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Final clinical long case 6

Created: 7/4/2004

A 68-year-old man has an implanted pacemaker and a past history of angina-like chest pain. He also has chronic obstructive pulmonary disease but maintains that he can climb stairs and has a reasonably active life. He has been smoking 20 cigarettes a day for many years. He is scheduled for an elective right nephrectomy for renal cell carcinoma and has recently undergone haemodialysis. He is on perindopril 20 mg once daily, frusemide 500 mg once daily and aspirin 75 mg twice daily. On examination, he has pitting pedal oedema and is wheezing.

The result of investigations are as follows:


– Na+: 138 mEq/L
– K+: 3.5 mEq/L
– Cl–: 110 mEq/L
– Urea: 30 mmol/L
– Creatinine: 524 µmol/L
– Liver function tests: within normal limits (WNL)


– Haemoglobin: 7.5 g/dl
– Haematocrit: 25%
– Platelet count: 227 X 106
– White blood cell count:  5.5 X 106

Pulmonary function tests

– FEV1: 1.8 L
– FEV1/FVC: 55%
– TLCO Within normal limits
– Flow–volume loop: an obstructive pattern loop was provided

Chest X-ray findings

– Implanted pacemaker
– Chronic venovenous haemofiltration (CVVH)
– Right subclavian lines
– Right internal jugular vein central line
– Cardiac/pulmonary fields within normal limits

ECG findings

– Completely paced rhythm 60/min
– Left axis deviation
– Wide QRS complexes >3 mm
– ST elevation with tall T waves in V2-V5


1. Summarise the case
2. What physiological system should be discussed here?
3. The surgeon wants to operate immediately for fear of metastasis if postponed – would you anaesthetise? If not, why not? When would you deem it appropriate to operate? What more information do you require?
4. Discuss the results of all of the investigations above
5. What would be your anaesthetic plan?

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