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Final clinical long case 22

Created: 25/10/2007
A 75-year-old female presents for elective fixation of C3 and C5. She has a history of rheumatoid arthritis. Over the past 6 months she has complained of weakness in the right leg and both hands.

Diclofenac and prednisolone.

Blood pressure: 190/80 mmHg
Heart rate: 84/min
Lung function test: Reduced FRC and FEV1 to about 45% predicted. She also has a restrictive picture
Full blood count: Mild anaemia and elevated mean cell volume
Arterial blood gases: Mild respiratory alkalosis; nothing significant
Urea and electrolytes: Elevated urea; no other derangements.
Chest X-ray: Hyperinflated, right basal consolidation, trachea deviated to the right side.

1. Summarise the case.
2. What are the anaesthetic considerations in rheumatoid arthritis.
3. Give a detailed analysis of investigations, especially the chest X-ray.
4. What would be your anaesthetic management?
5. What drugs would you give the patient?
6. Discuss your airway management, giving detailed discussion of asleep fibreoptic intubation.
7. Discuss the positioning considerations.
8. What blood pressure would you be happy with intraoperatively?
9. Describe your fluid management for this patient.
10. How would you extubate this patient? What postoperative respiratory support should be given?
11. Discuss high-dependency unit/intensive care unit care.

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