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Final clinical long case 57

Created: 31/7/2015
An elderly man who has undergone left pneumonectomy following tuberculosis in adulthood and a triple-vessel coronary artery bypass graft, and has mild renal impairment presents for elective repair of an 8 cm abdominal aortic aneurysm (AAA). He undergoes a chest CX-ray, pulmonary function tests (PFTs), urea and electrolytes and an ECG.

1. Summarise the case.
2. Discuss renal impairment with respect to AAA repair.
3. Discuss PFTs: interpret values, discuss restrictive versus obstructive lung disease
- What is diffusion lung capacity for carbon monoxide (DLCO)?
- What is the differential diagnosis for a decreased DLCO?
4. Interpret the ECG: what is the significance of the Q wave in V1?
- Is ST elevation present?
- How can an ECG be interpreted when there is altered anatomy post-thoracotomy?
- Discuss cardiopulmonary exercise testing.
- How it is performed?
- Discuss the interpretation of anaerobic threshold.
5. Define METS.
6. What are the benefits and risks of AAA surgery versus conservative medication?
7. What would be your anaesthetic plan (including monitoring?)
- What analgesia would you administer?
- What are the advantages/disadvantages of epidural versus remifentanil infusion?
8. Describe the measurement of central venous pressure.
9. How would you manage an intraoperative anastomotic leak?
10. Discuss the management of hypotension
11. How would you assess and treat coagulopathy?
12. Postoperatively, when would you extubate?

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