Clinical Case

[anes_asmaj]

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I like reading some the clinical case trends (even if I don't completely understand them), so I thought I would post some from the residency program at my school.

1. (CA-1, 2, or 3) Tamponade: A 38-year-old woman is brought to OR for pericardial window and possible pericardectomy to treat a malignancy-induced tamponade. BP 85/55, P 98, CVP 22. Discuss your assessment of patient prior to anesthesia. Assuming pericardiocentesis unsuccessful and patient receiving dopamine at 8 meg/kg/min, how would you induce anesthesia? What are likely causes of hypotension during anesthetic induction? Should the trachea be intubated? Why/why not? Would laryngeal mask airway suffice? Why/why not? Should spontaneous ventilation be maintained?Why/why not?

2. (CA-2 or 3) Acute pain: You are consulted to provide pain relief for a 78-year-old man who fell and broke 4 ribs. He is now splinting his chest and not coughing while in the ICU. He has stable angina for which he takes atenolol and nitropaste daily. The surgeons request an epidural catheter. Is this reasonable? Advantages/disadvantages over PCA? Over intrapleural analgesia? Advantages/disadvantages of lumbar vs. thoracic catheter? What opioid? Why?

 

[VentdependenT]

1.
-uhh, local and go. Drain the thing first. Then we can go ahead and "induce."

What are likely causes of hypotension during anesthetic induction? Drop in preload from PPV and the vasodilation/catecholamine drop from induction drugs. Tank em up first. SV is fixed. If preload drops you're hosed. So, like I said, tank em up.

Should the trachea be intubated?
Depends. Are these people doing a sternotomy for the malignant pericardial removal or are they just tapping it. Like I said, drain it first then tube patient. If we need to go sternotomy first (for whatever reason, vascular tumor, inexperienced surgeon, fearful academician) breath em down, give a squirt of whatever (fancy written academic answer= ketamine), stick in tube. Put on Pressure Support. Have pressors and inotropics ready.

Would laryngeal mask airway suffice? If they aren't going to do a stenotomy yes. Despite what surgeon may think a pericardiocentisis can, and for a reason like this, should be done under local.

Should spontaneous ventilation be maintained? Until extraluminal pressure can be relieved, yes. See above.




2. (CA-2 or 3) Acute pain: You are consulted to provide pain relief for a 78-year-old man who fell and broke 4 ribs. He is now splinting his chest and not coughing while in the ICU. He has stable angina for which he takes atenolol and nitropaste daily. The surgeons request an epidural catheter. Is this reasonable? Advantages/disadvantages over PCA? Over intrapleural analgesia? Advantages/disadvantages of lumbar vs. thoracic catheter? What opioid? Why?[/QUOTE]

PCA and call it a day. I aint sticken a needle in this old dudes back after a fall. PCA is equal in terms of pain control. Perhaps decrease in morbidity but not mortality. Early ambulation to cut down on dvt.