INTRA-OPERATIVE

Chapter 17

Incidental Finding of an Amyloidosis

Dr. Vasanthi Vidyasagaran*

Department of Anaesthesiology, Kauvery Hospital, Chennai, Tamilnadu, India

*Correspondence: Vasanthi.vidyasagaran@gmail.com

Dr. Vasanthy Vidyasagaran Muralidharan

Anaemia or Hydrocele
Anaemia or Hydrocele

A 23-year-old girl with no known comorbidities was posted for excision of bilateral fibro adenoma of the breast. She was assessed preoperatively as fit and well, with ASA 1 status. No abnormalities were detected on airway assessment. Results of investigations were within normal limits.

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She was induced using Propofol 100 mg and the relaxant used was Atracurium 25 mg. Following manual mask ventilation for 3 minutes, laryngoscopy was done. A fairly large mass arising from the right vocal cord was seen, it did not appear like a polyp. Whether to intubate, use a LMA, or postpone the procedure was contemplated.

It was decided not to intubate the patient and the surgery was postponed. Photograph of the lesion was taken and shown to the patient and her relatives. Fortunately, mask ventilation was possible. She came out of the relaxant effect in approximately 25 minutes, reversed, and allowed to wake up, without any further manipulations. Patient was referred to an ENT specialist. Following further assessment and investigation, she underwent a micro laryngeal excision of the lesion. Pathological examination confirmed it to be a case of amyloid lesion.

Discussion

An unexpected lesion in the airway, the extent and nature of which was unknown, made it precarious to proceed further in this elective procedure. This being Amyloidosis other systems – cardiovascular, respiratory, airway tract, skin, renal, liver, nervous, autonomic, and haematological could have been involved. In a situation like this, decision making is crucial.

Decision against intubation was due to the following

  1. Injury to the mass, bleeding, dislodgement, aspiration, and airway obstruction.
  2. Also, after the surgery, the presence of a mass may be attributed to injury from intubation
  3. Completing the surgery under mask ventilation alone was not considered a good choice due to fear of prolonged surgery and airway obstruction.
  4. Supraglottic devices were avoided as it was not sure if we could maintain the airway throughout this procedure.

Decision making is an integral part of Anaesthesia practice. It is up to the anaesthesiologist to decide whether to take up the patient or not based on scientific evidence.

Do not compromise in elective patients.

References

  1. Ian Fleming et al. Amyloidosis and anaesthesia Continuing Education in Anaesthesia, Critical Care & Pain | 2012
  2. Amyloidosis – EMedicine by MedScape medicine.medscape.com/article/335414-overview
  3. Jan 27, 2017 – Amorphous eosinophilic interstitial amyloid observed on a renal biopsy.
  4. Cardiac Amyloidosis – EMedicine by MedScape emedicine.medscape.com/article/1967220-overview
  5. Mar 21, 2017 – Cardiac amyloidosis is a clinical disorder caused by extracellular deposition of insoluble fibrils (approximately 7.5-10 nm wide) with …

Chapter 18

Innovative Positioning

A 25-year-old man was involved in a high-speed road traffic accident.

He was the pillion rider on a two-wheeler, thrown off after colliding with a heavy motor vehicle and had landed on a fence. The rod of the fence went through his rectum and came out through his right flank region postero-anteriorly, protruding about 3 feet on either side of the abdomen.

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He was brought to the casualty, with the rod, after having travelled 80 kilometres in severe pain and shock. He was on the left lateral position as he could not lie supine. He was conscious and oriented; a brief history could be elicited from the relatives who brought him to the hospital. His last meal was four hours ago and he did not have any other medical illness.

Clinically he was pale, had tachycardia with a pulse rate of 160 beats/minute, and BP of 80/36 mm Hg. An emergency laparotomy had to be performed.

The immediate concerns included:

  • Hemodynamic instability – patient could crash any time even before induction
  • Positioning of the patient – any manipulation of the rod may lead to collapse of patient
  • Massive blood loss on removal of the rod – potentially leading to shock and subsequent Multi Organ System Failure.
  • Intubation in lateral position – securing the airway could be difficult

Two wide bore IV cannulas were introduced and Ringer Lactate was started. Meanwhile adequate blood products were ordered and supplied without delay. It was decided to induce and secure the patient’s airway in the casualty itself as he was deteriorating rapidly. Using a Bain circuit connected to the central oxygen supply, a rapid sequence induction was done with fentanyl, midazolam and airway was secured with a cuffed 7.5 endotracheal tube using 60mgs of suxamethonium with the patient in the lateral position itself. He was then shifted to the operating theatre.

Positioning him supine was the next dilemma. The patient was placed lateral on one operating table; a second table was mobilised and the patient turned supine such that the rod was between the tables. Two operating tables were placed side by side in such a way that the patient’s body lay centred between the two tables and the projecting rod passed through the gap between them.

Surgery commenced immediately with anticipation of major vessel and organ injury. Six units of packed cells were made available. Surgeon removed the rod after exposing the site of injury through laparotomy from the anterior aspect. There was no major vessel injury. The rectum and colon were injured. Colostomy was performed and bowel repair was done. Perineal repair was further done in lithotomy position. Peritoneal lavage was done and drain tubes were kept. Four units of packed cells and 4 units FFP were given. Nor adrenalin drip was on flow.

Pain relief was provided with Morphine and Paracetamol. Urine output was maintained at 20- 30 ml/hr. Postoperatively, the patient was shifted to the intensive care unit. He recovered well.

Discussion

Trauma patients with penetrating injuries, with indwelling foreign body projecting out pose several challenges to the anaesthetic and surgical team. Through and through penetrating injury with polytrauma may be encountered quite commonly in road traffic accidents.

Primary survey including Airway, Breathing, Circulation, Disability and Exposure along with resuscitation, followed by secondary survey and definitive management as per ATLS guidelines, is essential to ensure effective management. Attention to detail by anticipating problems and preventing deterioration of the clinical condition is the key to successful management of all patients, and especially true in trauma as these patients are usually young and respond well to treatment.

This patient with polytrauma is presented here for challenges faced in positioning the patient due to a projecting foreign body. This is uncommon and can be tricky. Careful thought process and application of the ‘two table technique’ made it possible for surgeons to perform the surgery efficiently and limit damage. The other option was for the surgeon to stand on a stool and remove the rod from a height. This may have been more cumbersome.

This two-table technique has been described in literature. Few were intubated in the lateral position, and some managed by hanging the torso of patient partially out of the table, with manual support.

References

  1. Thrivikrama Padur Tantry, et al. Penetrating abdominal injury in a polytrauma patient: Anaesthetic challenges faced. J Anaesthesiol Clin Pharmacol. 2011;27(2): 272-4.
  2. Cavina E, Neidhart JP. The trauma of the abdomen: European course of trauma care. Available from: http://www.med.unipi.it/cdu/ECTC/indexectc.htm
  3. Bowley DM, Robertson SJ, Boffard KD, et al. Resuscitation and anaesthesia for penetrating trauma. Curr Opin Anaesthesiol. 2003;16:165-71.
  4. Kaur K. Penetrating abdomino-thoracic injury with an iron rod: An anaesthetic challenge. Indian J Anaesth. 2014;58(6):742-5.

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