When someone gives me this type of information I try to elicit the source of the complications but doing this is not always possible.
Todays case:
Essentially healthy 57 yo female with a retroperitoneal mass. She states that she had an aunt die at 47 you during a routine gall bladder case. She doesn't know if it was open or lap. A brother that ended up in the ICU after a routine case. And that she had some difficulty breathing after anesthesia in the past but it didn't warrant an ICU admit. All of these cases were done at a very small rural hospital and the records are unattainable.
What's your thoughts and plans.
I'd take the information in with a grain of salt, albeit with a higher index of suspicion if anything looks weird during the case....unexplained tachycardia, increasing CO2, temp 38.0 with no Bare Hugger, etc.
Probably means diddly squat. But enter the case with
Eyes Wide Open.
If there is pseudocholinesterase deficiency, doesnt really matter in the grand scheme of things. Chances are she's gotta good chance of going to the ICU intubated anyway. Remember, pseudocholinesterase deficiency is highlighted as a major deal in our residency training....but it isnt, really......nobody dies from it in the hands of anesthesiologists....its more of an inconvenience....academic thing to put major stress into residents minds?.....yes....ever really a groundbreaking scenerio?.....no.....patients just need a vent post-op when it's discovered.....then it doesnt happen again. So keep this genetic aberration in perspective.....its just an inconvenience. No more, no less.
Not enough real info to warrant radically changing your anesthetic (to TIVA, for example) in my humble opinion. If you think so, I respect that. I wouldnt.
I'd do the case normally.
Type &
match 4 units prbcs.
Midazolam 2mg, fentanyl 100 ug on the way to the back.
Into the OR. Pre O2, monitors on.
Propofol 100-150 mg.
Lid reflex gone, rocuronium 50 mg.
Tape her eyes.
Think about how great your GRMN investment is doing (
300% beaaatch...geez....thats about sixty large-profit for yours truly!!!!) while you bag for a minute or so.
Tube in. Tape it.
Connect da circuit.
Sevo at 3%, fresh gas flow at 6 liters for the first fifteen minutes. I usta use N20 but now its all oxygen.
Wanna place an A line? Youre justified.
I'd definitely place a subclavian/IJ. You can do it without as long as you have a cuppla big peripherals but with this big surgery, what with the ICU stay etc, the patient will benefit from it.
Position the patient where da surgeon needs her.
If you've placed an A line, draw an H&H to see where you stand.
You can reduce your sevoflurane by now.
Fresh gas flow (all O2....
hey its my case) down to 2L/min.
Update da chart.
Think about ordering fried oysters and crawfish, with a potato salad side, from
The Galley on Metairie Road for dinner.