[Qwiigley]

Lets look at a made up case and see how many different ways we can do the anesthesia for the case.

74 yo male, a fib, COPD mild, GERD, Kidney tumor, no problems with diabetes, thyroid, or neuro. Meds include: coumadin (stopped 5 days ago), lipitor, prilosec, Advar, albuterol prn, MVits. Ht 5'10", 70 kg. Walks daily, plays tennis. Married. Medical clearance ok'd. Cardiac clearance not obtained.

Surgery scheduled: removal of kidney tumor; open.

SRNAs in clinicals welcome to join in.

[kirbybunny]

Originally Posted by Qwiigley

Lets look at a made up case and see how many different ways we can do the anesthesia for the case.

74 yo male, a fib, COPD mild, GERD, Kidney tumor, no problems with diabetes, thyroid, or neuro. Meds include: coumadin (stopped 5 days ago), lipitor, prilosec, Advar, albuterol prn, MVits. Ht 5'10", 70 kg. Walks daily, plays tennis. Married. Medical clearance ok'd. Cardiac clearance not obtained.

Surgery scheduled: removal of kidney tumor; open.

SRNAs in clinicals welcome to join in.

Sent you a PM.

~ Jen

[ICUDOUCME?]

Well, SRNA here in my senior year of clinicals
I may get laughed off the board but here goes:

(74 yo male, a fib, COPD mild, GERD, Kidney tumor, no problems with diabetes, thyroid, or neuro. Meds include: coumadin (stopped 5 days ago), lipitor, prilosec, Advar, albuterol prn, MVits. Ht 5'10", 70 kg. Walks daily, plays tennis. Married. Medical clearance ok'd. Cardiac clearance not obtained.

Surgery scheduled: removal of kidney tumor; open.)


Pre-op: Ranitidine 50 mg IV, ipratoprium neb tx, check coags, versed 1-2 mg IV. Epidural placed for post-op pain control.

Induction: Fentanyl 100-200 mcg IV prior to induction. RSI w/ Etomidate 0.2 mg/kg, Sch 1.5 mg/kg, w/ defasc. dose of Roc 5 mg.

Maintenance: Sevo 1.7%. Titrate fentanyl if needed during case. Dose epidural w/ 0.25% Marcaine 5-10 mls as tolerated (BP), and 100 mcg fentanyl. Vec for relaxation to one twitch.

Reversal: neostig 0.04 mg/kg/ glycopy 0.007 mg/kg

Post-op: Awake extubation. Re-dose epidural w/ 0.25 % Marcaine.

Notes; Fluid replacement judiciously given, limit fluids to replacement and insensible loss only. Use phenylephrine for hypotension.

[dfk]

Originally Posted by Qwiigley

Lets look at a made up case and see how many different ways we can do the anesthesia for the case.

74 yo male, a fib, COPD mild, GERD, Kidney tumor, no problems with diabetes, thyroid, or neuro. Meds include: coumadin (stopped 5 days ago), lipitor, prilosec, Advar, albuterol prn, MVits. Ht 5'10", 70 kg. Walks daily, plays tennis. Married. Medical clearance ok'd. Cardiac clearance not obtained.

Surgery scheduled: removal of kidney tumor; open.

SRNAs in clinicals welcome to join in.

diagnosed afib? if so, try to find cardiology report. may not need clearance, but on coumadin and lipitor, so some sort of CAD possible. get EKG.
b/c pt states walks daily and plays tennis, that's not really telling us how they tolerate the activity, such as SOB. so, determine actual function. perhaps CXR and/or PFTs if time allows.
since GERD is hx, check if prilosec adequate/well controlled. if no c/o waking up in middle of night, laying flat, etc...and is under good control, i wouldn't be too concerned needing RSI. heck, everyone has GERD...
assuming pt has no decline in kidney function (not on dialysis or in any failure):
pre-op: CBC/coags/lytes/BUN/Cr/EKG/CXR - meds: Versed 1-2 mg, Fentanyl 50 mcg, +/- Reglan 10 mg, albuterol puffs, Ancef 1 gm IV (assuming no allergies)..
induction: propofol 120 mg IV, lidocaine 40 mg IV, fentanyl 100 mcg IV, Rocuronium 40 mg IV.
maint: Sevo 2-3%, Roc 10-20 mg IV as needed Q 20-30 min depending on case length and need, dilaudid 2 mg IV over half an hour if BP supports it.
emerg: Glyco 0.4 mg, Neostig 2 mg, (give in divided dose over 30 sec to avoid tachy, which worsens a-fib/atrial kick/filling time), albuterol puffs..
since no RSI, would consider deep extubation meeting parameters of adequate Vt/RR/Sats..
off to PACU with O2 and OPA..

[Qwiigley]

I like this! Everyone has different ideas and thoughts!

[stanman1968]

You can do this in more ways then GA. How about spinal or epidural? Hell you could even do this with paraertebral block. It is not all GA.

[Qwiigley]

Very true Stanman! Thanks for bringing that up. Its good to look at many different options.
The idea behind this question was just that, to look at the many ways different people do thier cases and learn from it.

I made up this case, so there may be flaws in its "reality" factor. This reflects a typical patient in the hospital where I work.