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Oral case 80

Created: 3/11/2004

A 52-year old 70 kg man is scheduled for an inguinal hernia repair. Four months ago, he had a myocardial infarction, but is now free of angina. He has moderate hypertension and is on hydrochlorothiazide 50 mg qd, and propranolol 50 mg qid. Blood pressure is 150/90 mmHg, pulse is 80 bpm, and respirations are 12.

 Preoperative Evaluation

I. Evaluation of hypertension

1. Is this patient's blood pressure adequately controlled?

2. Does it need further evaluation?

3. How would you further evaluate?

4. Describe the purpose of the autonomic nervous system.

The autonomic nervous system controls involuntary physiologic reflexes to maintain homeostasis. It innervates the heart, lungs, endocrine and exocrine glands, the central nervous system, the gastrointestinal and genitourinary systems, and regulates temperature and metabolism. It is composed of the sympathetic and parasympathetic systems, with the sympathetic system being responsible for the "fight or flight" response. The parasympathetic system has opposing effects.

5. What is the anatomy and physiology of the sympathetic nervous system?

The sympathetic system has preganglionic fibers from the thoracic and lumbar spinal cord, which originate from the intermediolateral columns. They synapse on either prevertebral ganglia, a terminal ganglion, or the paired paravertebral sympathetic chain. These preganglionic fibers release acetylcholine which stimulates postganglionic nicotinic receptors, and may ascend or descend the sympathetic chain before synapsing. The postganglionic neurons release norepinephrine.

4. What is the mechanism of action of propranolol and hydrochlorothiazide?

5. What are the side effects of each?

6. Are these of concern for anesthesia? Why or why not?

II. Significance of prior myocardial infarction

1. What is the risk of reinfarction?

2. What is the mortality?

3. Should this patient have a preoperative stress test?

4. Should surgery be delayed?

5. Until when would you delay the case?

III. Premedication

1. The patient asks to not have any recall about the surgery. What options do you have?

2. How does lorazepam differ from diazepam?

 Intraoperative Course

I. Choice of anesthetic technique

1. Discuss advantages and disadvantages of regional vs local vs general for this case.

2. You select a continuous epidural. Which drug will you use?

3. Will you give epinephrine with the local anesthetic?

4. How would you recognize intravascular injection?

5. Do cardiac effects of local anesthetics alter your choice? Why or why not?

6. How would your choice be altered?

II. Monitoring techniques

1. What are your minimum monitoring requirements?

2. You choose not to have a pulmonary artery catheter. What does the central venous pressure tell you?

3. Discuss lead V5 vs Lead II. 4. Would you use the same monitors whether regional or general was being used? Explain.

III. Intraoperative angina: diagnosis and treatment

1. The patient develops angina and ST segment elevation is noted intraoperatively. What is your diagnosis?

2. What is your treatment?

3. What is the role of nifedipine vs nitroglycerine?

4. What is the mechanism of action of nitroglycerine?

It penetrates the vascular endothelium and forms nitric oxide, which binds to the enzyme guanyl cyclase, forming cyclic guanine monophosphate, which causes relaxation of vascular smooth muscle. Its most prominent effect is on venous capacitance vessels.

4. The patient develops multiple premature ventricular contractions, and ventricular fibrillation ensues. What is your immediate management?

5. What is your subsequent management?

IV. Management of restlessness

1. The patient becomes very restless during the procedure. The surgeon suggests light general anesthesia by mask. Do you agree? Why or why not?

2. What is your differential diagnosis?

3. How would you treat this patient? Explain your rationale.

 Postoperative Care

I. Postoperative hypotension: management

1. Upon arrival in the recovery room, blood pressure is 80/50 mmHg, and pulse is 40 bpm. Why?

2. What is your differential diagnosis?

3. What is your treatment?

II. Persistent epidural block: management

1. After three hours, no change in the degree of blockade is evident. Are you concerned?

2. What is your differential diagnosis?

3. How would you diagnose an epidural hematoma?

4. How would you treat an epidural hematoma?

III. Management of sheared catheter

1. When the epidural catheter is removed, a portion of the tip is missing. What do you do?

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