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Oral case 70

Created: 11/10/2004

A 45-year old 110 kg man is scheduled for emergency surgery for removal of a piece of metal from his right eye. Past medical history is significant for recurrent asthmatic episodes, for which he is currently on aminophylline. He ate dinner two hours prior to his accident. Blood pressure is 140/90 mmHg, pulse is 100 bpm, oral temperature is 37 degrees centigrade, and hematocrit is 45 gm/dl.

 Preoperative evaluation

I. Respiratory evaluation

1. Why is the history of asthma of concern to you?

2. What are the long-term pulmonary effects of asthma?

3. What laboratory tests would you order to help evaluate pulmonary status?

4. Would you give more aminophylline preoperatively?

5. How would you decide whether or not to give more beta agonist?

6. Would you give other bronchodilators preoperatively?

7. Would it make a difference if this patient were wheezing preoperatively?

 Intraoperative course

I. Management of anesthesia

1. What are your major concerns in planning induction?

2. For an awake intubation vs a rapid sequence: which drugs would you avoid? Why?

3. What other alternatives are there?

4. Discuss the use of hyperventilation.

II. Maintenance

1. Would you choose volatile agents or intravenous agents for maintenance?

2. What are the effects of each on the bronchi and intraocular pressure?

3. Discuss the interaction of volatile agents with aminophylline.

4. What is the mechanism of action of aminophylline?

5. Does obesity influence the choice of maintenance drugs? Explain.

6. Are muscle relaxants necessary?

7. Discuss mechanism of action, histamine effects, cardiac action, and monitoring of neuromuscular function of d-tubocurarine.

8. Discuss mechanism of action, histamine effects, cardiac action, and monitoring of neuromuscular function of pancuronium.

9. Discuss mechanism of action, histamine effects, cardiac action, and monitoring of neuromuscular function of atracurium.

III. Selection and interpretation of monitoring data

1. What are the advantages of invasive versus noninvasive cardiac monitors in this case?

2. What is the accuracy of automated blood pressure recorders.

3. How do automated blood pressure recorders work?

4. What complications are associated with their use?

5. Compare side port to main line end-tidal CO2 monitoring.

6. Discuss the correlation of end-tidal CO2 with paCO2.

IV. Assessment and management of bronchospasm

1. The patient develops wheezing while the eye is still opened. What are the hazards?

2. What is your differential diagnosis?

3. What is your treatment?

 Postoperative care

I. Management of extubation

1. A colleague suggests you extubate the patient while he is still deep. Do you agree? Explain your rationale.

2. How does obesity influence your decision?

II. Management of postoperative hypertension

1. In the recovery room, blood pressure is 220/110 mmHg. What is the cause?

2. What is the treatment?

III. Management of postoperative nausea and vomiting

1. The recovery room nurse calls because the patient is nauseated and has vomited twice. Possible causes?

2. Is this hazardous? Explain.

3. What is your treatment?

4. What is the mechanism of action for any drugs you choose?

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