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Oral case 78

Created: 11/10/2004

A 50-year old 75 kg man is to have right nephrectomy for a malignant neoplasm. He had a carcinoma of the base of the tongue resected two years ago, with resultant loss of jaw and tongue mobility. Other complicating features include a 60 pack-year history of smoking, and "allergy" to novocaine. Blood pressure is 150/90 mmHg, pulse is 72, temperature is 37 degrees centigrade, and hemoglobin is 11 gm/dl.

 Preoperative Evaluation

I. Evaluation of renal function

1. Must renal function be assessed preoperatively? Explain.

2. How do you assess renal function?

3. What is the significance of renal function if creatinine is 3.0 mg/dL?

4. How does this alter your management?

II. Evaluation of the airway

1. How will you assess upper airway adequacy?

2. What is the significance to anesthesia?

3. Does his lung function need assessment?

4. Is assessment necessary due to his smoking history, or because of the nephrectomy? Explain.

5. What pulmonary tests are needed, and why?

III. Assessment of local anesthetic allergy

1. Does this history need to be clarified if you do not plan regional anesthesia? Explain.

2. How would you evaluate this allergy?

 Intraoperative Course

I. Selection and management of anesthesia

1. A colleague suggests avoidance of enflurane. Do you agree? Explain.

2. What agent would you prefer? Explain.

3. Are renal effects of anesthetics of primary importance here?

4. Compare respiratory effects of anesthetics, with relevance to this case.

5. Compare neuromuscular properties, with relevance to this case.

II. Management of the airway

1. You are uncertain of the ability to perform direct laryngoscopy and intubation. How will you proceed with induction?

2. How would you manage awake intubation?

3. Discuss sites of topical and regional blockade.

III. Detection and management of ventilatory problem

1. During operation in the left decubitus position, the patient begins respiratory efforts despite previously adequate anesthesia. What are possible causes?

2. What immediate steps do you take?

3. What further studies do you want?

4. Suppose paO2 is 60 mmHg and paCO2 is 40 mmHg in an FIO2 of 50%. Interpret.

IV. Provision of muscle relaxation

1. Muscle relaxation is inadequate for ureterectomy despite earlier use of pancuronium. How will you proceed?

2. Is the nerve stimulator needed? Why or why not?

3. Does renal status influence your decision? Why or why not?

4. Does renal status assist with reversal? Why or why not?

V. Management of anaphylaxis

1. Shortly after intravenous cephalosporins was given as requested, blood pressure decreases to 50 mm Hg systolic, and heart rate is 90 bpm. Is this due to antibiotic?

2. What are other causes?

3. What is your management?

 Postoperative Care

I. Evaluation of nerve injury

1. The night after surgery, the patient complains of a numb hand, which cannot be extended. How would you localize the deficit?

2. List possible causes.

3. How would you prevent this from occurring?

4. What is your present management?

II. Management of late incisional pain

1. Three months postoperatively, the incision site still is painful. How can you assist with a precise diagnosis and relief of the pain?

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