Dr. C.G.

Raghuram
Professor,
Dept. of Anaesthesiology,
Osmania General Hospital,
Hyderabad.

PROBLEMS ASSOCIATED WITH

PBC NECK

Grossly restricted neck movements

Patients are likely to be malnourished ,anemic and

hypoproteinemic

Possibility of restricted mouth opening and narrowed nasal

passages.

Difficult laryngoscopy and endotracheal intubation

Compromised airway

Psychiatric tendencies in patients and possible drug interactions

in anaesthesia

Poor oral hygeine in patients

RELEVANT ASPECTS IN
HISTORY

Duration of contractures

History of convulsions

Difficulty in breathing and swallowing

H/O motion sickness

H/O snoring

H/O epistaxis and bleeding from oral cavity

H/O psychiatric problems

H/O acid peptic disease and reflux

RELEVANT EXAMINATION
OF PATIENT

Nature of contracture
- soft
- firm(hard)

Location of contracture

Duration of contracture

Extent of contracture ( sterno cleido mastoid involved?)

Is mouth opening restricted ?

Can the mandible be moved up and down

Are the nasal passages patent?

Is the patient dyspneic, can he lie down comfortably ?

Can he blow air through mouth and nose

INVESTIGATIONS

SURGICAL PROFILE:

Complete blood picture

Blood Grouping
Random blood sugar
Urea and Creatinine
Serum electrolytes

X-Ray chest PA view

ECG 12 lead
HbsAg ,HIV , HCV

THYROID PROFILE

PREPARATION OF THE
PATIENT

Improve oral hygeine

Correct anemia and hypoproteinemia

H2 receptor antagonists, prokinetics

Anti emetics

Aggressive treatment of upper and lower

respiratory tract infections

PRE- MEDICATION
GUIDELINES

Avoid heavy sedation.

Preserve respiration drugs that depress respiration

viz. narcotics are better avoided till airway is
secured

I.M. glycopyrolate / atropine is better than I.V.

premedication.

Continue H2 receptor blockers and antiemetics

Consider pre-op nasal decongestants they help

you in putting a naso-pharyngeal airway

PRE MEDICATION
(Cont..)

Use topical viscous anaesthesia for oral

cavity and pharynx before induction of
anaesthesia - it helps in improving
quality of anaesthesia

Consider superior laryngeal nerve block

if hyoid and upper margin of thryiod
cartilage are visible.- it reduces
incidence of laryngospasm during
anaesthesia

USEFUL TIPS IN
ANAESTHESIA

Aim to have total control of the airway- that should

be the ultimate goal

Preserve spontaneous respiration till trachea is

intubated

Consider using nasopharyngeal airway, oropharyngeal airway, and laryngeal mask airway
where ever feasible these devices improve quality
of anaesthesia.

Consider superficial cervical plexus block if

contracture is situated in between sternomastoids- it
gives useful analgesia for the operative field .

I.M Ketamine is a more useful option than I.V. Ketamine in a

dose of 2-5 mg/kg

REASONS :
Analgesia lasts longer upto 30-45 mins .By which time the
contracture release will mostly be released.

Less risk of resp. depression

Stable hemodynamics

Provides an ideal environment along with tumescent or

regional technique.

Patient can be smoothly transitioned into an inhalational

technique

USEFUL TIPS (Cont )

If using LMA , fix the LMA to the maxilla /upperlip

.Never to the mandible.

Consider using a muscle relaxant only if mask/LMA

ventilation is possible . Otherwise avoid them

Try endotracheal intubation in deep planes of

inhalational anaesthesia.In spontaneous respiration
as far as possible.

Consider bougies ,tube exchangers where ever

laryngoscopy and endotracheal intubation obscures
visibility.

Fix E.T tubes always to the maxilla .Fixing them to

mandible can soak them and soil them with blood
and secretions from the operative field and can also
interfere with field of surgery .

Use narcotics like fentanyl etc ., only after

securing access to trachea.

N.S.AIDS are very useful for post op analgesia

.Hence use them.

Avoid narcotics , tramadol and metronidazole in

patients with migraine and motion sickness.

PRECAUTIONS IN THE POST-OP

PERIOD

Extubate only when sure.

Watch for airway obstruction .

Observe resp. pattern.

Use nasopharyngeal /oral airway if needed.

Anti-emetics to be continued post-op

TUMESCENT TECHNIQUE

Solution for tumescent contains lignocaine

,adrenaline,hyaluronidase and saline/water

FORMULA :

0.5% Lignocaine solution with 1 in 1,00,000

adrenaline
{ 25 ml 2 % lignocaine
+ hyalase 1 to 2 ml
+ 1ml of 1 in 1,00,000 adrenaline
+ dist. Water to a total volume of 100ml }

Cont.

Helps release of contracture without much

blood loss.

Helps surgery in aspect of hydrostatic

cleavage of operative field and subsequent
dissection.

Risk of toxicity less due to poor vascularity

of scar tissue and use of adrenaline .

PARTING TAIL PIECE

A 35 yr old female, weighing 60 kgs is posted for a dense

tough contracture involving anterolateral aspects of neck .

Contracture released with tumescent + IM .Ketamine .

Patient intubated with 7.5mm cuffed ET tube under deep

inhalational anaesthesia with O2 +N2O+ Isoflurane .

4 mg vecuronium given .

Surgery lasts two hours

At the end, patient reversed as there are respiratory efforts

Patient regains respirations but is deeply

drowsy , reflexes sluggish.

Patient regains consciousness 12 hrs

after surgery.

WHAT HAS GONE WRONG ??