Term 2 Week 9 (w/c 12/03012)
This week #gasclass moves back into theatre.
You have been allocated to a vascular list. On the list is a patient who requires fistula formation.
As you walk to the ward what thoughts regarding the patients condition and potential comorbidities cross your mind?
You have thought about various comorbidities surrounding the patient. You meet the surgeon whilst walking to the ward. The surgeon tells you that the patient has had dialysis dependent renal failure for many years and has had multiple previous fistlulae that have failed. The patient was dialysed yesterday evening in preparation for theatre.
What are your thoughts now? What would be your anaesthetic plan?
There is a split between LA, Regional and GA. The surgeon continued to tell you that she intends to create a left brachio-basillic fistula. The vessels look very small on doppler and that the procedure is likely to be difficult and take a long time.
Would this change your plan? Any other concerns now?
So leaning towards giving a GA for this procedure you get to see the patient. He has had previous GA’s and does not want a regional block under any circumstances.
He has longstanding ESRF of unknown aetiology, he is hypertensive controlled with medication but no ACE-I. 2 years ago he had a stroke but has no residual deficit. Post dialysis bloods reveal Na 140 K 3.9 Ur 13.5 Cr 210. Reading his notes you notice a 24hr ECG which shows multiple runs of VT. The man admits to having had dizzy spells. Asking about the treatment for this he casually mentions “it’s ok doc I’ve got a shock thingy fitted”
What are you going to do now? Will this alter your anaesthetic plan?
There are no trick questions in #gasclass. It is an educational tool only. Everyones opinion is as valid as the next person. Follow the conversation by using (or searching for) the hashtag #gasclass on twitter. We welcome input from all specialities and you can send us a direct message if you would prefer to remain anonymous.