal body movement or loss of consciousness Urinary complaints Known allergies Asthma in his family or smoker in the household He is currently not on any medications. 7/4/2022 Eyob Asefa 5

6. Physical examination G/A: Acutely sick looking on a chronic background V/S : PR: 126 RR: 28 T°: 36.2 °C Anthropometry : Wt: 6Kgs Ht: 68Cm MUAC: 10.5 cm W/A: < -3 Z Score H/A: between -2 & -3 Z sore W/H: < - 3 Z Score HEENT: Pale conjectiva , NIS AF 1*1CM, No frontal bossing or gross deformity 7/4/2022 Eyob Asefa 6

7. Continued Airway : pediatric airway , central incisors erupted Chest : clear with good air entry bilateraly No. Richatic rosary CVS: S1 & S2 are well heard No murmur or gallop Abd: scaphoid abdomen No palpable organomegally No signs of fluid collection 7/4/2022 Eyob Asefa 7

8. Continued Functional double barrel illeostomy GUS: NMTEG MSS: Baggy pants appearance Intg: severe Palmar pallor, No rashes CNS: Alert 7/4/2022 Eyob Asefa 8

9. INVESTIGATIONs BG & RH: O+ve CBC : WBC 15.5K with N 21.6% & L 67.8 % Hg/Hct = 6.5/21.6 % PLT = 77k 7/4/2022 Eyob Asefa 9

10. Continued LFT: AST= 10 ALT= 33 ALP= 222( 2X elevated ) Serum Albumin: 2.6 RFT Cr = 0.2 Urea: 16 7/4/2022 Eyob Asefa 10

11. Continued Serum electrolytes Na+ = 137 K+ = 4.02 Cl- = 111.7 Ca = 7 (low) P = 2.6 7/4/2022 Eyob Asefa 11

12. Continued Planned procedure: Ileostomy reversal Ass’t = Same + Bicytopenia ( Moderate Aneima + Severe Thrombocytopenia) + ASA ||| + Pediatric Airway Anesthetic Concerns: Bleeding Hemodynamic instability Delayed Awakening Hypoglycemia Hypothermia Full stomach with pediatric airway 7/4/2022 Eyob Asefa 12

13. Plan Preop Get written informed consent Keep him NPO after midnight for fluid diet after 4:00 AM for breast milk After 6:00 AM for clear fluid Prepare 1 unit of PRBC, 2 units of FFP and 2 units of Platlet Prepare emergency medications + lasix, D40% +Fentanyl Prepare ICU bed with Machine Determine RBS in the morning Secure 2 large bore IV Cannulas Ceftriaxone 200mg + Metronidazole 60mg 30’ prior to inscion 7/4/2022 Eyob Asefa 13

14. Intraop Patient was put on Monitoring: ASA standard + Precordial stethoscope Radiant warmer was set up and warm fluid was used Mode : GA with ETT No 3.5 cuffed caudal block with 10ml of 0.125% bupivacaine Induction: RSI( Fentanyl + propofol + Sux) with single attempt Maintainance: Isoflorane + Fentanyl + Vecuronium 7/4/2022 Eyob Asefa 14

15. Intraop VS BP: SBP: 80 – 98 DBP: 45 - 54 PR: 110-150 Pso2 : >95% Capillary refill: 2 – 3 seconds 7/4/2022 Eyob Asefa 15

16. Intraop UOP : 10ml over 1hr Blood loss: < 10ml Total crystaloid administered: 25ml NS RBS: 168mg/dl DOS: 1hr DOA : 1hr:50’ Patient was exutbated after he is fully awkae ( Reversal agents were avoided and vecuronium was allowed to wear of spontaneously) Transferred to PICU with stable vital signs. 7/4/2022 Eyob Asefa 16

17. Post op Observed at PICU for 24hrs and transferred to Ward. She stayed for 1 week and discharged. Vs at the ICU PR: 120-140 RR: 20-28 T°: 35.9- 37.2 Pso2: 90-96% 7/4/2022 Eyob Asefa 17

18. Thank you! 7/4/2022 Eyob Asefa 18