FYS 4250

1. FYS4250 Lecture 8 “Every patient is a mystery!” C Spiegel

2. Case 8 Footage.shutterstock.com - A 35 year old man experience a three day progressive numbness in the right arm with weakness of the underarm and fingers and seeks his family doctor. What is the most likely cause?

3. Case 8 - During examination, the patient describes a headache of gradual onset but no disturbance of visual function and no blind spots. There are small signs of impairment of consciousness, but no history of fainting or other blackouts. The patient was admitted to hospital for a thoroughly examination, at admission the blood pressure is 110/72 mmHg, the heart rate is 67 bpm, the temperature is 36.2 °C and the heart is regular without murmurs. His abdomen is mildly distended with hypoactive bowel sounds an marked left lower quadrate tenderness. The saturation is 99% and the HIV assay is negative. He does not smoke, nor is he drinking alcohol. How will you examine this patient?

4. Case 8 - A CT-caput reveals a tumor located in the sulcus sentralis which can explain the paralysis. The patient is scheduled for a surgical tumor recession and starts the procedure with measuring the cardiac output.

5. Measuring the cardiac output

6. Swan-Ganz Catheter (Pulmonary artery catheter) Image: Tormod Martinsen

7. Swan-Ganz Catheter (Pulmonary artery catheter)

8. Swan-Ganz Catheter (Pulmonary artery catheter) http://www.google.no/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CCwQFjAA&url=http%3A%2F%2Fwww.bu.edu%2Fav%2Fcourses%2Fmed%2F05sprgmedanesthesiology%2F002%2FPulmonary%2520Artery%2520Catheter.ppt&ei=0YNEUuK4E8rbsgbF-YH4Dg&usg=AFQjCNFom3GiBoeCG1LM7SOWnaBhVIoV7Q&sig2=KGFSfzNK3XNrq-pwpiKFhA&bvm=bv.53217764,d.Yms&cad=rja

9. Fick’s method, cardiac Output (Continuous)

10. Indicator-dilution method

11. Measured hemodynamic parameters • Central Venous Pressure (CVP) • The CVP is recorded from the proximal port of the PAC in the superior vena cava or from the right atrium • Pulmonary Artery Pressure (PAP) • The PAP is measured from the tip of the PAC with a deflated balloon • Pulmonary Capillary Wedge Pressure (PCWP) • The PCWP is recorded from the tip of the PAC catheter with the balloon inflated • PCWP ≈ LAP (Left Atrial Pressure) • Cardiac Output (CO) • The CO is calculated using the thermodilution technique

12. Swan Ganz -Risks • Accidental puncture of arteries • Bleeding • Air embolism • Pneumothorax • Thromboembolism • Valve injury • Infection • Pulmonary Artery Rupture

13. Measuring the blood flow, ultrasound

14. Ultrasonic doppler flowmeter

15. Transducer systems (transit time)

16. Doppler flowmeter, sinewave

17. Quadrature-phase detector

18. Directional flowmeter waveforms

19. Case 8 - Due to a sudden drop in saturation, cerebral oxygenation is measured. This is not routine for cerebral surgical procedures, but is more typical for heart surgery

20. Monitoring the cerebral oxygenation

21. Cerebral oximetry http://www.perfusion.com/cgi-bin/absolutenm/articlefiles/chen2008/chen2008.pdf

22. http://www.perfusion.com/cgi-bin/absolutenm/articlefiles/chen2008/chen2008.pdfhttp://www.perfusion.com/cgi-bin/absolutenm/articlefiles/chen2008/chen2008.pdf

23. Cerebral oximetry http://www.perfusion.com/cgi-bin/absolutenm/articlefiles/chen2008/chen2008.pdf

24. Cerebral oximetry http://www.perfusion.com/cgi-bin/absolutenm/articlefiles/chen2008/chen2008.pdf

25. Cerebral oximetry http://www.perfusion.com/cgi-bin/absolutenm/articlefiles/chen2008/chen2008.pdf

26. Cerebral oximetry http://www.perfusion.com/cgi-bin/absolutenm/articlefiles/chen2008/chen2008.pdf

27. Cerebral oximetry http://www.perfusion.com/cgi-bin/absolutenm/articlefiles/chen2008/chen2008.pdf

28. Case 8 - The surgeon decides to use a harmonic scalpel for tumor recession

29. Ultrasoundsurgery • An alternative to electrosurgery

30. Ultrasoundsurgery

31. Ultrasoundsurgery

32. Cavitation Mechanic abrasion Thermal effect Ultrasound ablation

33. Ultrasound ablation: Cavitation Principle of operation: Cavitaion

34. Ultrasound ablation Principle of operation: Cavitaion

35. Ultrasound main advantage

36. Ultrasound main advantage

37. Electrosurgery vs Ultrasoundsurgery Adv. Ultrasoundsurgery • Can cut through thicker tissue • Greater precision • Less toxic surgical smoke • Less lateral thermal damage Disadv. Ultrasoundsurgery • Takes more time to cut and coagulate • Can only coagulate as it cuts

38. Neuro navigation

39. Intraoperative Navigation 1st step: Preoperative Scan • Utilization of preoperative scans – no navigation scan necessary • No fiducials necessary Benefit: Reduction of radiation dose for patient Source: Brainlab

40. Intraoperative Navigation 2nd step: Intraoperative preparation – Patient reference star Non-invasive referencing with headband - generally used for sinus surgery in ENT Minimal invasive referencing in bone structure - generally used for skull base surgery, lateral indications or CMF cases Benefit: Referencing according to needs and indication. Source: Brainlab

41. Intraoperative navigation 3rd step: intraoperative registration • Surface scanning with a laser • No given registration points or registration routes • Registration accomplished in one minute • Registration possible in a sterile environment Benefit: Touchless registration saves sterile environment. Source: Brainlab

42. Intraoperative Navigation 4th step: Navigation Benefit: Time saving setup and workflow as well as advanced functionalities Source: Brainlab

43. intraoperative Navigation 4th step: Instrument integration • Simple integration of all instruments • Different geometries of stars and adapter clamps fit on every instrument Benefit: Fast integration of every rigid instrument available in the OR Source: Brainlab

44. intraoperative Navigation Image integration Benefit: Video integration endoscope and micorscope as well as image injection in microscopes Source: Brainlab

45. Case 8 - The patient recovers slowly, and after a convalescence of a couple of months, the strength in the right arm and fingers has been partly regained. The headache was cured the moment he woke up after the anesthesia, but he struggled to find the right words during regular conversation. All blood-tests and CT-scans after the surgery was negative, and after half a year he was able to return to his job as a carpenter. However, after almost a year, the same symptoms re-emerged and he experience a new progressive numbness in the right arm with weakness of the underarm and fingers. Why?

46. Case 8 - An MRI-scan of the brain and spinal cord with contrast, a so called FLAIR MRI (fluid-attenuated inversion recovery) is carried out. In the axial T2-weighted image of a typical vascular brainstem involvement of transverse pontine fibers, there are obvious signs of some typical peripherally located white matter lesions close to the trigeminal tract. http://www.radiologyassistant.nl/data/bin/w440/a519092a08bf88_1.jpg What is the true diagnosis?

47. Case 8 - The patient was diagnosed with multiple scleroris, treated with corticosterios (methylprednisolone) to reduce nerve inflammation and discharged from hospital. There is no cure for multiple sclerosis, but medication can slow down the progression of the disease and soften the symptoms What is the true diagnosis?