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Oral case 86

Created: 3/11/2004

A 55-year old 62 kg woman who has severe asthma with audible wheezing is scheduled for total abdominal hysterectomy for cancer. She is on aminophylline and uses albuterol inhaler also. Blood pressure is 160/80 mmHg, pulse is 110 bpm, respirations are 18, temperature is 99 degrees Fahrenheit, and hemoglobin is 9.5

 Preoperative Evaluation

I. Evaluation of asthma

1. Are pulmonary function tests indicated preoperatively? Why or why not?

2. Arterial blood gas shows pH=7.39, paCO2 =48 mmHg, and paO2=65mmHg. What is your interpretation?

3. Would you want further preparation as a result of these data?

II. Chronic drug therapy

1. Is a preoperative theophylline level required? Why or why not?

2. What interactions do aminophylline and albuterol have with anesthetic drugs?

III. Anemia

1. Does she need a preoperative blood transfusion? Explain the factors you use in reaching a decision.

2. How do you evaluate her preoperative blood volume?

3. How do you evaluate her preoperative pulmonary status?

 Intraoperative Course

I. Monitors

1. Would you place an arterial catheter? Why or why not?

2. Would pulse oximetry and oxcillotonometry be equally acceptable? Explain your choice and your rationale.

II. Choice of anesthesia

1. Would you use epidural anesthesia for this case? Why or why not?

2. The patient insists on being asleep. What is your response?

3. Would you use an intravenous or an inhalational induction?

4. Discuss pros and cons of a thiopental induction.

5. What are other options for induction? Explain your rationale.

6. Would you maintain anesthesia with a nitrous/narcotic technique, or a volatile agent? Explain your rationale.

III. Muscle relaxation

1. Would you use one muscle relaxant for intubation and another for maintenance? Explain.

2. Would you choose a succinylcholine infusion, or a non-depolarizing relaxant for this three-hour case? Explain.

3. Is d-tubocurarine an appropriate relaxant for this case? Why or why not?

4. What is the comparative pharmacology?

IV. Decreased compliance

1. Immediately after intubation, the peak airway pressure is 40 cm H2O and the tidal volume is 600 ml. What is the significance of this?

2. What are your next steps?

 Postoperative Care

I. Postoperative monitoring

1. After the anesthetic is complicated only by bronchospasm on intubation, you decide to place the patient in the intensive care unit for twenty-four hours. The surgeon wants to know why you want to do this. Your reply?

2. What are your principles of pulmonary management?

II. Postoperative pain relief

1. Are epidural narcotics indicated?

2. Compare epidural narcotics with the intravenous and intramuscular routes.

3. Are epidural narcotics safer than an intercostal block with bupivacaine?

4. Compare monitoring requirements.

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