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Final clinical long case 63

Created: 6/9/2018
A 64-year-old man presents for thoracic spine surgery. He has a history of hypertension and has recently been treated by his GP with antibiotics for a cough. He also reports having been very sick on morphine in the past.

Drug history

Pulse: 75 bpm
Blood pressure: 108/50 mmHg
Auscultation: widespread crepitations.
Blood results: urea 25 mmol/L, Creatinine 156 µmol/L, K+ 5 mEq/L, Na+ 151 mEq/L, Hb 12.1 g/dl, white cell count 12 × 109/L, glucose 14 mg/dl, with raised neutrophils.
Arterial blood gases (on air): mixed acidosis with normal anion gap
Pulmonary function tests: peak expiratory flow rate and forced vital capacity (FVC) low, but within normal range; forced expiratory volume in one second (FEV1) 1.8 L; FEV1/FVC 43%
Chest X-ray: shows hyperinflated lungs with consolidation right lower lobe
ECG: sinus rhythm, left-axis deviation, first-degree heart block.

1. Summarise the case.
2. Discuss his arterial blood gas results. What are the causes of metabolic acidosis and what is the likely cause in this case?
3. What are the causes of acute renal failure? What do you think is the most likely cause in this case?
4. Discuss his ECG. Does first-degree heart block concern you?
5. What do his lung function tests show?
6. How would you optimise his chronic obstructive pulmonary disease treatment preoperatively?
7. How would you manage this case?
8. Assuming that he is now optimised from his recent chest infection, discuss your induction and airway management.
9. How do you insert a double lumen tube?
10. What type and size of tube would you use?
11. If he desaturated during the surgery, how would you manage this?
12. What would be your plan for analgesia?
13. What would be your plan postoperatively?
14. What would inform your decision about whether to extubate him or keep him ventilated?

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