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Oral case 57

Created: 5/10/2004

A 35-year old 62 kg woman with asthma is scheduled for elective repeat cesarean section. She uses a nebulizer device intermittently for shortness of breath, and now has respiratory wheezes. Blood pressure is 115/60 mmHg. Pulse is 110, respirations are 20, and temperature is 37 degrees centigrade.

 Preoperative evaluation

I. Evaluation and management of pulmonary status

1. What physical findings do you expect?

2. What laboratory tests do you want? Explain.

3. Do you want pulmonary function tests? Explain.

4. How would you prepare this patient for surgery and anesthesia?

5. What are your endpoints in preoperative therapy?

6. What is the significance of preoperative therapy to anesthesia?

II. Physiologic effects of pregnancy

1. What are the physiologic effects of pregnancy?

2. What is the significance of these changes to her lung disease?

3. What effect will this have on her intraoperative course?

B. Choice of anesthetic technique and drugs

1. Would you choose regional or general anesthesia? Explain your choice.

2. What effect does each have on uterine blood flow?

3. What are some special hazards of each technique?

4. What drugs would you use?

5. What effects would these drugs have on the mother and on the fetus? Emphasize the respiratory system in your answer.

II. Management of epidural and complications

1. Soon after drug injection, the mother convulses. What are the causes?

2. What is your treatment?

3. What effect will this have on the cardiovascular system?

4. What effect will this have on fluid management?

5. How will you titrate drugs for this treatment?

6. She has sudden onset of 3 mm ST segment depression. What are the causes?

7. What is your treatment?

III. Intraoperative bronchospasm: management

1. During cesarean section, the patient complains of shortness of breath, and wheezing increases. The paCO2 is 45 mmHg. What other tests do you want?

2. What is your differential diagnosis for wheezing in this setting?

3. How will you manage the wheezing?

IV. Infant resuscitation

1. At one minute, the neonate is blue, gasping, flaccid, areflexic and the heart rate is 90 bpm. What is the Apgar score?

2. What is your treatment?

3. How will you decide whether or not to intubate the trachea?

4. You are unable to pass a nasogastric tube. What is your differential diagnosis?

5. A systolic murmur is audible over the precordium. What is your differential diagnosis?

6. The Apgar is 7 at five minutes. What is the prognosis?

7. What is your management?

 Postoperative care

I. Recovery room protocol

1. What are the indications for discharge after epidural?

2. Must the patient remain in the recovery room until sensation returns? Why or why not?

3. What is the relation of return of sensation to reversal of sympathetic block?

4. How do you test for each of the above?

5. What indications do you use for discharge after general anesthesia?

6. When is the use of naloxone indicated in the recovery room?

7. What are the indications for discharge after use of naloxone?

8. What observation period is appropriate after narcotic reversal? Explain.

II. Management: postoperative spinal complications

1. The initial attempt at epidural anesthesia caused a wet tap. Now, the patient has a headache. What other findings are expected?

2. What is your management?

3. What are the complications of your management?

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