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Oral case 5

Created: 3/9/2004

A three-year old 32-kg boy is scheduled for suspected ruptured liver or spleen. He was thrown from an automobile and on admission had a fractured wrist, tender abdomen, and a normal neurologic exam. Vital signs are as follows: blood pressure 84/50 mm Hg, pulse 112, temperature 36 degrees oral, and he has a hemoglobin of 10.

 Preoperative evaluation

I. Priorities of assessment:

1. You are the first to arrive in the emergency room. Describe your initial assessment.

Initial assessment of any trauma patient consists of evaluating the airway, breathing, and circulation. The cervical spine, airway, and face should be checked for injury, and the respiratory rate, depth of effort, symmetry of breath sounds, and oxygen saturation are evaluated. The blood pressure, heart rate, estimated blood loss, urine output and response to fluid therapy assist in evaluating hemodynamic status. Level of consciousness and neurologic deficits must also be assessed, and the primary and associated injuries should be checked, while maintaining a high index of suspicion for finding unexpected injury. A history of medical problems, allergies, medicines, and prior anesthesia should be elucidated if possible.

2. What tests, if any, would you order? Why?

 Intraoperative course

I. Monitors-interpretation of data

1. Is an arterial catheter warranted? Why or why not?

2. What site and what method would you use?

3. Would you use a central venous line? Why or why not?

4. Where would you place a central venous line?

5. Would you place it before induction?

6. What other monitors would you use? Why?

 Selection of anesthetic technique

1. Will a rapid sequence induction be needed? Why or why not?

The use of succinylcholine for rapid sequence induction and intubation includes situations in which the patient has a full stomach and the need to secure the airway rapidly is desired, so the patient does not aspirate gastric contents. These situations include trauma, diabetes mellitus, hiatal hernia, pregnancy, obesity, and severe pain.

2. How would you accomplish a rapid sequence technique?

3. What are some adverse events associated with the use of succinylcholine?

Adverse events include prolonged action due to pseudocholinesterase deficiency, liver disease, pregnancy, malnutrition and malignancies; bradycardia, hyperkalemia, malignant hyperthermia, increased intraocular pressure, increased intracranial pressure, increased gastric pressure, and phase II blockade.

4. In what cases are you likely to see hyperkalemia from succinylcholine?

Burns, muscular diseases, prolonged immobility, spinal cord injury, upper and lower motor neuron disease, and closed head injury.

5. What maintenance drugs would you use?

6. Would you avoid potent inhalational agents? Why or why not?

7. What property of inhalational agents correlates with potency?

Although there is not a particular property of volatile anesthetics that predicts potency, increasing lipid solubility correlates best with potency. This observation was made by Meyer and Overton, who believed that the incorporation of lipophilic molecules into the bilipid membrane caused anesthesia to occur.

8. What factors increase speed of induction of inhalational agents?

Faster induction is seen with an increase in alveolar concentration of gas, with a high-flow breathing circuit, an increase in minute ventilation for the more soluble gases decreased cardiac output, and the second gas effect.

9. Describe the second gas effect.

This occurs when nitrous oxide is the second gas used for anesthesia. Since it is so insoluble in blood, its rapid absorption from the alveoli causes a sharp rise in the concentration of the other inhalational agent.

10. Would you use nitrous oxide? Why or why not?

11. Is special equipment needed? Explain.

 Fluid management with liver injury

1. Partial hepatectomy will be needed because the lateral lobe is badly damaged. Would you alter your blood orders?

2. What is your likely component therapy regimen?

3. Would you give calcium? Why or why not?

4. The urine turns red. What is your management?

 Management of relaxants

1. How do you determine the requirement of muscle relaxant?

2. Describe monitoring.

3. Relate your dosing to liver function, temperature, and duration of the case.

4. How are your decisions about reversal of neuromuscular blockade altered?

 Postoperative Care

I. Management of pain

1. The child remains intubated. Is he a candidate for epidural blockade?

2. Is he a candidate for intravenous narcotics?

3. Which drugs would you give, and why?

 Anesthesia for reoperation

1. 48-hours later, this patient needs anesthesia for abdominal pack removal. Is ketamine a good choice? Why or why not?

2. Are the newer narcotics a good choice? Why or why not?

3. Is etomidate a good choice? Explain.

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