Medical brain notes 7

  Clinical cases In the following eight cases, we briefly describe anesthetic approaches, issues, and some potential complications. The reader will find many of the points discussed in the first two sections in the management of these cases. An alternative is a problem-oriented approach, namely first to read the cases and then, primed with many questions, delve into the first two sections. Clinical talk teems with acronyms. Some abbreviations used throughout the cases include: ABG: arterial blood gas. ABP: arterial blood pressure (from an invasive arterial catheter). ACE: angiotensin-converting enzyme. ACT: activated clotting time. Airway: read the Airway evaluation chapter to understand the examination. aPTT: activated partial thromboplastin time. ASA: American Society of Anesthesiology physical status classification. BIS: bispectral index. BP: blood pressure. BUN: blood urea nitrogen. CPAP: continuous positive airway pressure. CPP: cerebral perfusion pressure. Cr: creatinine. CV:...

  Breast biopsy under conscious sedation The following case will emphasize conscious sedation and its potential complications. Learning objectives: ·             general pre-operative evaluation ·             sedative agents ·             respiratory depression: detection, management ·             mask ventilation ·             laryngeal mask airway ·             reversal of sedation. The patient, a 40-year-old and otherwise healthy woman, comes for breast biopsy. This procedure is usually performed in two stages: first a radiologist places a nee-dle percutaneously into the lump. Next, the patient reports to the operating room for removal of the lump, pathol...

  Carpal tunnel release under Bier block The following case will describe the use of intravenous regional anesthesia. Learning objectives: ·             pre-operative management of the asthmatic patient ·             intravenous regional anesthesia ·             local anesthetic toxicity ·             intra-operative bronchospasm. A 50-year-old asthmatic woman comes for carpal tunnel release. This minor procedure is usually performed as an outpatient. That is, the patient comes in the day of surgery, and returns home afterward. History. She has frequent painful tingling of her right hand, consistent with carpal tunnel syndrome. Her past medical history is significant only for asthma since childhood. The asthma is controlled with albuterol metered dose inhaler (MDI) ...

  Cataract removal under MAC The following case will describe the use of monitored anesthetic care (MAC). Learning objectives: ·             pre-operative management of the elderly patient ·             methohexital ·             oculo-cardiac reflex. An 85-year old woman comes for removal of a cataract. History. She has suffered significant visual loss from the cataract. Her past medical history reveals that she has given birth to four children and that she had an uncomplicated chole-cystectomy under general anesthesia 40 years ago. She has no family history of anesthetic complications. She takes no medications, has no allergies and does not smoke. She drinks wine socially. Physical examination reveals: African American woman in no acute distress; weight 65 kg; height 5 2  (155cm) BP 150/90 mmHg; HR 90 beats/min; ...

  Cesarean section under regional anesthesia The following case will emphasize regional anesthesia and obstetric issues. Learning objectives: ·             reflux: risks, prevention ·             physiology: fluid dynamics ·             neuraxial anesthesia: technique, epidural hematoma risk, hypotension risk ·             vasopressors: ephedrine vs. phenylephrine ·             neuraxial opioids: pros/cons, risks. A 28-year-old primiparous (first baby), pre-eclamptic woman requires a cesarean section for breech presentation of a 38-week fetus. History. She had a normal prenatal course. This morning she complained of headache, blurred vision and swelling in her face, feet and hands. She is hypertensive, has prote...