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Oral case 49

Created: 5/10/2004

A 32-year old with a 35-week pregnancy is scheduled for a semi-urgent cesarean section due to preeclampsia. She has type I diabetes mellitus for which she takes 40 U insulin in the morning. She is receiving a magnesium sulfate infusion, and intermittent doses of intravenous hydralazine. Her deep tendon reflexes are 3+. Blood pressure is 160/110 mmHg, pulse is 105, respirations are 26, temperature is 36.7, glucose is 250, BUN is 28, and creatinine is 1.3.

 Preoperative evaluation

I. Preeclampsia

1. What are the proposed mechanisms for the development of pre-eclampsia?

2. What are the risks to the mother and to the fetus?

3. Is this patient adequately treated? Explain.

4. What clinical signs can be used to clinically assess magnesium levels?

II. Hypertension

1. What is the etiology of the hypertension?

2. How would you manage the hypertension?

3. Is nitroprusside appropriate?

III. Renal function:

1. Is her renal function normal? Explain.

2. What may cause increased BUN and creatinine?

3. Are her volume status and renal perfusion adequate? Explain.

IV. Diabetes

1. Is her diabetes well controlled?

2. Do you desire further evaluation?

3. Would you give this patient preoperative insulin?

B. Intraoperative course

I. Monitors

1. What monitors would you institute before anesthesia?

2. Is a pulmonary artery catheter indicated? Explain.

3. How would you evaluate volume status?

4. How would you evaluate renal perfusion?

 Choice of anesthesia

1. Would you choose epidural anesthesia? Why or why not?

2. If not, what is your choice?

3. What is the significance of her preeclampsia to your choice?

4. What is the significance of her diabetes to your choice?

III. General anesthesia

1. The patient desires to be asleep. She has been NPO for six hours. How would you induce anesthesia?

2. What agents would you use for induction?

3. What agents would you use for intubation?

4. How will you maintain anesthesia?

5. What is the implication of magnesium therapy to your choice of muscle relaxants?

6. Would you continue the magnesium into the operating room?

IV. Neonatal resuscitation

1. The baby is delivered with poor muscle tone, no spontaneous respiration, and a pulse of 84 bpm. Another anesthesiologist can watch the mother. What is your priority in managing the newborn?

2. Would you give bicarbonate?

3. Would you give glucose?

4. What laboratory tests would you desire? Explain.

 Postoperative care

I. Failure to awaken

1. Twenty minutes after reversal of muscle relaxant, and ten minutes after anesthesia is stopped, the patient remains unresponsive and without spontaneous respiration. What is the cause?

2. How would you treat this patient?

II. Oliguria

1. The patient's urine output is 15 ml/hour for the first two hours in recovery. How would you assess this?

2. What are likely causes?

3. What is your management?

III. Seizure

1. Three hours after surgery, the patient has a grand mal seizure. Why?

2. What is your management?

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