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Final clinical long case 39

Created: 25/1/2012
A 60-year-old man is undergoing right radical nephrectomy for renal cell carcinoma; there is no evidence of metatastic disease. He is a life-long smoker (he smokes 20 cigarettes/day) and has chronic obstructive pulmonary disease. He is currently having haemodialysis. He has had a recent episode of chest pain.

Frusemide 500 mg
Perindopril 4 mg
Glyceryl trinitrate spray

Weight: 88 kg
Height: 170 cm
Pan systolic murmur, wheeze bilaterally
Full blood count (FBC): Hb 9.1 g/dl; mean cell volume, white cell count and platelets normal
Urea and electrolytes (U+Es): Na+ 141 mEq/L; K+ 4.4 mEq/L; Urea 25 mmol/L; Creatinine 534 µmol/L
Liver function tests: Normal
Glucose: Normal (random)
ECG: Atrial pacing, 80 bpm with left bundle branch block
Chest X-ray (CXR): right internal jugular line and a dialysis line in situ, dual chamber pacemaker wires in place; cardiomegaly
Pulmonary function tests (PFTs): FEV1/FVC 54%; reduced transfer factor


1. Summarise the case.
2. Discuss the patient’s demographics.
3. Discuss his FBC, U+Es, ECG, CXR and PFT’s and their significance.
4. What are the causes of anaemia in chronic renal failure, and what is the treatment?
5. Discuss the patient’s cardiovascular, respiratory and renal history and how this would affect your management.
6. What investigations would you carry out preoperatively?
7. You are shown an echocardiogram for this patient, which shows an ejection fraction of 60%, with no valve abnormality. How would this information affect your anaesthetic management?
8. Discuss left ventricular impairment, stress testing and optimisation.
- Discuss the timing of dialysis preoperatively, the pacemaker check, autonomic neuropathy, and drug handling.
9. How would you anaesthetise this patient?
10. What are the advantages/disadvantages of a high-dependency unit bed, lines, epidural in this patient?
11. Discuss intercostal and paravertebral nerve block, including induction, positioning on the table,thermoregulation and DVT prophylaxis
12. What are the alternatives to non-regional analgesia techniques in chronic renal failure?
13. Discuss epidural insertion and the timings of low-molecular-weight heparin and unfractionated heparin administration (take into account the need for dialysis).

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