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Central Venous Pressure Monitoring

Case Synopsis A 65-year-old man is taken to the operating room for coronary artery bypass grafting. After induction of anesthesia, a right internal jugular triple-lumen central venous catheter (CVC) is placed. The operation proceeds without complications, and the patient is taken to the intensive care unit at the conclusion of the case. As the patient recovers from surgery, his care team decides to leave his CVC…

Carbon Dioxide Absorbers

Case Synopsis A 75-year-old woman with perforated diverticulitis is undergoing a laparoscopic hemicolectomy under general anesthesia. The patient’s abdomen has been insufflated with CO 2 to a pressure of 15 to 20 mm Hg for 45 minutes. The end-tidal CO 2 is observed to rise to 50 mm Hg without any adjustment made in the minute ventilation during this time. Over the last 15 minutes, the…

Anesthesia Circuit

Case Synopsis A 57-year-old woman who is a heavy smoker experiences a difficult endotracheal intubation during induction of anesthesia. Mask ventilation also is difficult, partly because of the high inspiratory pressures required and partly because of a poor mask fit, with a resulting considerable leak between the mask and face. The first and subsequent attempts at intubation are greeted with a stiff bag and a lack…

Respiratory Depression After Spinal Anesthesia

Case Synopses Case 1 A 75-year-old man underwent total knee replacement under spinal anesthesia with local anesthetic and 300 μg of diamorphine or 100 μg of morphine. Late that evening he appears extremely sleepy and has oxygen saturation of 94% on nasal oxygen. Case 2 A 60-year-old woman underwent a total vaginal hysterectomy under spinal anesthesia with local anesthetic and 300 μg of diamorphine. In the…

Local Anesthetic Systemic Toxicity

Case Synopsis A 76-year-old man (184 cm, 58 kg, American Society of Anesthesiologists [ASA] status 3) was scheduled for a total shoulder arthroplasty. His medical history was significant for coronary artery disease with remote bare metal stent placement and atrial fibrillation. A continuous interscalene block was planned for postoperative analgesia. The patient was sedated with intravenous midazolam and fentanyl before the insertion of a perineural interscalene…

Epidural Anesthesia : Unintended Intrathecal Injection

Case Synopsis A frail, 55-kg, 79-year-old woman is admitted for elective hip replacement as the first surgery of the day in a specialty orthopedic surgery center. An epidural catheter is placed for surgical anesthesia and postoperative analgesia. With the patient sitting on the operating room table, catheter placement is uneventful. Fifteen milliliters of local anesthetic (2% lidocaine with 5 μg/mL of epinephrine) is administered via the…

Blood and Blood Products : Transfusion Reactions and Complications

Case Synopsis A 33-year-old woman, G3P2002 at 34 weeks’ gestation with a known history of placenta previa, undergoes ultrasound concerning for placenta accreta. The patient underwent a successful cesarean section under epidural anesthesia but required allogeneic blood transfusions that included 6 units of packed red blood cells (PRBCs), 2 units of fresh frozen plasma (FFP), and 6 units of platelets. The patient was hemodynamically stable at…

Blood and Blood Products : Infections

Case Synopsis A 70-year-old man with a history of coronary artery disease and a new diagnosis of abdominal aortic aneurysm is being evaluated in the preoperative area for an open repair. His hemoglobin is 10 g/dL, and you decide to obtain his informed consent for the possibility of blood product transfusions. During the process of obtaining consent, he becomes visibly upset during the discussion. On further…

Volatile Anesthetics : Organ Toxicity

Case Synopsis A 53-year-old woman has laser excision of vocal cord papillomas under anesthesia with halothane and spontaneous ventilation. She has had several prior excisions, including one a month earlier, all with halothane; all were uneventful. However, 1 week after this surgery, she develops fever, nausea, and malaise, along with severe jaundice and markedly elevated serum transaminase concentrations. Problem Analysis Definition Organ toxicity caused by volatile…

Succinylcholine

Case Synopsis A 52-year-old woman with bipolar depression undergoes her first electroconvulsive therapy (ECT) treatment. Past history is otherwise pertinent only for hemiparetic, static encephalopathy as a result of meningitis in infancy and hypertension. Medications include lamotrigine, lurasidone, and lisinopril. Induction of anesthesia with 80 mg methohexital and 60 mg succinylcholine is uneventful, and she receives unilateral ECT. She is still apneic 15 minutes after the…

Reversal Agents : Naloxone, Flumazenil, and Sugammadex

Naloxone Case Synopsis An otherwise healthy 65-year-old, 80-kg man is given 2 mg of fentanyl intravenously (IV) during a 3-hour coronary artery bypass grafting procedure. Postoperatively, the patient remains intubated and mechanically ventilated and is transferred to the intensive care unit (ICU) in stable condition. The surgeons opt for early extubation of the patient, but he remains deeply sedated, does not respond to painful stimuli, and…

Perioperative Fluid Management

Case Synopses Case 1 A 72-year-old man is scheduled to undergo transverse colectomy and primary reanastomosis for a nonobstructing carcinoma. He has a history of hypertension that is well controlled by a diuretic and is otherwise healthy. Case 2 A 35-year-old woman is scheduled to undergo laparoscopic cholecystectomy for cholelithiasis. Other than mild obesity (preoperative weight 88 kg), she is healthy. Problem Analysis Definition Fluid administration…

Nondepolarizing Neuromuscular Block

Case Synopsis Following emergence and tracheal extubation after general anesthesia with neuromuscular relaxation, a 52-year-old woman with a history of chronic renal insufficiency has labored breathing with paradoxic movement of the chest wall and abdomen and intermittent upper airway obstruction. Problem Analysis You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If you are a member. Log…

Nonbarbiturate Anesthetics

Case Synopsis A 53-year-old, 75-kg man with a past medical history significant for poorly controlled hypertension and non–insulin-dependent diabetes is scheduled for an external fixation of a femur fracture sustained after a fall off a ladder 2 days ago. The patient has been NPO since the accident and on maintenance fluids of lactated Ringer’s solution at 75 mL He has no known drug allergies and takes…

Nitrous Oxide : Neurotoxicity

Case Synopsis A 7-week-old infant underwent a Kasai procedure for the diagnosis of biliary atresia. The patient received isoflurane and nitrous oxide, and the operation was uneventful. Five days after the surgery, the patient developed hypotonia, hyporeflexia, and apnea. Computed tomography showed severe cerebral atrophy, and homocysteine was detected in the infant’s urine. Problem Analysis Definition Nitrous oxide (N 2 O), also known as laughing gas,…

Muscle Relaxants

Case Synopsis A 2-year-old boy presents for inguinal herniorrhaphy. During mask induction with oxygen, nitrous oxide, and sevoflurane, he develops laryngospasm, which is treated with intramuscular succinylcholine. A wide-complex QRS tachycardia is subsequently noted on the electrocardiogram monitor. Problem Analysis Definition There can be complications with all neuromuscular relaxant drugs; however, the potential for serious complications is greatest with succinylcholine (SCh). Although these complications have limited…

Magnetic Resonance Imaging

Case Synopsis A 4-year-old boy with a 10-day history of persistent nausea, vomiting, and otitis media requires magnetic resonance imaging (MRI) of the brain to evaluate possible intracranial process. The anesthesiology consultant was called to evaluate and assist with the anesthetic. Acknowledgment The author wishes to thank Dr. Hind M. Gautam and Dr. Christopher M.B. Heard for their contributions to the previous edition of this chapter.…

Magnesium

Case Synopsis A 23-year-old pregnant woman at 34 weeks and 3 days’ gestation with severe preeclampsia is brought emergently to the operating room for cesarean delivery under general anesthesia. She is currently receiving a magnesium infusion for treatment of her preeclampsia. Forty-five minutes after uneventful rapid-sequence induction with propofol and rocuronium, followed by an uneventful delivery, the patient has continued profound neuromuscular blockade (train of four…

Ketamine

Case Synopsis A 22-year-old woman is posted for an emergency appendectomy. She is hemodynamically stable and administered a spinal anesthesia. The surgeon makes the abdominal incision, but on deeper dissection the patient cries out in pain. The anesthesiologist administers bolus ketamine intravenously (2 mg/kg) and asks the surgeon to go ahead. Soon after the bolus dose, there is respiratory depression and apnea for a few seconds,…

Intrathecal Opioids

Case Synopsis An otherwise healthy 26-year-old woman undergoes cesarean section for delivery of a breech infant. Spinal anesthesia is used, consisting of 1.6 mL of 0.75% hyperbaric bupivacaine (12 mg) with preservative-free morphine (0.3 mg). The surgery is uneventful, and the infant has Apgar scores of 9 and 9 at 5 and 10 minutes, respectively. The patient remains in the recovery room for 2 hours and…