Case Week 2 (w/c 10/10/11)
You have been asked to give an anaesthetic to a 32 year old female for a breast biopsy. There is a strong family history of breast Ca. She has mild asthma and uses her inhalers daily.
What is your default technique for this?
Keep your answers brief initially. More information regarding the case will be available once we have had some replies & remember the aim is to educate trainee anaesthetists.
Don’t forget to use #gasclass in your reply. (You can keep track of the discussion by searching for #gasclass!)
Additional case details
You make a preoperative visit to the patient. She tells you that about 2 weeks ago she had an URTI for which she required more use of her “blue” inhaler. She now feels much better and her inhaler use is back to normal.
Will any of the above change your plan? Explain with provisos if necessary
Final additional details
She gives a history of daily reflux, worse recently. She is on no anti-reflux medication She has a BMI of 32.
Would this information change your plan? What features of reflux would make you change your plan?
Summary of Comments
Cases similar to this are undertaken on a regular basis.
The case illustrates that anaesthetists need to keep an open mind when making an anaesthetic plan and that further information may require them to change from their “standard” technique for the procedure.
The majority of people felt that initially keeping it simple with spontaneous ventilation via a LMA was apropriate.
There was a discussion regarding the choice of volatile for maintenance of anaesthesia. This led on to how low can you go? (with regards FGF) cost of volatiles added into the equation.
The addition of the recent URTI – most stuck with their original plan of LMA / SV but most wanted to ensure that the asthma was improved and that the patient was “optimised” – preop nebuliser in some cases, there was concern regarding PONV and Dexamethasone seemed to be the clear winner here in its use as an antiemetic. Discussion regarding other agents which could potentiate histamine release.
The final information regarding her severe reflux ensured a chnage of view in the vast majority of contributors – ETT rather than LMA although a suggestion was made of the pro-seal LMA. How do we go about securing the airway. The jury is out – RSI with Thiopentone/Suxamathonium or Propofol/Rocuronium. However more discussion regarding PONV. The final thoughts were was the asthma truly astma or a manifestation of her reflux… we will never know.
Thank you once again for your contributions this week.