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Final clinical long case 42

Created: 8/6/2012
A 68-year-old man presents with chronic renal failure; he is scheduled for nephrectomy for carcinoma of the kidney.

He has a pacemaker, ischaemic heart disease and chronic obstructive pulmonary disease.

Anaemia (haemoglobin 9 g/dl), platelets 130 x 109/L
Significant renal impairment, potassium normal.
ECG: paced, wide QRS
Chest X-ray: pacemaker, single lead, heart slightly enlarged, lung fields unremarkable
Lung function tests: reduced forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) but also a significantly reduced lung transfer factor for carbon monoxide (TLCO).

1. Summarise the case.
2. Discuss the effect of his anaemia on his surgery.
3. What will be the impact of chronic renal impairment on bleeding, and on renal function perioperatively?
4. What does the wide QRS imply?
- Discuss the relevance of the presence of a pacemaker in this case.
- Discuss atrial and ventricular pacing and biventricular pacing.
5. Is the chest X-ray anteroposterior or posteroanterior?
6. Discuss the results of the lung function tests.
7. What further investigations would you carry out?
8. Discuss the following:
  • Dialysis preoperatively 
  • XM and transfusion intraoperatively, monitoring of haemoglobin levels and coagulation intraoperatively 
  • Invasive monitoring 
  • Pacemaker issues 
  • High-dependency unit bed bed – comorbidities, blood loss and coagulation, warming, renal support 
  • Epidural, possible coagulopathy problems, alternative pain relief, importance of respiratory disease in this case 
  • General anaesthetic, filling before induction, induction agent, muscle relaxant 
  • Would you extubate if the patient is warm, stable, not acidotic, and with good respiratory function?

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