FORMER MATHS TEACHER AT DAV-BHEL SCHOOL, RANIPET(1999-2022)

Sunday, March 22, 2009

04 Operation And Discharge


DISCHARGE SUMMARY

 

Patient’s Name          :     MISS. KAVYASHREE .P        ID No.    :           0803051132   

Age / Sex                  :     3 YEAR / FEMALE             D.O.A.    :           25.04.2005     

                                                                        D.O.S.    :           29.04.2005     

                                                                              D.O.D.    :           12.05.2005           





DIAGNOSIS                                   :              Congenital heart disease

   Multiple atrial septal defect

                                                                        Moderate pulmonary artery hypertension          

                                                                        Non compaction of ventricles

                                                                        Bi-ventricular dysfunction

OPERATION PERFORMED       :


Gluteraldehyde treated pericardial patch closure of atrial septal defect with central fenestration + patent ductus arteriosus ligation + plication of atero- posterior tricuspid valve commissure.

BRIEF HISTORY :


3 year old, Kavyashree is the only child born to non-consanguinous parents. Full term normal delivery. No history of birth asphyxia. History of recurrent respiratory tract infection. No history of cyanosis / spells / convulsions. Diagnosed case of multiple atrial septal defect. She underwent Cardiac catheterization on 17.03.2005 which revealed multiple atrial septal defect, no compaction of ventricles with bi-ventricular dysfunction, moderate pulmonary artery hypertension and was advised atrial septal defect closure.  Now she is admitted here for the same.

PHYSICAL EXAMINATION:


Height – 100 cms.                                Weight – 12 kgs.                                  BSA – 0.58 m2

PR – 100 / min, Regular                        BP – 130 / 90 mmHg                           CVS – S1 S2 +

RS – Clear                                           Peripheral pulses felt                             Saturation – 98%

 

INVESTIGATION:

HAEMATOLOGY

Blood Group

-

O Positive

Hb

-

11.8gms / dl

PCV

-

36%

Platelets

-

2.7 lacs/mm3

Reticulocyte Count

-

4.0Cells/cu.mm

Total Leucocyte count

-

13,800Cells/cu.mm

Neutrophils

-

39%

Lymphocytes

-

56%

Eosinophils

-

03%

ESR

-

½ hr – 06mm, 1 hr-15 mm


BIO CHEMISTRY

 

 

 

 

 

RBS   

-

117mg / dl

Blood Urea 

-

22mg / dl

S.Creatinine 

-

0.6mg / dl

Total Bilirubin 

-

2.3mg / dl

Direct Bilirubin 

-

0.8mg / dl

Indirect Bilirubin 

-

1.5mg / dl

SGOT

-

35 IU / L

SGPT 

-

16 IU / L

ALK. Phosphatase   

-

386 IU / L

Total Proteins 

-

6.5gm / dl

S.Albumin  

-

3.5gm / dl

S.Globulin  

-

3.0gm / dl

 

ELECTROLYTES

 

 

 

 

 

Sodium

-

137mEq / L

Potassium 

-

3.12mEq / L

Serology

-

Non Reactive

 

 

 

                                                                

COAGULATION PROFILE

P.T                                  Test - 18.6 sec.                     Control - 13.5 sec.

INR                                1.49

A.P.T.T                           Test - 33.0 sec.                     Control - 32.0 sec.

 

CXR                   :        CTR 75%, Gross cardiomegaly +, increased Pulmonary Blood Function, pulmonary venous congestion

 

ECG                   :        Sinus rhythm, Bi-atrial enlargement, LV dominance, rSR IN v1

 

ECHO                :        (16.03.2005) Mulitple ASD with left to right shunt.  Ventricular non compaction involving both RV and LV with compromised biventricular function, mild MR.

 

 

CATH                :        (17.03.2005) Multiple atrial septal defect. Non compaction of ventricles.  Biventricular dysfunction.  Moderate pulmonary arterial hypertension

                                    Elevated LV & RV EDP

                                               

 

COURSE IN THE HOSPITAL:

Patient underwent Gluteraldehyde treated pericardial patch closure of atrial septal defect with central fenestration + patent ductus arteriosus ligation + plication of atero posterior tricuspid valve commissure on 29.04.2005 and was shifted to the ICU with inotropic support and  stable haemodynamics.   She was  electively ventilated for a period of 48 hours and extubated on the 2nd postoperative day, weaned off inotropic support .Echo done on the  3rd  postoperative day revealed  bilateral pleural effusion and pericardial effusion  and she was dyspnoeic too. Hence forth  bilateral ICD  was inserted   and was taken up for re-exploration in view of    increased drains  and mediastinal widening by CXR.  Plenty of clots evacuated  from the   pericardial cavity and she was stabilized and shifted to  the ICU with stable haemodynamics. She was shifted to the ward on the  6th  postoperative day.  Sutures and pacing wires were removed on the 11th  postoperative day.

 

 

CONDITION ON DISCHARGE:

Ambulant, hemodynamically stable, wounds healed well.

 

CXR                :     CTR – 0.75%, lung fields clear

 

ECG                :     HR – 113/min, Normal sinus rhythm, evidence LV enlargement with strain

 

ECHO             :     (10.05.2005) No residual ASD.  Mild TR with peak gradient of 31 mmHg.  Moderate  mitral regurgitation.  No RVOT and LVOT obstruction.  Left arch.  No CoA.  No residual PDA.  Both diaphragm moving well.  No pleural and pericardial effusion.  Adequate RV function.  Mild LV dysfunction.


Saturation      :     96%


ADVICE:

                                    Salt free diet

                                    Fluids – 630ml / day

Review after 3 months with prior appointment.



MEDICATIONS:


 

       Tab. Lasix 10 mg twice daily

       Tab. Aldactone 12.5 mg twice daily



 

                                    DR. CHRISTOPHER ROY, MS, M.Ch.

                                                                       JR.CONSULTANT CARDIAC SURGEON





DR. RAVI AGARWAL, MS, M. Ch.

CONSULTANT CARDIAC SURGEON

 

 

 

Dr. K.M. CHERIAN, MS, FRACS, D.Sc. (Hon)











OPERATION NOTES


Name

KAVYASHREE.P.

Patient Id

080305001132

Surgery No

1093

Surgery Date

29/04/2005

Surgeon Name

Dr K.M. CHERIAN 

Dr  SOMA GUHATHAKURTA

Dr  SENTHIL KUMAR SUBBIAN

Anaethetist

Dr  SUMAN

Perfusionist

LAVANYA SEKHAR

Nurse

MARY / SUDHA

Opn. Theatre

Theatre - II

Blood Group

O +

Weight

12 Kgs

Height

100 Cms

BSA

0.58 Sq.m.

 

 



FINAL DIAGNOSIS:


CONGENITAL HEART DISEASE

MULTIPLE ATRIAL SEPTAL DEFECT.

MODERATE PULMONARY ARTERIAL HYPERTENSION.


SURGERY PERFORMED:

GLUTERALDEHYDE TREATED PERICARDIAL PATCH CLOSURE OF ATRIAL SEPTAL DEFECT WITH CENTRAL FENESTRATION + PDA LIGATION + PLICATION OF ANTERO POSTERIOR TRICUSPID VALVE COMMISSURE.


MORPHOLOGY

Left Aortic Arch

Normal Pulmonary Venous Drainage

RA Hugely dilated

RV dilated.

Small aorta 1/3 the size of PA

Large ostium secundum ASD. 4 x 3 cms.

No LSVC.

 

INCISION

Median Sternotomy

 

CARDIAC INCISION

Right Atriotomy

 

PROCEDURE

Mid line sternotomy. Right lobe of thymus excised.

Systemic heparinisation followed by Aorto bicaval cannulation and CPB.

PDA dissected & ligated with silk. Heart fibrillated using fibrillator and RA opened. Gluteraldehyde treated pericardial patch used to close ASD.  It was fenestrated in the center. Commissure between anterior and posterior bicuspid leaflets plicated using 3/0 Prolene stitch.

RA closed using 5/0 Prolene continuous sutures.

After de airing heart defibrillated into normal sinus rhythm.

Core rewarmed and CPB weaned off.

Heparin neutralized with protamine and decannulated.

Haemostasis secured and chest closed in layers.

Sternum - 2/0 steel wires

Subcutaneous tissue - 2/0 Centicryl

Skin - 4/0 Centicryl (Subcuticular).

 

CPB DATA

Cannulation : Aortic Size : 16  Type : POLYSTAN

Venous SVC Size : 22  Type : RMI

              IVC Size : 24  Type : RMI

Cooled to : 35oC

Modified ultra filtration volume :  350ml

Cross clamp time: 20 mins

CPB time: 60 mins

 

POST BYPASS DETAILS

Spontaneous Recovery into Sinus rhythm

Mediastinal Drains : 2

PACING WIRES : ATRIAL 2 AND VENTRICULAR 1

 

POST BYPASS HAEMODYNAMICS

CVP:16mmHg ABP:82/44mmHg

 

 

STERNAL CLOSURE

2 STEEL

 

CHEST CLOSURE

CENTICRYL

 

SUPPORTS

ADRENALINE 0.1 Mcg/Kg/min

DOPAMINE 5 Mcg/Kg/min

MILRINONE 0.5 Mcg/Kg/min

 








SURGEON

Medical Record(s) Incharge