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UBP Question 8

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Question 8


(Short Form)


A 48 year-old obese male is scheduled for elective uvulopalatopharyngoplasty (UPPP). The patient has a history of 12 months progressive weight gain (85 pounds) and excessive daytime somnolence. His wife reports extremely loud snoring at night with agitation and confusion upon waking. He lives a sedentary lifestyle and has significant dyspnea with exertion. Past medical history includes uncontrolled hypertension, hypothyroidism, hiatal hernia, and depression. Medications include HCTZ, lisinopril, synthroid, prevacid, and zoloft. Vital Signs: Weight = 104 kg, height = 172 cm, BP = 165/90 mmHg, HR = 86 bpm. Polysomnography (sleep studies) revealed 280 episodes of apnea or hypopnea lasting greater than 10 seconds, recorded over an eight hour period of sleep.


Pre-operative Management


1) What is the significance of his polysomnography study results?

UBP Answer: Complete answer is found in the UBP Practice Set #4

2) What is the difference between obstructive sleep apnea (OSA), obstructive sleep hypopnea syndrome (OSH), obesity-hypoventilation Syndrome (OHS), and Pickwickian syndrome?

UBP Answer: Complete answer is found in the UBP Practice Set #4

3) Would you administer anesthesia for this surgery at an outpatient surgery center?

UBP Answer: Complete answer is found in the UBP Practice Set #4

4) How would you evaluate this patient’s cardiac status? Does he need further testing?

UBP Answer: Complete answer is found in the UBP Practice Set #4

5) What cardiac abnormalities would you expect to find in someone with long standing obstructive sleep apnea (OSA)?

UBP Answer: Complete answer is found in the UBP Practice Set #4

6) How would you evaluate this patient’s airway?

UBP Answer: Complete answer is found in the UBP Practice Set #4

7) The patient is extremely anxious and starting to hyperventilate. The nurse wants to know if she can administer preoperative midazolam. What do you think?

UBP Answer: Complete answer is found in the UBP Practice Set #4

(Long Form)



A 48 year-old obese male is scheduled for elective uvulopalatopharyngoplasty (UPPP). The patient has a history of 12 months progressive weight gain (85 pounds) and excessive daytime somnolence. His wife reports extremely loud snoring at night with agitation and confusion upon waking. He lives a sedentary lifestyle and has significant dyspnea with exertion.


PMHx: HTN
Hypothyroidism
Hiatal hernia
Depression

Meds: HCTZ, lisinopril, synthroid, prevacid, and zoloft

Allergies: Sulfa

PE: Vital Signs: Wt = 104 kg, height = 172 cm, BP = 165/90 mmHg, HR = 86 bpm
Airway: Mallampati III, short neck, micrognathia, full cervical range of motion
CV: Loud second heart sound (P2)
Lungs: Decrease breath sounds bilaterally, no wheezing

Labs: Hgb = 19 gm/dL; K = 3.8 mEq/L

EKG: Right axis deviation, possible LVH

ECHO: Enlarged right ventricle, right ventricular systolic pressure > 40 mmHg

Polysomnography: 280 episodes of apnea or hypopnea lasting greater than 10 seconds, recorded over an eight hour period of sleep.


Intra-operative Management


1) Which monitors would you place for this case?

UBP Answer: Complete answer is found in the UBP Practice Set #4

2) What is your plan for intubation?

UBP Answer: Complete answer is found in the UBP Practice Set #4

3) The patient, who would rather be asleep for intubation, tells you that he was successfully intubated under general anesthesia two years ago, without any problems. What would you say to him?

UBP Answer: Complete answer is found in the UBP Practice Set #4

4) What type of endotracheal tube would you place? What does UPPP surgery involve?

UBP Answer: Complete answer is found in the UBP Practice Set #4

5) After successful awake intubation the surgery begins. How would you maintain anesthesia for this case?

UBP Answer: Complete answer is found in the UBP Practice Set #4

6) Assuming the surgeon is planning on using a laser for the procedure, would you use an oxygen/nitrous oxide mixture?

UBP Answer: Complete answer is found in the UBP Practice Set #4

7) Does the dosing of intravenous anesthetic agents need to be adjusted due to the patient’s obesity?

UBP Answer: Complete answer is found in the UBP Practice Set #4

8) Suddenly the airway pressure alarm goes off and the bellows do not fill in between breaths. What do you think is going on?

UBP Answer: Complete answer is found in the UBP Practice Set #4

9) The surgeon reports that he has accidentally cut a hole in the endotracheal tube and there is a large leak in the oropharynx. What would you do?

UBP Answer: Complete answer is found in the UBP Practice Set #4
10) After a brief episode of hypoxia, you successfully exchange the ETT over an exchange catheter. The hypoxia resolves, but the blood pressure is now 66/31 mmHg. What is your differential diagnosis?

UBP Answer: Complete answer is found in the UBP Practice Set #4

11) The patient’s ECG tracing shows the following:


What would you do?
UBP Answer: Complete answer is found in the UBP Practice Set #4
12) Could you administer Amiodarone for pharmacologic cardioversion?
UBP Answer: Complete answer is found in the UBP Practice Set #4

Post-operative Management

1) How would you manage post-operative pain in this patient?

UBP Answer: Complete answer is found in the UBP Practice Set #4

2) After successful extubation the patient is taken to the PACU. How would you monitor this patient’s respiratory status post-operatively and when would you consider it safe to discharge him home?

UBP Answer: Complete answer is found in the UBP Practice Set #4

3) 30 minutes later you are called stat to the PACU where you find the staff attempting to mask ventilate your patient. He is hypoxic with a SaO2 of 78%. What would you do?

UBP Answer: Complete answer is found in the UBP Practice Set #4



4) Bag mask ventilation is ineffective, intubation attempts are unsuccessful, and he has become bradycardic. What would you do?

UBP Answer: Complete answer is found in the UBP Practice Set #4

5) After successful tracheostomy and resuscitation, the patient remains mildly hypoxic with a SaO2 of 89% while breathing 100% oxygen. What do you think is going on?

UBP Answer: Complete answer is found in the UBP Practice Set #4

6) Physical exam reveals diffuse pulmonary crackles and CXR shows generalized pulmonary edema that was not present preoperatively. What could have caused this?

UBP Answer: Complete answer is found in the UBP Practice Set #4

7) Assuming this were negative pressure pulmonary edema, how would you manage his condition?

UBP Answer: Complete answer is found in the UBP Practice Set #4



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