Term 3 Week 3 (w/c 14/5/12)
Welcome to week three of this term. @gasclass is in theatre again this week.
You were called at 1655 on Friday by the Max-Fax SHO regarding a patient on your Monday operating list who has Rheumatoid Arthritis.
What problems do patients with RA pose to an anaesthetist?
Please post one potential problem per tweet and do not tweet again until someone else has put a problem. This should encourage new tweeters to join in.
Thank you for your contributions yesterday.
The patient is a 58 year old lady who requires a radical neck dissection for a neck mass following radiotherapy for a primary SCC base of tongue.
What is your anaesthetic plan? Do you require any specific investigations and why?
You visit the lady. She is on long term steroids for her RA and takes Methotrexate. She is on digoxin for AF. The lady has extensive joint involvement affecting, elbows, wrists, fingers, hips, knees, ankles and feet. Examination of the Respiratory and Cardiovascular systems are unremarkable. Reviewing the imaging and following discussion with the Surgeon there appears to be no recurrance of the base of tongue tumour. The neck mass does not alter the anatomy of the larynx.
FBC – Hb 10.3 WBC 9.4 PLTS 205 MCV 82
U&E Na 140 K 4.1 Ur 3.5 Cr 36
ECG – AF Rate 60
The Max-Fax SHO helpfully arranged the following x-rays.
What are your thoughts now? Does this change your anaesthetic plan? What is your postop plan of management?
Thank you for the contributions yesterday. The patient does have atlanto-axial dislocation as seen above.
You successfully secure the patients airway and the surgery proceeds uneventfully. Post op the patient is admitted to the High Dependency Unit.
Later on the first post-op night the patient develops a right sided neck swelling, becomes pale and stridulous.
What are your thoughts? How would you proceed now?
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