Abstract
Elderly female with chronic hypertension, known case of atrial flutter on rate control medication who recently treated for COVID-19 pneumonia on oxygen support(PFR=190) came to emergency room with complaints of abdominal mass and pain associated with vomiting, not passing stools. Diagnosed to have obstructed umbilical hernia with extensive secondary bacterial pneumonia with ARDS (ASA-4E). COVID-19 RTPCR test negative. Taken up for emergency laparotomy under combined spinal and epidural anaesthesia (CSEA). Post operatively patient was managed in intensive care unit for 5days with oxygen, invasive lines, vasopressor support and epidural infusion. Post covid patients presenting for emergency surgery requires evaluation of surgical illness and post covid sequels like oxygen dependency, cytokine storm, secondary bacterial infection, ARDS, lung fibrosis renal and liver dysfunction. Atrial flutter in perioperative period may lead to haemodynamic instability and thromboembolic events resulting in significant morbidity and mortality. Laparotomy in these patient is challenge. Needs better analgesia perioperative period to prevent further respiratory deterioration.
Highlights
A 81year old female with class 1 obesity known hypertension and atrial flutter, status post modified radical mastectomy for left carcinoma breast20 years ago was admitted with complaint of mass per abdomen since 3 years which is associated abdomen pain, vomiting and not passing stools since 3days
Patient was on treatment with telmisartan-40mg, tab Amiodarone-100mg, tab diltiazem-10mg and tab frusemide-40mg. metabolic equivalents (METs) less than 4
Patient was recently treated for COVID 19 pneumonia for 10days and discharged on home oxygen 1 week ago was on 17th day of covid illness
Summary
A 81year old female with class 1 obesity known hypertension and atrial flutter, status post modified radical mastectomy for left carcinoma breast. Patient is on 5L/min oxygen with simple mask. Patient was nil oral more than 8hours, 1 liter of ringer lactate bolus given; BP was improved to 130/72. Patient was continued with 5liter/min oxygen with simple mask. Patient was started with epidural infusion of Inj ropivacaine 0.2% and fentanyl 2mcg/cc 5ml/hour. Patient had hypotension BP being 80/46 mmHg. Treated with fluid bolus and Inj phenylephrine 50mcg bolus. Post-operatively patient shifted to ICU with 5L/min oxygen, post operatively patient was conscious, oriented hemodynamically stable. Post op day-1: Patient required more oxygen switched to 10L/min oxygen with NRBM. Post op day 2: HR-188/min, ECG- atrial flatter, reverted to sinus rhythm with inj amiodarone 150mg bolus, infusion started. Post op day 3: patient was conscious, oriented. Post op day 4: on 2L/min oxygen, saturation 96%, haemodynamically stable.
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