Term 9 (W/C Aug 30 to Sept 6)
Welcome back to another week of Gasclass! Life has been busy and the summer is drawing to a close, and more cases will (hopefully) be coming your way.
Today you’re on call on a weekend and you’re asked to do a B case for a C1-C2 fusion. This middle-aged man had a fall (EtOH related) several months ago and had multi-level C-spine fractures that was treated conservatively (initially with halo fixation and then Aspen collar). However, during his followup appointment and repeat CT scan it was found that his C2 vertebrae had bone resorption and non-union, therefore it was deemed unstable and would need operative fixation.
Important past medical history included previous STEMI requiring 2x BMS, and a residual LVEF of 35% with moderate diastolic dysfunction. He drinks and smokes heavily. He does not have any neurological consequences from his C-spine fracture at this point.
What are your considerations for this case, and how would you anesthetize him?
The surgeons plan on doing a posterior approach, which would require proning the patient.
What is the safest option for c-spine fixation for proning? What special considerations do you have for a prone case?
After placing an awake arterial line, you proceed to induce the patient. The initial view with VL and MILS is a Cormack-Lehane grade 4 (no epiglottis seen). What is your plan?
You remove the VL and BMV the patient (luckily they are easy!) while the RT turns on the bronch. With jaw extrusion and tongue retraction, you cannot identify any recognizable glottic structures with the bronch. Meanwhile, the blood pressure post-induction has drifted down to SBP 60.
What is your next step and plan?
You try to BMV and thankfully he remains easy. You place an LMA that allows for intubation and bronch through that — the cords are easily visible and the trachea is intubated with the bronch. You railroad the 7.5 ETT through the LMA with some coaxing, but you’re concerned that removing the LMA might cause extubation. What are your options to keep the ETT in place?
What is your plan to manage his hemodynamics now and during the case? (remember, his head will be in pins and proned).
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