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Oral case 109

Created: 19/1/2005

A 65-year-old 100 kg woman is to undergo colon resection for carcinoma. She smokes 40-50 cigarettes daily, and has had recurrent episodes of "asthma". She takes 20 U of NPH insulin each morning for adult-onset diabetes mellitus. The chest radiogram shows mild emphysema. Pulmonary function tests show an FVC of 65%, and FEV1 is 60% of predicted. Blood pressure is 130-170/80-110 mmHg, pulse is 80-95 bpm, respirations are 16, temperature is 37.5 degrees centigrade, hemoglobin is 9%, and blood glucose is 150-250 mg/dl.

 Preoperative evaluation

I. Evaluation of lung function

1. What are causes of "asthma"?

2. How do you decide if it is significant?

3. What is your interpretation of the pulmonary function test?

4. What additional information is needed?

5. What if the patient was wheezing now?

6. Would you postpone the operation for bronchodilator therapy?

7. Would you withdraw the cigarettes? Explain.

II. Diabetes mellitus

1. Is the serum glucose adequately controlled?

2. Is it important to control the glucose preoperatively? Explain.

3. Would you postpone the operation to revise the insulin therapy? Explain.

III. Hemoglobin

1. What is your interpretation of the hemoglobin in light of the lung disease?

2. What are possible causes?

3. Is further workup needed?

4. Would you transfuse the patient preoperatively? Why or why not?

5. A technically proficient surgeon ordered one unit of whole blood as a type and hold. Is this adequate?

 Intraoperative Course

I. Monitoring

1. Would you insert an arterial catheter? Explain.

2. Do transcutaneous oximetry and end-tidal CO2 measurement obviate the need for arterial blood gas analysis? Explain.

3. Would you monitor serum or urine glucose? Explain.

4. What are your goals for glucose control?

II. Anesthesia

1. Is regional anesthesia a good choice? Explain.

2. What is the effect on pulmonary function?

3. The patient prefers to be asleep. Is spinal anesthesia plus a hypnotic agent satisfactory?

4. The patient refuses spinal anesthesia. Is it safe to use thiopental?

5. Does thiopental promote bronchospasm?

6. What is the mechanism?

7. Is halothane/nitrous oxide satisfactory for maintenance?

8. What if aminophylline is given overnight?

9. Is enflurane a better choice?

10. Is nitrous oxide contraindicated in bowel surgery?

III. Wheezing

1. Wheezing is heard via esophageal stethoscope just after tracheal intubation and before incision. What is your differential diagnosis?

2. How do you rule each cause in or out?

3. Will you cancel the case if there is bronchospasm?

4. What is your treatment for intraoperative bronchospasm?

5. What if the heart rate was over 120 bpm after intubation?

6. How do you control the heart rate?

IV. Oliguria

1. 20 ml urine output is noted after 90 minutes and 1100 ml of fluids. What is your differential diagnosis?

2. Would you give more fluids?

3. Would you insert a CVP/SG catheter? Explain.

4. Is a diuretic indicated?

5. Which diuretic would you choose? Explain your rationale.

V. Extubation

1. Would you extubate under deep anesthesia, or when the patient is very awake in the recovery room? Explain.

2. Would you give intravenous lidocaine first? Explain.

 Postoperative care

I. Hypothermia

1. The rectal temperature is 34 degrees centigrade in the recovery room. Is this dangerous? Explain.

2. How would you rewarm the patient?

3. The patient begins to shiver vigorously. Will you treat it? Explain.

II. Pain

1. After extubation, the patient complains of severe back pain.

2. How would you treat it?

3. Are narcotic analgesics contraindicated after colon surgery?

4. Are they contraindicated with chronic obstructive pulmonary disease in the presence of wheezing?

5. Is an epidural narcotic or local anesthetic better? Explain.

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