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UBP Question 5

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Question 5


(Short Form)


You are performing the pre-anesthetic assessment for a 68 year old male with small cell carcinoma of the lung, scheduled for a left pneumonectomy in 2 weeks. He complains of dyspnea on exertion and uses supplemental oxygen at night. Past medical history includes COPD, asthma, HTN, peripheral vascular disease, and a 50 pack-year smoking history. Physical exam reveals digital clubbing and moderate expiratory wheezing. Medications include HCTZ, theophylline, Advair, ASA, home oxygen, and albuterol, prn. HR = 70, BP = 172/88 mmHg, SpO2 = 90%, Temp = 36.4 °C, Hct = 58.

Pre-operative Management


1. What would you include in your pre-anesthetic assessment?

UBP Answer: Complete answer is found in the UBP Practice Set #2

2. How would PFTs be helpful?

UBP Answer: Complete answer is found in the UBP Practice Set #2

3. What is the significance of his digital clubbing and elevated Hct?

UBP Answer: Complete answer is found in the UBP Practice Set #2

4. What cardiovascular evaluation would you require prior to surgery?

UBP Answer: Complete answer is found in the UBP Practice Set #2

5. The ABG shows: pH 7.38, PaCO2 50, and PaO2 61 on 2 liters oxygen. What is your interpretation?

UBP Answer: Complete answer is found in the UBP Practice Set #2

6. The patient’s preoperative FEV1 is 1.4 L. Will this patient tolerate a pneumonectomy postoperatively?

UBP Answer: Complete answer is found in the UBP Practice Set #2

7. What will be your anesthetic management goals for this case?

UBP Answer: Complete answer is found in the UBP Practice Set #2


(Long Form)

A 68 year old male is scheduled for a left pneumonectomy for small cell carcinoma of the lung. He complains of dyspnea on exertion and uses supplemental oxygen at night. He states that he has stopped smoking since his pre-anesthetic assessment 2 weeks ago.

PMHx: His past medical history includes COPD, HTN, peripheral vascular disease , and a 50 pack-year smoking history.

Meds: HCTZ
Theophylline
Advair
ASA
O2
Albuterol, prn

Allergies: PCN, Codeine

PE: Vital Signs: HR = 70, BP = 172/88, SpO2 = 90%, Temp 36.4 °C
Airway: Mallampati II
Lungs: Moderate expiratory wheezing
CV: RRR
Extremities: Digital clubbing

Chest CT: Multiple left lung nodules involving the left main-stem bronchus

ECG: Normal

Echo: Ejection fraction = 70%

Labs: Hct = 58; platelets = 214; K+ = 3.6 mEq/L
ABG: pH 7.38, PaCO2 50, PaO2 61 on 2 liters oxygen

PFTs: DLCO = normal; VO2 max = 12 mL/kg/min; ppoFEV1 = 37%


Intra-operative Management


1) What monitoring would you require for this case?

UBP Answer: Complete answer is found in the UBP Practice Set #2

2) After several attempts, you are unable to place the CVP in the right internal jugular vein. What are your options?

UBP Answer: Complete answer is found in the UBP Practice Set #2

3) Do you plan to place a right or left double lumen endotracheal tube (DLT) for one lung ventilation?

UBP Answer: Complete answer is found in the UBP Practice Set #2

4) How are you going to induce this patient?

UBP Answer: Complete answer is found in the UBP Practice Set #2

5) After induction, you perform laryngoscopy and have a grade 3 view. You are unable to pass the DLT. What would you do?

UBP Answer: Complete answer is found in the UBP Practice Set #2

6) You successfully place a single lumen ETT and exchange it for a left-sided DLT. Following initiation of one lung ventilation, the SpO2 drops to 87%. What would you do?

UBP Answer: Complete answer is found in the UBP Practice Set #2

7) You notice that you have been hyperventilating the patient and he is hypocapnic. How might this be contributing to the decreased PaO2?

UBP Answer: Complete answer is found in the UBP Practice Set #2

8) The patient is returned to the supine position, and his blood pressure drops from 143/88 mm Hg to 94/66 mm Hg. What will you do?

UBP Answer: Complete answer is found in the UBP Practice Set #2


Post-operative Management


1) What are your options for post-operative pain control?

UBP Answer: Complete answer is found in the UBP Practice Set #2

2) The patient does not meet your extubation criteria and requires postoperative ventilation. Would you take the patient to the ICU with a DLT?

UBP Answer: Complete answer is found in the UBP Practice Set #2

3) The patient’s blood pressure trends down to 94/70 mm Hg over several minutes. What do you think?

UBP Answer: Complete answer is found in the UBP Practice Set #2

4) You look at the CVP and notice it is elevated. What do you think?

UBP Answer: Complete answer is found in the UBP Practice Set #2

5) The patient is in atrial fibrillation. Why are post-thoracotomy patients at increased risk of developing supraventricular tachycardia?

UBP Answer: Complete answer is found in the UBP Practice Set #2




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