Term 2 Week 2 (w/c 23/01/12)
Welcome to Week 2 of the new term.
This weeks case takes gasclass to a new surgical specialty.
You have been asked by a Urologist to assess a 70 year old man who requires a PCNL for a large renal stone. You have arranged to see the man when he attends for pre-assessment.
What thoughts cross your mind and what would be your default anaesthetic technique for this type of surgery?
You arrive at the preassessment clinic. The man has been under the care of the Urologist for 15 months. At his last pre-assessment visit it was identified that he had severe mitral regurgitation and pulmonary hypertension. Further cardiological intervention is planned but only after the renal stone is removed. He is breathless on walking from the waiting room to the clinic room. A CT of his thorax has shown “widespread emphysema”
A chest x ray was performed before you arrived. His oxygen saturations are 94% on room air.
What are you thinking now? How does this change your anaesthetic plan?
His additional investigations are as follows:
ECG – AF U&E Na137 mmol/l K5.5 mmol/l Ur11.0mmol/l Cr 81 nmol/l Pro-BNP 21
Following a long discussion regarding the risks you agree to anaesthetise him. He receives a standard GA and has both arterial and CVC monitoring instigated.
Do you insert the invasive monitoring pre or post induction of anaesthesia?
Surgery goes uneventfully and takes approximately 2 hours.
Do you still need him to go to HDU?
You see him on HDU post op and he looks well. That evening he rapidly deteriorates, becomes acutely Short on breath, tachycardic, tachypnoeic and hypotensive. His temperature is 38 and his CXR reveals bilateral infiltrates.
What do you do now if you have to look after him on HDU. Would you consider escalating his care to ICU?
This weeks #gasclass has generated lots of discussion and a few new people have joined the discussion on Twitter. Thank you for participating.
Firstly we have learned that acronyms for procedures may not be understood, particularly if people reading the case are new to the specialty or do not undertake urology on a regular basis. The majority of people would perform a GA with ETT as the patient needs to be in the prone position.
With the additional information, there was great debate over stone surgery before cardiology assessment and intervention. Did the patient need the stone removal. In this case there was some confusion over the cause of the breathlessness. Was this respiratory or cardiac in nature. The initial view following assessment was that it was more likely to be respiratory and that stone removal would be preferable before any valve surgery due to the recurrent urinary infections the patient sustained.
A suggestion of regional anaesthesia for this case was made. This was a technique that very few people had experienced. Most felt that arterial monitoring was essential, however CVP monitoring was not deemed essential by all.
Once a decision has been made for post operative critical care then the patient should still be admitted even if the procedure is uneventful. The patient developed a bacteraemia and decompensated as a result developing ARDS.
Discussion over further management surrounded escalation of care and role of NIV in the management of the patient. It was felt that as the patient had requested active treatment for the stones then escalation of care including re-ventilation.
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.