TWilliam2019
Guru
Postoperative Diagnosis:
1. Angioedema
2. Difficult airway
3. Ascending aortic aneurysm s/p Hemi-arch replacement
Procedure:
1. Tracheostomy, open
2. Flexible bronchoscopy
Indications:
a 74 y.o. woman who presented to hospital yesterday for hem-arch repair of an ascending aortic aneurysm. Post-operatively she did well and passed all extubation criteria approximately 6 hours following the procedure. Immediately following extubation she developed shortness of breath and oropharyngeal swelling. Emergency re-intubation was attempted but failed. She underwent emergent bedside crycothryoidotomy which established the airway. She is returned to the operating room today for revision to formal tracheostomy.
Findings:
1. Successful placement of a 7Fr XLT Shiley tracheostomy.
2. Completion bronchoscopy revealed mild to moderate thick mucoid secretions throughout.
Procedure Details:
The patient had their history and physical updated prior to the procedure. They were then transferred to the operating suite and placed on the operating table where general anesthesia was affected. The patient was then prepped and draped in usual sterile fashion. A surgical timeout was used confirm patient identity as well as the surgery to be performed.
Next, the previous crycothryroidotomy incision above the sternal notch in the midline was extended. Dissection was carried down in between the strap muscles with electrocautery. The anterior surface of the trachea was identified, as was the 2nd and 3rd tracheal rings. The patient was placed on 100% FiO2. The tube cuff was deflated and the trachea punctured between the 2nd and 3rd rings. A guidewire was inserted into the trachea. The tracheotomy was serially dilated over the guidewire. An 7Fr Shiley XLT tracheostomy tube was lubricated and inserted over the wire using a modified Seldinger's technique. A cross table circuit was attached which verified adequate volume exchange and EtCO2. The crycothyroidotomy tube withdrawn from the patient and the tracheostomy tube secured. Surgicel to aid in hemostasis. Hemostasis was verified.
Next, the flexible bronchoscope was inserted into the tracheostomy tube and guided down into the trachea. The carina was visualized. The right mainstem bronchus was intubated. The orifice of the right upper lobe bronchus was identified. There were no gross lesions. The bronchus intermedius was intubated. The orifice of the right lower lobe and right middle lobe bronchi were identified and free from gross lesion. There were mild to moderate thick bloody secretions. All right airways to the level of the segmental bronchi were serially investigated and found to be free of other gross pathology. The bronchoscope was then returned to the carina and the left mainstem bronchus intubated. There were mild to moderate thick bloody secretions. The orifice of the left upper and lower lobe bronchi and free of any other gross lesion. All left airways were then serially investigated and found to be free of other gross pathology. The airways were suctioned and irrigated clear and the bronchoscope withdrawn from the patient.
1. Angioedema
2. Difficult airway
3. Ascending aortic aneurysm s/p Hemi-arch replacement
Procedure:
1. Tracheostomy, open
2. Flexible bronchoscopy
Indications:
a 74 y.o. woman who presented to hospital yesterday for hem-arch repair of an ascending aortic aneurysm. Post-operatively she did well and passed all extubation criteria approximately 6 hours following the procedure. Immediately following extubation she developed shortness of breath and oropharyngeal swelling. Emergency re-intubation was attempted but failed. She underwent emergent bedside crycothryoidotomy which established the airway. She is returned to the operating room today for revision to formal tracheostomy.
Findings:
1. Successful placement of a 7Fr XLT Shiley tracheostomy.
2. Completion bronchoscopy revealed mild to moderate thick mucoid secretions throughout.
Procedure Details:
The patient had their history and physical updated prior to the procedure. They were then transferred to the operating suite and placed on the operating table where general anesthesia was affected. The patient was then prepped and draped in usual sterile fashion. A surgical timeout was used confirm patient identity as well as the surgery to be performed.
Next, the previous crycothryroidotomy incision above the sternal notch in the midline was extended. Dissection was carried down in between the strap muscles with electrocautery. The anterior surface of the trachea was identified, as was the 2nd and 3rd tracheal rings. The patient was placed on 100% FiO2. The tube cuff was deflated and the trachea punctured between the 2nd and 3rd rings. A guidewire was inserted into the trachea. The tracheotomy was serially dilated over the guidewire. An 7Fr Shiley XLT tracheostomy tube was lubricated and inserted over the wire using a modified Seldinger's technique. A cross table circuit was attached which verified adequate volume exchange and EtCO2. The crycothyroidotomy tube withdrawn from the patient and the tracheostomy tube secured. Surgicel to aid in hemostasis. Hemostasis was verified.
Next, the flexible bronchoscope was inserted into the tracheostomy tube and guided down into the trachea. The carina was visualized. The right mainstem bronchus was intubated. The orifice of the right upper lobe bronchus was identified. There were no gross lesions. The bronchus intermedius was intubated. The orifice of the right lower lobe and right middle lobe bronchi were identified and free from gross lesion. There were mild to moderate thick bloody secretions. All right airways to the level of the segmental bronchi were serially investigated and found to be free of other gross pathology. The bronchoscope was then returned to the carina and the left mainstem bronchus intubated. There were mild to moderate thick bloody secretions. The orifice of the left upper and lower lobe bronchi and free of any other gross lesion. All left airways were then serially investigated and found to be free of other gross pathology. The airways were suctioned and irrigated clear and the bronchoscope withdrawn from the patient.