A 52-year old male is scheduled for laryngoscopy, bronchoscopy, and esophagoscopy for suspected carcinoma of the larynx. He has a history of asthma, chronic hypertension, and heavy smoking. Medications include theophylline, prednisone, and captopril daily, and inhaled albuterol on occasion. Blood pressure is 165/90 mmHg, pulse is 96 bpm, respirations are 20, and temperature is 37.6 degrees centigrade.
I. Pulmonary status
1. What additional preoperative data are required?
2. Chest radiograph shows consolidation of the right middle lobe, and a right pleural effusion. What is the significance of this?
3. Do you want additional studies?
4. Is spirometry indicated?
5. Do you wish an arterial blood gas?
6. How will the results of each test influence your management?
II. Steroid therapy
1. Is preoperative steroid coverage necessary? Why or why not?
2. What are the risks of omitting steroid therapy?
1. How would you premedicate this patient if local anesthesia were planned?
2. Would premedication differ if general anesthesia were to be used? Why or why not?
1. What monitors for bronchoscopy do you want if the patient is to have local with sedation?
2. What monitors for bronchoscopy do you want if the patient is to have general?
3. Why would you want different monitors?
4. Is pulse oximetry superior to transcutaneous oxygen monitoring? Explain.
1. The patient insists on general anesthesia. What are your major concerns?
2. Compare awake intubation vs inhalation induction vs rapid sequence induction.
3. Would topical anesthesia or nerve block be helpful?
4. Which ones would you use? Explain your rationale.
III. Anesthetic maintenance
1. Would you use inhalation agent, or nitrous/narcotic anesthesia for maintenance?
2. Explain your rationale.
3. Is nitrous oxide contraindicated? Why or why not?
1. Would you use a Bain circuit or a circle absorber? Why?
2. The surgeon requests high frequency jet ventilation for rigid bronchoscopy. Do you agree? Explain.
V. Multifocal premature ventricular contractions
1. Multifocal premature ventricular contractions develop during bronchoscopy. What is your differential diagnosis?
2. What is your treatment?
I. Postoperative delerium
1. The patient is combative thirty minutes postoperatively.
2. What is your differential diagnosis?
3. The nurse suggests sedation. Do you agree?
4. You suspect aspiration. How do you confirm this diagnosis?
5. How would you treat it?
II. Postoperative hypertension
1. In the recovery room, the blood pressure is 200/100 mmHg and the patient complains of left chest pain. What is your differential diagnosis?
2. How do you differentiate pneumomediastinum vs pneumothorax vs myocardial infarction?