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Oral case 72

Created: 11/10/2004

A 47-year old 80 kg man with a freely refluxing hiatal hernia is scheduled for repair using a thoracoabdominal approach. His past history includes 50 pack years of smoking cigarettes, and one episode of a spontaneous right pneumothorax. Blood pressure is 140/90 mmHg, pulse is 84, respirations are 16, and hemoglobin is 16.

 Preoperative evaluation

I. Assessment of pulmonary status

1. How does smoking affect lung function?
 2. Would you order pulmonary function tests? Explain.
3. Would you order a lung scan? Why or why not?
4. Is it of value to have the patient quit smoking the night prior to surgery? Explain.

II. Implications of freely refluxing hiatal hernia

1. Will this finding influence premedication? Explain.
2. Will this finding influence antacid therapy? Explain.
3. Will this finding influence H2-blocking agents? Explain.

 Intraoperative Course

I. Choice and management of anesthesia

1. Would you do an awake intubation, or a rapid sequence induction?

2. Is it important to avoid increases in blood pressure and heart rate from conscious intubation or rapid sequence? Why or why not?

3. Is a superior laryngeal nerve block indicated?

4. Is a transtracheal block indicated?

5. How is it performed?

6. What is transtracheal ventilation?

It is a non-surgical technique of securing the airway temporarily, if mask ventilation and oxygenation are difficult. A 12 or 14-gauge catheter is connected to a jet ventilator, and oxygen is delivered into the trachea through the cricothyroid membrane, at 50 psi. An inspiratory-to-expiratory ration of 1:4 seconds is used to intermittently deliver oxygen.

7. What are some risks of jet ventilation?

Inability to fully expire, with carbon dioxide retention occurring. Barotrauma occurs, due to high pressures.

6. Is a double lumen endotracheal tube indicated?

7. You decide to use a double lumen tube. Which type would you use? Explain.

8. Would nitrous oxide/narcotic be your choice for maintenance? Why or why not?

9. What is your choice for maintenance? Explain.

II. Management of muscle relaxation

1. Relaxant is needed at the onset, and at closure of the thoracoabdominal incision. What is your choice for blockade?

2. How will you monitor blockade?

3. What are your criteria for recovery of adequate muscular function?

4. What if reversal seems inadequate clinically?

5. Give reasons why inadequate reversal occurs.

6. What would your management be in this case?

III. Intraoperative complications

1. During abdominal exploration, the patient is markedly hypotensive. What is your differential diagnosis?

2. What is your treatment?

3. While the surgeon is working in the chest, the patient's saturation drops to 87%. What is your differential diagnosis?

4. What is your treatment?

 Postoperative care

I. Failure to arouse

1. Despite onset of spontaneous breathing and no residual neuromuscular blockade, the patient is not aroused after discontinuing anesthetic. What is your differential diagnosis?

2. How do you establish a diagnosis?

3. How do you treat?

II. Evaluation of possible myocardial ischemia

1. In the recovery room, the electrocardiogram shows ST segment depression. What immediate steps do you take? Explain your rationale.

2. What is your immediate management if ischemia is established?

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