NEET MDS Lessons
General Surgery
Tracheostomy
Tracheostomy is a surgical procedure that involves creating an opening in the trachea (windpipe) to facilitate breathing. This procedure is typically performed when there is a need for prolonged airway access, especially in cases where the upper airway is obstructed or compromised. The incision is usually made between the 2nd and 4th tracheal rings, as entry through the 1st ring can lead to complications such as tracheal stenosis.
Indications
Tracheostomy may be indicated in various clinical scenarios, including:
- Acute Upper Airway Obstruction: Conditions such as severe allergic reactions, infections (e.g., epiglottitis), or trauma that obstruct the airway.
- Major Surgery: Procedures involving the mouth, pharynx, or larynx that may compromise the airway.
- Prolonged Mechanical Ventilation: Patients requiring artificial ventilation for an extended period, such as those with respiratory failure.
- Unconscious Patients: Situations involving head injuries, tetanus, or bulbar poliomyelitis where airway protection is necessary.
Procedure
Technique
- Incision: A horizontal incision is made in the skin over the trachea, typically between the 2nd and 4th tracheal rings.
- Dissection: The subcutaneous tissue and muscles are dissected to expose the trachea.
- Tracheal Entry: An incision is made in the trachea, and a tracheostomy tube is inserted to maintain the airway.
Complications of Tracheostomy
Tracheostomy can be associated with several complications, which can be categorized into intraoperative, early postoperative, and late postoperative complications.
1. Intraoperative Complications
- Hemorrhage: Bleeding can occur during the procedure, particularly if major blood vessels are inadvertently injured.
- Injury to Paratracheal Structures:
- Carotid Artery: Injury can lead to significant hemorrhage and potential airway compromise.
- Recurrent Laryngeal Nerve: Damage can result in vocal cord paralysis and hoarseness.
- Esophagus: Injury can lead to tracheoesophageal fistula formation.
- Trachea: Improper technique can cause tracheal injury.
2. Early Postoperative Complications
- Apnea: Temporary cessation of breathing may occur, especially in patients with pre-existing respiratory issues.
- Hemorrhage: Postoperative bleeding can occur, requiring surgical intervention.
- Subcutaneous Emphysema: Air can escape into the subcutaneous tissue, leading to swelling and discomfort.
- Pneumomediastinum and Pneumothorax: Air can enter the mediastinum or pleural space, leading to respiratory distress.
- Infection: Risk of infection at the incision site or within the tracheostomy tube.
3. Late Postoperative Complications
- Difficult Decannulation: Challenges in removing the tracheostomy tube due to airway swelling or other factors.
- Tracheocutaneous Fistula: An abnormal connection between the trachea and the skin, which may require surgical repair.
- Tracheoesophageal Fistula: An abnormal connection between the trachea and esophagus, leading to aspiration and feeding difficulties.
- Tracheoinnominate Arterial Fistula: A rare but life-threatening complication where the trachea erodes into the innominate artery, resulting in severe hemorrhage.
- Tracheal Stenosis: Narrowing of the trachea due to scar tissue formation, which can lead to breathing difficulties.
Neuromuscular Blockers in Cardiac Anesthesia
In patient on β-blockers, the choice of neuromuscular blockers (NMBs) is critical due to their potential cardiovascular effects. Here’s a detailed analysis of the implications of using fentanyl and various NMBs, particularly focusing on vecuronium and its effects.
Key Points on Fentanyl and β-Blockers
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Fentanyl:
- Fentanyl is an opioid analgesic that can cause bradycardia due to its vagolytic activity. While it has minimal hemodynamic effects, the bradycardia it induces can be problematic, especially in patients already on β-blockers, which reduce heart rate and blood pressure.
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β-Blockers:
- These medications reduce heart rate and blood pressure, which can compound the bradycardic effects of fentanyl. Therefore, careful consideration must be given to the choice of additional medications that may further depress cardiac function.
Vecuronium
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Effects:
- Vecuronium is a non-depolarizing neuromuscular blocker that has minimal cardiovascular side effects when used alone. However, it can potentiate decreases in heart rate and cardiac index when administered after fentanyl.
- The absence of positive chronotropic effects (unlike pancuronium) means that vecuronium does not counteract the bradycardia induced by fentanyl, leading to a higher risk of significant bradycardia and hypotension.
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Vagal Tone:
- Vecuronium may enhance vagal tone, further predisposing patients to bradycardia. This is particularly concerning in patients on β-blockers, as the combination can lead to compounded cardiac depression.
Comparison with Other Neuromuscular Blockers
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Pancuronium:
- Vagolytic Action: Pancuronium has vagolytic properties that can help attenuate bradycardia and support blood pressure. It is often preferred in cardiac anesthesia for its more favorable hemodynamic profile compared to vecuronium.
- Tachycardia: While it can induce tachycardia, this effect may be mitigated in patients on β-blockers, which can blunt the tachycardic response.
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Atracurium:
- Histamine Release: Atracurium can release histamine, leading to hemodynamic changes such as increased heart rate and decreased blood pressure. These effects can be minimized by slow administration of small doses.
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Rocuronium:
- Minimal Hemodynamic Effects: Rocuronium is generally associated with a lack of significant cardiovascular side effects, although occasional increases in heart rate have been noted.
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Cis-Atracurium:
- Cardiovascular Stability: Cis-atracurium does not have cardiovascular effects and does not release histamine, making it a safer option in terms of hemodynamic stability.
Cardiovascular Effects of Sevoflurane, Halothane, and Isoflurane
- Sevoflurane:
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Maintains cardiac index and heart rate effectively.
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Exhibits less hypotensive and negative inotropic effects compared to halothane.
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Cardiac output is greater than that observed with halothane.
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Recovery from sevoflurane anesthesia is smooth and comparable to isoflurane, with a shorter time to standing than halothane.
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- Halothane:
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Causes significant decreases in mean arterial pressure, ejection fraction, and cardiac index.
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Heart rate remains at baseline levels, but overall cardiovascular function is depressed.
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Recovery from halothane is less favorable compared to sevoflurane and isoflurane.
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- Isoflurane:
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Preserves cardiac index and ejection fraction better than halothane.
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Increases heart rate while having less suppression of mean arterial pressure compared to halothane.
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Cardiac output during isoflurane anesthesia is similar to that of sevoflurane, indicating a favorable cardiovascular profile.
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