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General Data
A.M. 4 month old male Filipino Catholic Born and currently residing in Trece Martires admitted on May 13, 2012
Chief Complaint
HPI
The patient was born term with cleft lip
and palate
Physical Examination
Vital Signs
HR 108
RR 24
Temp 36.5
Weight 5.5kg
Physical Examination
SHEENT (+) good turgor (-) pallor, jaundice, lesions (+) cleft lip and palate, complete normocephalic pink palpebral conjunctivae
Physical Examination
(-) retractions
clear breath sounds
Physical Examination
Abdomen
no edema
no cyanosis
Physical Examination
CNS GCS 15 Motor: 5/5 on all extremities
Laboratories
CBC
Laboratories
Chest Xray non-specific pneumonitis
Impression
Plan
cheiloplasty under Geta-inh-Jackson
Rees
pH 7.29 PCO2 23 PO2 110 HCO3 10.8 B.E. 14.5 02 sat 98%
correction done with NaHCO3 10meqs 30min SIVP then 14meqs x 4 hours
(+) improving activity hr 140 rr 40 (assisted), temp 36.5C O2 sat 100% (-) alar flaring (-) retractions (+) minimal rales (+) bibasal ronchi (+) good pulses 30 (spontaneous)
12 hours post op
HR 50-60 RR 40 (A/C mode) O2 sat 60-70% Temp 36.5C (+) poor activity (+) weak pulses (+) respiratory distress (+) alar flaring (+) retractions (-) breath sounds
12 hours post op
patient reintubated
CPR done
blood noted per orem
CBC
Chest Xray
13 hours post op
GCS 3
HR 216
RR 60 assisted temp 37.3C O2 sat 78% (+) respiratory distress (+) retractions (+) ronchi
25 hours post op
HR 216
RR 60 assisted temp 37.3C O2 sat 78% (+) respiratory distress (+) retractions (+) crackles on both lung fields (+) poor pulses
GCS 3 HR 0
RR 60 assisted
temp 35C O2 sat - no reading (+) poor activity (+) retractions (+) respiratory distress (+) crackles on both lung fields (+) poor pulses patients parents opted DNR
Final Diagnosis
acute respiratory failure secondary to
pulmonary hemorrhage
Discussion
Discussion
A.M. 4month old male unremarkable preoperative history underwent cheiloplasty under GETAINH-Jackson Rees
Discussion
aspiration anaphylaxis unknown history of preoperative respiratory tract infection undiagnosed asthma post extubation spasm
Discussion
extubation triggering agent bronchospasm hypoxia metabolic acidosis
reintubation
assisted ventilation pulmonary hemorrhageanemia respiratory distress hypoxia seizures (clotted blood per ET) deterioration/CP arrest hypoxia
Bronchospasm
manifests during anesthesia as expiratory wheeze/no breath sounds
on auscultation
Bronchospasm
may appear as an entity on its own or
be a component of another problem
Bronchospasm
Signs increasing circuit pressure desaturation wheeze rising ETCO2 and prolonged
expiration
Bronchospasm
Think of
anaphylaxis/allergy to drugs/IV fluids/latex airway manipulation/irritation/secretions esophageal/endobronchial intubation pneumothorax inadequate anesthetic depth or failure of anesthetic delivery system
Bronchospasm
if intubated endobronchial position esophageal position if mask/LMA in use laryngospasm/airway obstruction regurgitation/vomit/aspiration
airway irritation anaphylaxis misplacement of endotracheal tube aspiration pulmonary edema following failed
intubation
aspiration
pneumothorax pulmonary edema profuse bronchial mucus drug induced
Bronchospasm
Emergency management
100% oxygen cease stimulation/surgery request immediate assistance deepen anesthesia give beta adrenergic agonists (salbutamol) corticosteroids
Pulmonary Hemorrhage
rare, but catastrophic complication with
a high risk of morbidity and mortality
Pulmonary Hemorrhage
acute pulmonary infection severe asphyxia hyaline membrane disease assisted ventilation PDA congenital heart disease erythroblastosis fetalis hemorrhagic disease of the newborn
thrombocytopenia
inborn errors of ammonia metabolism cold injury
Pulmonary Hemorrhage
treatment blood replacement PEEP suctioning to clear the airway intratracheal administration of
epinephrine