Term 2 Week 1 (w/c 16/1/12)
Happy New Year to everyone and welcome to our new term.
Firstly, thanks to all those who filled in our short survey. It has been very useful for us to know that we are widely read although we have some shy followers who are reticent about tweeting. For those of you who haven’t filled in our minuscule survey please follow this link
The case for this week
You are asked by the orthopaedic surgeon to see a 71 year old lady who is due to have hand surgery. He has asked you to see her in outpatients with a view to bringing her in the following week for her operation. Setting off towards OPD what thoughts cross your mind?
What do you see as your default anaesthetic technique for hand surgery?
You arrive in OPD to see the patient. The hand surgery is for Dupuytrens contracture which is fairly extensive and disabling in her dominant hand. The reason that the orthopaedic surgeon has asked for you to see the patient is that she was recently admitted with breathlessness and the diagnosis was exacerbation of COPD.
Will this change your anaesthetic plan?
You are now able to see the patient. Your fears about why an orthopaedic surgeon would notice respiratory risk are well founded. On questioning the patient has an exercise tolerance of about 10m on the flat around her bungalow. She takes prednisolone 5mg daily for her chronic obstruction, as well as a full therapeutic set of inhalers.
The F2 has helpfully done some gases on air. pH 7.38, PO2 7.9, PCO2 6.4, Bicarbonate 35
Her CXR has been reported six months earlier as showing bulbous emphysema, with apical bullae
predominating on the side of operation.
Does any of this change your current plan?
It doesn’t look like this changes too much for most people. Those that prefer to choose one technique preferentially still want to choose that. Having consented the patient for your chosen anaesthesia she leaves the clinic.
Sadly the combination of poor mobility, steroids and a fall the following weekend land her on your trauma list with a fractured humerus for a hemiarthroplasty on the same side as her proposed hand surgery.
What will you do now? Your options are looking much more restricted!
Thanks everyone. A good start to the term with 200 or so hits on the blog this week. The general feeling of RA versus GA did not really shift too much across the case study. Those who would be delighted to block for hand surgery were almost equally delighted to opt for regional for shoulder surgery despite, or even because of, the respiratory issues.
The joy of Twitter as a discussion forum is that the experience of the anaesthetist cannot be guessed from the discussion in the way that a departmental meeting may show that those with grey/no hair may have been happier to just get on with a GA.
We hope that this will encourage those who read the discussion, but don’t Tweet, to join in and especially ask questions of the proponents. If you haven’t already completed the micro survey please link here.
Transcript #gasclass – Term 2 Week 1
See you next week.
There are no trick questions on #gasclass. It is an educational tool only so please feel free to join the conversation. Remember to include the phrase #gasclass in your response. This is referred to as a ‘hashtag’ and you can easily follow the conversation by searching for ‘#gasclass’ in your twitter client.