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Dental Injuries

Case Synopsis A 54-year-old woman is scheduled for a laparoscopic cholecystectomy under general anesthesia. Preoperative examination reveals a body mass index of 32, a short neck, and a Mallampati score of III. Dental examination reveals multiple caries, several crowns on molar teeth, and prominent upper incisors. She has been told in the past that she was “a difficult intubation.” A videolaryngoscope was used successfully for endotracheal…

Delayed Emergence

Case Synopsis 1 A 65-year-old man undergoes open reduction and internal fixation of a tibial fracture under general anesthesia (GA). He has a history of hypertension and diabetes mellitus. He was on ramipril and metformin. GA drugs included midazolam 2 mg, total intravenous anesthesia with propofol and remifentanil, and he was ventilated on i-gel. Morphine 20 mg was given toward the end of the operation. After…

Corneal Injury

Case Synopsis A 25-year-old woman in the postanesthesia care unit (PACU) complains of pain and a foreign body sensation in her right eye. Earlier that day, she underwent nasal polypectomy under general endotracheal anesthesia. Physical examination reveals residual petroleum-based ointment containing mascara particles around both eyes, right-sided conjunctival erythema, marked tearing, photophobia, and diminished visual acuity. A pulse oximeter probe is attached to her right index…

Celiac Plexus Block : Side Effects and Complications

Case Synopsis A 71-year-old man is referred to the pain management center for abdominal pain secondary to a diagnosis of metastatic pancreatic cancer. The patient recently underwent a local anesthetic block of the celiac plexus with 80% relief of his abdominal pain. He presents today for a neurolytic block using phenol. The procedure seems uneventful until he is ready to be transferred to the recovery area,…

Bronchospasm

Case Synopsis A 6-year-old boy with a history of mild intermittent asthma is scheduled for urgent laparoscopic appendectomy. After preoxygenation and a rapid-sequence induction, the patient is easily intubated. There is no sign of aspiration. After intubation, peak inspiratory pressure increases from 18 to 35 cm H 2 O, accompanied by a decrease in oxygen saturation from 100% to 82%, a decrease in blood pressure from…

Bradyarrhythmias

Case Synopsis During an open abdominal aortic aneurysm repair, a 71-year-old man suddenly becomes profoundly hypotensive after acute blood loss. The mean arterial blood pressure is 40 mm Hg, and the electrocardiogram (ECG) shows a wide complex rhythm of 35 beats per minute. The patient’s preoperative ECG showed a first-degree heart block with a bifascicular bundle branch block pattern. Problem Analysis Definition Bradyarrhythmias include cardiac rhythm…

Awareness Under Anesthesia

Case Synopsis “I thought I was about to die. [One minute] I was wheeled into a fairly routine orthodontic operation. … Suddenly, I was aware something had gone very wrong. I could hear what was going on around me, and I realised with horror that I had woken up in the middle of the operation, but couldn’t move a muscle. … I lay there, frantically trying…

Autonomic Dysreflexia

Case Synopsis A 35-year-old man with T1 spinal cord transection 3 years ago, sustained in a motorcycle accident, is scheduled for elective cystoscopy with removal of a bladder stone. In the preoperative holding area, he feels anxious and has a pounding headache, facial flushing, and hypertension (168/100 mm Hg). His admission blood pressure was 92/58 mm Hg. Problem Analysis You’re Reading a Preview Become a Clinical…

Angioedema and Urticaria

Case Synopsis A 57-year-old hypertensive African American woman with recent initiation of angiotensin-converting enzyme (ACE) inhibitor undergoes laparoscopic cholecystectomy under general endotracheal anesthesia. After 1 hour in the recovery room, the patient complains that her tongue feels “thick.” On examination the tongue is grossly swollen and protruding from the patient’s mouth; she is able to speak and denies dyspnea or pruritus; no urticaria or wheezing is…

Anaphylaxis and Anaphylactoid Reactions

Case Synopsis A 54-year-old woman presents for a hysterectomy and oophorectomy for ovarian mass. She is induced with propofol, fentanyl, and vecuronium. Sevoflurane in air/oxygen is delivered for maintenance. She receives 2 g of cefotetan shortly after intubation. Within the next 20 minutes, she develops hypotension refractory to phenylephrine and ephedrine. End-tidal CO 2 is 22 mm Hg. Epinephrine in doses of 100 μg are repeatedly…

Alleged Malpractice

Case Synopsis A 23-year-old woman undergoes emergency cesarean section under general anesthesia for fetal bradycardia and placental abruption. She is hypotensive (blood pressure 70/30 mm Hg) and tachycardic (heart rate 150 beats per minute) as the procedure begins. After delivery, the baby has poor Apgar scores, with evidence of fetal acidosis (cord pH 7.01). Postoperatively, the patient complains of awareness during surgery. The baby develops cerebral…

Air Emboli

Case Synopsis An 8-week-old infant is undergoing a craniectomy for sagittal craniosynostosis. As the surgeon is excising the cranial bone segment, precordial Doppler sounds change, and the blood pressure rapidly declines ( Fig. 127.1 ). Problem Analysis Definition Gas bubbles within the vascular system are termed gas emboli or air emboli. When venous air emboli enter the arterial circulation, they are termed paradoxic air emboli. Venous…

Adverse Events and Unanticipated Outcomes : Comprehensive Disclosure

Case Synopsis A 38-year-old woman with a history of hypertension and obesity (body mass index 32) is scheduled to undergo a laparoscopic cholecystectomy for chronic recurrent cholecystitis. In the preoperative assessment, she discusses her allergy to penicillin with the anesthesiologist. They explore this a bit more, and the patient explains that it was a reaction from childhood that she does not recall but one her mother…

Adverse Neurologic Sequelae : Peripheral Nerve Injury

Case Synopsis A 62-year-old man underwent coronary artery bypass graft surgery via a median sternotomy, with harvesting of the internal mammary artery. During a routine postoperative visit, the patient complains of a “tingling” sensation in the fourth and fifth fingers of his left hand. On physical examination, he has decreased sensation over those fingers, with minimally reduced muscular function in the ulnar distribution. A neurology consultation…

Adverse Neurologic Sequelae : Central Neurologic Impairment

Case Synopsis A 68-year-old man with a history of insulin-dependent diabetes mellitus, hypertension, and an 80 pack-year smoking history is scheduled for four-vessel coronary artery bypass grafting (CABG). After uneventful induction of anesthesia, severe aortic atheromatous disease is observed via transesophageal echocardiography in the aortic arch, so epiaortic ultrasound scanning is performed before aortic cannulation to ascertain the optimal location. The patient is maintained during cardiopulmonary…

Vaporizers

Case Synopsis A 54-year-old man, American Society of Anesthesiologists (ASA) physical status 2, undergoes general anesthesia for a laparoscopic ventral hernia repair. His baseline blood pressure is 120/70 mm Hg. After an uneventful intravenous induction and tracheal intubation, the sevoflurane vaporizer concentration dial is set to deliver 3% sevoflurane in oxygen at a fresh gas flow of 6 L Mechanical ventilation is begun, and the patient’s…

Transesophageal Echocardiography

Case Synopsis A 75-year-old woman undergoing emergency coronary artery bypass graft surgery for unstable angina has incomplete revascularization due to lack of a suitable conduit. Insertion of a transesophageal echocardiography (TEE) probe during cardiopulmonary bypass is difficult. After several attempts, the probe suddenly advances; however, its tip appears in the surgical field anterior to the heart, after perforating the pharynx. Subsequent discussion with the patient’s husband…

Surgical Electrocautery

Case Synopsis A 59-year-old man is having an open resection of the right colon for cancer. The surgeon is having a difficult time getting exposure, due to adhesions from a previous surgery. On several occasions, he complains that the electrosurgical unit (ESU) is not working properly and wants the energy increased. The circulating nurse complies with his requests. Eventually a new ESU is obtained, but this…

Scavenging Systems

Case Synopsis A 25-year-old man with no significant medical history presents for tonsillectomy. After induction of anesthesia and tracheal intubation, anesthesia was maintained using a mixture of O 2 /N 2 O/isoflurane at a total fresh gas flow (FGF) of 6 L The patient was breathing spontaneously from a circle breathing system. At the request of the surgeon, the anesthesia machine was moved a little to…

Rapid Fluid and Blood Delivery Systems

Case Synopsis A 65-year-old man is brought to the operating room for emergent repair of a ruptured abdominal aortic aneurysm. The patient is intubated, hypothermic (34.5°C), and hypotensive (blood pressure 85/60 mm Hg). Volume resuscitation is instituted with warmed intravenous (IV) fluids under pressure using a Level 1H-1200 IV fluid warmer. Before skin incision, the blood pressure drops to 60/30 mm Hg, and the end-tidal carbon…