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Moderator:
Dr. Lokesh Kashyap
www.anaesthesia.co.in
anaesthesia.co.in@gmail.com
Patient Particulars
Name: Sunita
Age: 21yrs
Sex: female
Occupation: none
Residence: Bihar
Date of admission:24/08/08
Date of examination: 03/09/08
Proposed date of surgery: 04/09/08
SUNITA, 21 F
Chief Complain:
Facial
.HOPI
Progressively
.HOPI
No
Past History
h/s/o OSA
No other comorbid illness
Previous exposure to GA U/E
Personal History
Vegetarian
No addiction
Bowel & bladder habit: normal
Sleep: disturbed
Appetite: poor
Brushing teeth: Once a day
Menstrual History:
Menarche at 13yrs, normal cycle, duration and flow.
Family History
Treatment History
History of Allergy
Physical examination
General survey:
Airway Examination-11parameters
Inter-incisor
gap: 3.5cm
Buck teeth: present
Length of incisor: <1.5cm
Upper lip Bite: Class III
MMP: Class IV
Palate: no arching / not narrow
TMD: 1.5cm
RHTMD: 100
Mandibular
Movement
Respiratory system
R.R.-18/min
B/l
Cardiovascular System
S1,
functions normal
No sensory/ motor deficit
Abdomen
Soft,
Investigations:
Hb: 11.7g%
TLC: 4500/cc
Platelet: 252 thousand/cc
BU/Cr: 22/0.6
Na/K : 147meq/l; 4.4meq/l
LFT: wnl
ABG: pH: 7.39; pO2: 93.6 mmHg; pCO2: 43.3 mmHg;
HCO3: 25.9 mmol/l; Sat: 97%
Polysomnography:
Severe OSA
Average minimum oxygen saturation:94.46%
Min oxygen saturation: 57.4%
224 times oxygen saturation < 90%
AHI: 54.61 events/hr
CXR:
Surgery Planned
Distraction Osteogenesis
Clinical Diagnosis
Post
Questions?
TEMPORO
MANDIBULA
R JOINT
Movements of TMJ
Depression:
Airway Management
Fiber optic intubation:
- awake
- following induction of anesthesia with spontaneous breathing
- following induction & respiratory paralysis
Blind nasal intubation:
-awake
- following induction of anesthesia with spontaneous breathing
- following induction & respiratory paralysis
Retrograde intubation
Tracheostomy
BERMAN
WILLIAMS
OVASSAPIAN
Solutions:
The tube should be loaded over the scope to prevent inadvertently passing
through the Murphy eye of the tube.
Once the scope has been inserted into the trachea, airway intubator should
be removed.
When there is difficulty in advancing a tube, withdraw the tube for a few
centimetres, rotate it 90 anticlockwise.
If it is still difficult to advance the tube it may be rotated by 180, and the
position of the head and neck adjusted.
Some definitions:
Or
A 50% or more decrease in nasal pressure excursion
for 10 seconds or longer with either a 3% or more O2
desaturation or an arousal
OSA:
Or
RERA:
Severity of OSA
Sleepiness
Gas exchange abnormalities:
Mild: Mean oxygen saturation remains greater than or equal to 90% and
minimum remains greater than or equal to 85%.
Moderate: Mean oxygen saturation remains greater than or equal to 90%
and minimum oxygen saturation remains greater than or equal to 70.
Severe: Mean oxygen saturation remains less than 90% or minimum
oxygen saturation remains less than 70%.
Respiratory disturbance:
Mild: AHI 5-15
Moderate: AHI 16-30
Severe: AHI greater than 30
Management of OSA
Lifestyle modification
Oral appliances:
Surgery
-Septoplasty
-Polypectomy
-Turbinoplasty
-Radiofrequency ablation of the soft palate and tongue base
-Uvulopalatopharyngoplasty (UPPP)
-Hyoid suspension
-Mandibular advancement, genioglossus advancement, and/or maxillary
advancement
Monitoring improvement
Diminished
Diminished
Quality
of life improvement.
Name:
Today's Date:
Your Age (Years):
How likely are you to doze off or fall asleep in the following situations, in contrast to
feeling just tired? This refers to your usual way of life in recent times. Even if you have
not done some of these things recently, try to work out how they would have affected
you. Use the following scale to choose the most appropriate number for each situation:
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Key: < 10 points = probably normal 10-12 points = mild sleepiness 13-17 points =
moderate sleepiness 18-24 points = severe sleepiness
Literature:
History of snoring
Beard
Edentulous
Langeron et al, Anesthesiology, November 2006
Neck movement
Patient is asked to hold the head erect, facing
directly to the front maximal head extension
angle traversed by the occlusal surface of
upper teeth
Grade I
:
> 35
Grade II :
22-34
Grade III :
12-21
Grade IV :
< 12
Sensitivity
Specificity
MMP class
49%
86%
TMD
20%
94%
Sternomental
distance
62%
82%
Mouth opening
22%
97%
46%
89%
MMP + TMD
56%
97%
Combination Score
Wilson Score
5 factors
Each
jaw
Demerits of ASA
Demerits of ASA Algorithm:
algorithm:
Open ended, wide
choice of techniques
Emphasis on prediction
of difficult airway
No stratification of
available a/w devices
No expression of
strength of
recommendation
Extubation strategy
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