Preoperatively
This is a 50 years old 60 kg male ASA III patient presented with road traffic accident when he was driving a car, he had loss of consciousness at that time and had mild traumatic brain injury, neck injury and he was on cervical collar associated to this he had blunt chest injury indicative of lung contusion and had chest pain and the pain worsen when he tried to breath and ambulate and also the patient had bleeding at the time of accident. Otherwise he has no history of chronic medical illness like diabetes mellitus, hypertension, respiratory disease, neurologic disease like epilepsy, he has no history of cigarette smoking and alcohol consumption, no history of current medication intake, no history of allergy, no history of upper respiratory tract infections, no previous history of surgery and anesthesia. On physical examination the patient was acute sick looking on intranasal O2 with 3L with spo2 of 93% and vital sign was blood pressure 110/70 mmHg, pulse rate 93 beats per minute, respiratory rate 20 breaths per minute and temperature 36.7 oC. The patient has slightly pale conjunctiva and his mallampati score was II and difficult to assess the other airway parameters due to rigid cervical collars. During preoperative evaluation the cardiorespiratory system, genitourinary and gastrointestinal system was normal but on musculoskeletal system he had severe tenderness on both legs and had long posterior gutter on both legs. Brain CT shows there are two epidural blood collections: 1st : left parietal with a thickness of 5.5 mm, 2nd left temporal with a thickness of 6.1 mm, on cervical spine CT there is C7 left lateral mass facet transverse process fracture plus C6 left lateral mass fracture. Laboratory investigation of the patient was described below (Table 1).
Then with appropriate communication with surgical team we prepared cross match blood for intraoperative and an intensive care unit for postoperative follow up and the patient transferred from the ward to the operation room via stretcher.
Table 1
preoperative laboratory investigation of the patient
Laboratory investigation | Components | Result |
Complete blood count | White blood cell count | 10.1x106/mcL |
Neutrophil | 71.1% |
Hemoglobin | 10.7 gm/dl |
hematocrit | 30.2% |
Platelet | 198k mm3 |
Blood group and Rh | O positive |
Serum electrolytes | Sodium | 127mEq/l |
Potassium | 4.3 mEq/l |
Chloride | 96 mEq/l |
Liver function tests | Aspartate aminotransferase | 38 mmol/l |
Alkaline phosphatase | 65 mmol/l |
Renal function tests | Serum creatinine | 1.2 mg/dl |
Blood urea nitrogen | 18.2 mg/dl |
Intraoperatively
After the patient arrived to the operation room for an indication of bilateral femoral sign nail and left distal tibiofibular sign nail an informed consent was taken and then monitors attached like NIBP, ECG and pulse oximetry and arterial line for invasive blood pressure monitoring. The initial vital sign was BP: 125/70 mmHg, PR: 91 BPM, Spo2:97% then planned to proceed with general anesthesia with endotracheal intubation and initially premedicated with fentanyl 100mcg, morphine 3mg,ceftriazone 1gm, then the induction agent was ketamine 50mg and propofol 70mg,for facilitation of intubation suxamethonium chloride 120mg. The patient intubated after preoxygenation with 10 LPM for 5 minutes one anesthesia provider released the cervical collar after the patient induced and the cervical spine maintained with manual inline stabilization and intubated with endotracheal tube of 7.5 mm and laryngoscope blade of size four then the neck maintained in neutral position and the tube fixed with tape and the chest checked for bilateral breath sound then the surgery started. Anesthesia was maintained with isoflurane range from 0.5–1% and for muscle relaxant vecronium given with a total dose of 12 mg and then the patient also received 1g of tranexamic acid. During the intraoperative period he was hemodynamically stable and his RBS at the mid of surgery was 112 mg/dl. The patient receives a total of 2000ml normal saline and 1000 ml ringer lactate with intraoperative blood loss of around 724 ml and urine output of 1300ml. Neuromuscular relaxant was reversed with atropine 1mg and neostigmine 2.5mg. For postoperative management bilateral fascia iliaca compartment block (FICB) with 25 ml of 0.25% bupivacaine bilaterally and lateral approach popliteal nerve block using 20 ml of 0.25% bupivacaine given. Duration of surgery and anesthesia was 3 hours and 35 minutes and 4 hours 40 minutes respectively.
Postoperatively
After the end of the surgery the patient did not fulfill the criteria to extubate then planned to transfer the patient to ICU with ambubag with adequate preparation including emergency drugs and ventilating the patient with ambubag then the ICU was already prepared and the patient put on mechanical ventilation on pressure support ventilation (PSV) mode then the hemodynamics was normal with vital sign of BP: 108/68 mmHg, PR: 75 BPM and SPO2 of 99%. After two hours the patient tried to maintain his saturation and had adequate breathing pattern, then the ICU anesthesiologist extubated the patient with adequate trying of his tolerance to extubation. Fourteen days later he was discharged from the hospital and advised to follow up.