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Oral case 141

Created: 27/3/2005

A 19-year-old 60 kg woman is scheduled for debridement and open reduction, internal fixation of a left mid-femoral compound fracture sustained in a car accident. She is 28 weeks pregnant, awake and alert. She complains of a headache, and has bruises on her face and chest. Her blood pressure is 100/70 mmHg, pulse is 115 bpm, respiration rate is 20 breaths per minute and her haematocrit is 37.

 Preoperative evaluation

I. Cardiovascular status

1. Her haematocrit was 43 one year ago. What is your interpretation of her current level?

2. What effects does pregnancy have on the haematocrit?

3. What effects does the fracture have on the haematocrit?

4. Is she hypovolaemic?

5. How would you determine if she is hypovolaemic?

6. Is an electrocardiogram necessary?

7. There are unifocal premature ventricular contractions on the electrocardiogram, and the cardiologist suggests the diagnosis of cardiac contusion. Would you perform further studies?

II. Ventilatory status

1. What is the significance of her chest bruises?

2. How would you assess mediastinal and thoracic injury?

3. The chest radiograph shows a less than 10% pneumothorax. Is a preoperative chest tube indicated?

4. Are pulmonary function tests needed? Which of these would you perform?

5. Would you obtain an arterial blood gas measurement?

6. How will these data alter your management?

III. Foetal status

1. What are your concerns about the foetus?

2. Would you call the obstetrician to evaluate the patient preoperatively?

3. How will this information affect your management?

 Intraoperative course

I. Maternal monitoring

1. Is a central venous catheter indicated? Explain.

2. Are pulse oximetry and end-tidal CO2 satisfactory substitutes for arterial blood gases?

3. Would you use an arterial line?

4. What are the benefits versus the risks of an arterial line?

II. Anaesthetic choice

1. Is regional preferable to general anaesthesia for the foetus?

2. Is regional preferable to general anaesthesia for the mother?

3. Is spinal anaesthesia appropriate?

4. The patient insists on a general anaesthetic. What are the risks to the foetus?

5. Is the use of nitrous oxide acceptable?

6. Which airway protection techniques would you use?

7. Discuss the use of ketamine versus thiopental versus etomidate for induction.

III. Foetal monitoring

1. Will you monitor the foetus?

2. If so, how would you monitor the foetus?

3. The foetal heart rate decreases from 140 to 120 bpm during anesthetic induction. What is your interpretation?

4. The foetal heart rate decreases to 80 bpm. Are you concerned? Explain.

5. How would you treat this foetal bradycardia?

IV. Hypotension and poor ventilatory compliance

1. Thirty-minutes after induction, hypotension and poor ventilatory compliance occur. What is your differential diagnosis?

2. What is your management of each differential?

3. Oliguria follows. What is the aetiology?

4. What is the treatment?

 Postoperative care

I. Premature labour

1. Abdominal pain with evidence of uterine contraction is observed. What tocolytic treatment would you give?

II. Pain treatment

1. The patient complains of severe leg pain. What is your treatment plan, in light of the pregnancy?

2. Are epidural and systemic opioids equally satisfactory?

3. What are the effects on the foetus?

III. Confusion, agitation and hypoxaemia occur six hours postoperatively

1. What is your differential diagnosis?

2. Discuss your treatment of aspiration and fat embolus.

3. Would you reintubate this patient? Explain.

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