ksb0211
Guest
Hoping for some input from anyone else with fresh eyes. I've talked myself in and out of codes. LOL Thanks in advance....
The patient was brought to the operating room. Once in the operating room, we have seen that she had a flexion contracture of the neck, and at the anterior neck it was absolutely rock hard, a sternal notch was discernible, but just both strap muscles were much more prominent than typical. We made an incision transversely across the neck approximately 2 cm, carried down, and there were absolutely no anatomic planes whatsoever, and this was a bloodless field, a lot of fibrosis, got down (the patient is emaciated, quite thin) we were able to find the trachea, but really just by inference not by anatomic means beacause everything was so scarred and it maybe wonder if this patient had received radiation therapy to the neck. The trachea eventually cut a horsehose type hole into it and we foudn the ET tube. The trachea that is in fittin gwith this operative field was absolutely just a concrete tube and we went ahead and trimmed it, we had regular scissors, they did not work. We asked for a large Mayo scissors to be brought in and we trimmed the trachea with the Mayo scissor and it just sort of popped away as we broke through the shell of a calcified tracheal cartilage, pulled the ET tube back, went down with a #6 Shiley, got the tube in, it seemed like it was in a good position. We thought we were finished, but we could not get a good end-tidal CO2, this was of course concerning. Finally pulled the thing and reintubated right on the spot. We did that about 4 times. We popped the balloons and then finally just got the tube in and we just had poor end-tidal CO2 as we decided to switch try to do a bronchoscopy on her, so we had a disposable brochoscope brought and wend down, and put the ET tube up on the body of the filament for the bronchoscope wend down, coudl see the carina and then tried to introduce tube without the dilator on on the nose. I pulled that back up and elected to go with a ifferent system, switched to a different tracheostomy tube and I think it was a Bard got in easily got an end-tidal CO2, but the volumes were poor, but it was a relatively small tube compared to the #6 Shiley that we had been using. Eventually, we switched to another Pyrex tube, introduced that once again could not get end-tidal, went back with the ET tube, had end-tibal, and we probably made 7 attempts at this with perforating balloons and with numerous tractions and finally we decided that her anntomy was probably such that this trach was going further back than it was perceptible. We also did not want to risk injuring anything, so we just abandoned the procedure at this point and left it with ET tube. Our plan would be to bring her back with formal bronchoscopy, something we could clean and then hopefully get that scope down into the appropriate place and then run the tube down because of this remarkably distorted anatomy because this was likely flexion contracture. Sterile dressing applied. The patient actually did not turn a hair. We had no hypoxic episodes in the course of all this. Anesthesia did a wonderful job. We just really did not have nay problems other than the fact we could not get decent end-tidal CO2, so when the time was up, we could not get good volumes. The patient tolerated the procedure well.
The patient was brought to the operating room. Once in the operating room, we have seen that she had a flexion contracture of the neck, and at the anterior neck it was absolutely rock hard, a sternal notch was discernible, but just both strap muscles were much more prominent than typical. We made an incision transversely across the neck approximately 2 cm, carried down, and there were absolutely no anatomic planes whatsoever, and this was a bloodless field, a lot of fibrosis, got down (the patient is emaciated, quite thin) we were able to find the trachea, but really just by inference not by anatomic means beacause everything was so scarred and it maybe wonder if this patient had received radiation therapy to the neck. The trachea eventually cut a horsehose type hole into it and we foudn the ET tube. The trachea that is in fittin gwith this operative field was absolutely just a concrete tube and we went ahead and trimmed it, we had regular scissors, they did not work. We asked for a large Mayo scissors to be brought in and we trimmed the trachea with the Mayo scissor and it just sort of popped away as we broke through the shell of a calcified tracheal cartilage, pulled the ET tube back, went down with a #6 Shiley, got the tube in, it seemed like it was in a good position. We thought we were finished, but we could not get a good end-tidal CO2, this was of course concerning. Finally pulled the thing and reintubated right on the spot. We did that about 4 times. We popped the balloons and then finally just got the tube in and we just had poor end-tidal CO2 as we decided to switch try to do a bronchoscopy on her, so we had a disposable brochoscope brought and wend down, and put the ET tube up on the body of the filament for the bronchoscope wend down, coudl see the carina and then tried to introduce tube without the dilator on on the nose. I pulled that back up and elected to go with a ifferent system, switched to a different tracheostomy tube and I think it was a Bard got in easily got an end-tidal CO2, but the volumes were poor, but it was a relatively small tube compared to the #6 Shiley that we had been using. Eventually, we switched to another Pyrex tube, introduced that once again could not get end-tidal, went back with the ET tube, had end-tibal, and we probably made 7 attempts at this with perforating balloons and with numerous tractions and finally we decided that her anntomy was probably such that this trach was going further back than it was perceptible. We also did not want to risk injuring anything, so we just abandoned the procedure at this point and left it with ET tube. Our plan would be to bring her back with formal bronchoscopy, something we could clean and then hopefully get that scope down into the appropriate place and then run the tube down because of this remarkably distorted anatomy because this was likely flexion contracture. Sterile dressing applied. The patient actually did not turn a hair. We had no hypoxic episodes in the course of all this. Anesthesia did a wonderful job. We just really did not have nay problems other than the fact we could not get decent end-tidal CO2, so when the time was up, we could not get good volumes. The patient tolerated the procedure well.