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Misidentification of a Patient

Case Synopsis A 12-year-old boy was brought to the operating room for a liver transplant late one Sunday evening. Frequent blood draws were done throughout the case, and the tests were run on a point-of-care machine in the operating room. The machine allowed for both manual and barcode input of the patient’s medical record number. However, the manual input was disabled several years ago in all…

Metabolic Acidosis and Alkalosis

Case Synopsis A 56-year-old taxi driver presented to the emergency department (ED) with a 2-day history of abdominal pain and intractable vomiting. He was diagnosed with acute small bowel obstruction. His blood gas (room air) and chemistry panel on arrival were pH 7.38, Pa co 2 28 mm Hg, Pa o 2 100 mm Hg, Na 145 mEq/L, K 3.8 mEq/L, Cl 90 mEq/L, HCO 3−…

Long QT Syndromes and Torsades de Pointes

Case Synopsis A 65-year-old woman undergoes laparoscopic hysterectomy under general anesthesia. She has paroxysmal atrial fibrillation, for which she takes sotalol, and has recently commenced diuretic therapy for pedal edema. After completion of uneventful surgery, ondansetron is administered, shortly followed by sudden-onset polymorphic ventricular tachycardia (VT). Because the patient is hemodynamically unstable, asynchronous DC cardioversion is performed and a magnesium infusion commenced. After successful cardioversion, her…

Local Anesthetic Neurotoxicity : Cauda Equina Syndrome

Case Synopsis A 48-year-old man underwent right inguinal hernia repair under spinal anesthesia. With the patient in a sitting position, a 24-gauge pencil-point needle was inserted at the L4–L5 level. Spinal medications included 75 mg of 5% lidocaine hydrochloride with 7.5% glucose, 0.1 mg of epinephrine, and 25 μg of fentanyl, resulting in an L3 block after 5 minutes. The patient was then placed in the…

Latex Reactions in Health Care Personnel

Case Synopsis A 44-year-old anesthesiologist notes a rash on his right middle finger that has recently progressed to urticaria. He has been in good general health all his life; however, he is allergic to fish and ragweed pollen, and he was treated for eczema as a child. The rash has been intermittently present for several years and is exacerbated by wearing gloves to perform medical procedures.…

Laryngeal and Tracheal Injury

Case Synopsis A 58-year-old, 50-kg woman presents to the operating room for total abdominal hysterectomy. After intravenous induction of general anesthesia, direct laryngoscopy is performed, yielding a view of only the arytenoids with the application of cricoid pressure. A single-use, coude-tip bougie is passed blindly until a positive hold-up sign is obtained, after which a 6.5-mm endotracheal tube is passed over the bougie into the trachea.…

Intractable Nausea and Vomiting

Case Synopsis A 28-year-old, 110-kg woman presents with intractable nausea and vomiting in the postanesthesia care unit after undergoing laparoscopic cholecystectomy under general anesthesia. The anesthesia was unremarkable except for preoperative anxiety and moderate postoperative upper airway obstruction, which was easily corrected by insertion of an oral airway. Past medical history was significant for unanticipated hospital admission for postoperative nausea and vomiting after previous inguinal hernia…

Intracranial Hypertension

Case Synopsis A 64-year-old man is scheduled for a craniotomy for resection of a brain tumor. He presented to the emergency department with progressive personality changes, memory disturbances, and urinary incontinence. Physical examination is remarkable for confusion, papilledema, and left hemiparesis. Computed tomography scan reveals a large mass with surrounding edema consistent with a glioblastoma. He has been started on dexamethasone (Decadron) 4 mg every 6…

Interscalene Nerve Block: Potential Severe Complications

Case Synopsis A 25-year-old man presents for rotator cuff repair and has an interscalene block and catheter placed. The block is performed using Winnie’s landmarks and with the aid of a nerve stimulator. A triceps response is obtained at a depth of 2.5 cm. The catheter is threaded 6 cm past the tip of the stimulating needle. The procedure is uneventful, except for transient resistance encountered…

Infectious Complications of Central Neuraxial Block

Case Synopsis A 58-year-old man with a history of insulin-dependent diabetes mellitus, rheumatoid arthritis, and bladder cancer status postneoadjuvant chemotherapy underwent a radical cystectomy and diversion. A lumbar epidural catheter was placed for perioperative analgesia, and the patient received an epidural infusion of ropivacaine and fentanyl for 3 days postoperatively. At the time of epidural catheter removal, the insertion site was surrounded by a small area…

Inadequate Pain Relief

Case Synopsis A 30-year-old man, otherwise healthy, undergoes an ankle fusion as an outpatient procedure. The surgically uncomplicated procedure is performed under general anesthesia with endotracheal intubation. After emergence, the patient experiences severe, intractable pain, with subsequent postoperative nausea and vomiting (PONV) after opioids are used in the postanesthesia care unit (PACU). The patient eventually requires unplanned hospital admission for intractable pain, PONV, and somnolence. The…

Hypothermia

Case Synopsis A 74-year-old woman with a history of dementia and osteoporosis is admitted after an unwitnessed fall in her house. She presents to the operating room and undergoes repair of a fractured hip under epidural anesthesia with general endotracheal intubation. She receives 4 units of packed red blood cells. In the postanesthesia care unit, she is confused and disoriented. Her heart rate is 110 beats…

Hyperthermia (Perioperative)

Case Synopsis A 23-year-old woman with a past medical history significant for bipolar disorder on a mood stabilizer requires emergent surgery for a ruptured appendix. The patient has no history of previous surgery and is unaware of any relevant family history. Preoperative vital signs are blood pressure 130/90 mm Hg, heart rate 105 beats per minute, temperature 38.5°C, and respiratory rate 15 breaths per minute. Thirty…

Hyperglycemia and Diabetic Ketoacidosis

Case Synopsis A 75-year-old woman with type 2 diabetes mellitus, controlled by glyburide 5 mg twice a day, presents for scheduled coronary artery bypass grafting. She has diabetic nephropathy with a serum creatinine of 1.8 mg The patient did not take her oral antidiabetic medication before surgery, and her fasting plasma glucose was 130 mg After cardiopulmonary bypass, the intraoperative plasma glucose was 236 mg There…

Fat Embolism Syndrome

Case Synopsis A 29-year-old man who has suffered fractures of the femur and tibia in a motorcycle accident is brought to the operating room for intramedullary nailing of both injuries. Surgery is unremarkable, but the patient is noted to have persistent tachycardia in the recovery room, despite adequate fluid resuscitation and pain control. The following morning, he is tachypneic and complains of significant shortness of breath.…

Embolic Events of Pregnancy

Case Synopsis A 34-year-old pregnant woman, gravida 3 para 2, presents at 29 weeks of gestation requiring an emergency cesarean delivery for preterm labor. After initiation of spinal anesthesia and delivery of the neonate and placenta, the parturient complains of nausea and promptly becomes unresponsive and apneic. She is intubated and rapidly becomes hemodynamically unstable and coagulopathic. After supportive treatment, she is able to be extubated…

Disorders of Water Homeostasis: Hyponatremia and Hypernatremia

Acknowledgment The authors would like to thank Drs. J. Thomas Murphy and John L. Atlee for their contributions to the previous edition of this chapter. Hyponatremia Case Synopsis 1 A 68-year-old man with a medical history of hypertension, chronic obstructive pulmonary disease, chronic renal insufficiency, and insulin-dependent diabetes mellitus presents for right total-knee replacement. His laboratory values are as follows: serum sodium, 130 mEq/L; serum osmolality,…

Difficult Airway and Failed Extubation

Case Synopsis An obese man (body mass index 40) sustained closed head injury, lung contusions, and C-spine injury after a fall from a tree. Tracheal intubation was performed by paramedics at the scene, and the patient was transported to the hospital. Three days later, the patient had satisfactory neurologic and respiratory recovery, but the neck collar was still in place. After meeting extubation criteria, his trachea…