Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Disorders of Potassium Balance

Case Synopses Hypokalemia A 70-year-old man with hypertension is anesthetized for emergency surgery for a bowel obstruction. His only daily medication is hydrochlorothiazide. His preoperative serum potassium concentration was 3.4 mEq Intraoperative oliguria is treated with 10 mg of intravenous furosemide. He produces 900 mL of urine in the next hour, and his electrocardiogram (ECG) shows new U waves and five premature ventricular systoles per minute.…

Barbiturates : Porphyrias

Case Synopsis An anxious 24-year-old woman presents with nausea, vomiting, and abdominal pain and is scheduled for exploratory laparotomy. Past history is remarkable for a negative exploratory laparotomy 2 years ago. Blood pressure is 150/90 mm Hg, and pulse is 105 beats per minute; the physical examination reveals abdominal tenderness. Electrolyte levels and white blood cell count are normal. With direct questioning about family history, the…

Autonomic Hyperreflexia

Case Synopsis A 34-year-old male veteran who sustained a complete spinal cord injury at C5 during combat 10 years ago underwent a cystoscopy with ureteral stent placement under conscious sedation. During the procedure the patient became hypertensive to 260/120 mm Hg and bradycardic with a heart rate of 42 beats per minute. He complained of headaches and blurred vision and started becoming agitated and confused. Acknowledgment…

Antihistamines : H 1- and H 2-Blockers

Case Synopsis A 90-year-old man with a past medical history of multiinfarct dementia presented with hematuria and is found to be confused and agitated in the postanesthesia care unit after cystourethroscopy. The patient received midazolam preoperatively, fentanyl and propofol on induction, and 50 mg of diphenhydramine after an episode of erythema. Acknowledgment This author wishes to acknowledge Drs. Habibi and Riley for contributions to the chapter…

Antiemetics

Case Synopsis A 30-year-old female patient was scheduled for hysteroscopy as a day-case procedure. She has no past medical history of relevance. Metoclopramide 10 mg and ondansetron 4 mg were administered followed by propofol/fentanyl via intravenous induction and sevoflurane for maintenance of anesthesia. Postoperatively she had intractable vomiting that delayed her discharge from the postanesthesia care unit and was only controlled through the use of a…

Antibiotics

Case Synopsis A 23-year-old man presents for reduction and fixation of an open tibial fracture after falling off a horse. During the presurgical briefing/time-out, the surgeon requests that the patient be given vancomycin, 1 g, before incision. After propofol and succinylcholine administration and successful endotracheal intubation, anesthesia is maintained with sevoflurane, N 2 O 50%/O 2 50%, and fentanyl, 2 μg Four minutes after vancomycin is…

Troubleshooting Common Problems During Cardiopulmonary Bypass

Complications of Aortic Root Cannulation: Acute Aortic Root Dissection Case Synopsis A 75-year-old man with a history of calcific aortic stenosis was scheduled for valve replacement. Induction of anesthesia, sternotomy, and insertion of perfusion cannulas were uneventful. However, the aortic tissue appeared thin and calcified. The aortic purse strings and cannula appeared well placed, but when cardiopulmonary bypass (CPB) was initiated, the pump arterial line pressure…

Toxic Ingestion

Case Synopsis A 25-year-old restrained male driver involved in a rollover motor vehicle accident presents acutely for repair of bilateral open tibia fractures. Loss of consciousness was reported at the scene. The patient is currently alert but disoriented, with a Glasgow Coma Scale score on examination of 14. He also exhibits slurred speech and injected conjunctivae. He admits to ingestion of alcohol and amphetamines just before…

Thoracic Aortic Aneurysm

Case Synopsis An 80-year-old man with previous abdominal aortic aneurysm (AAA) repair presents with abrupt-onset back pain starting 1 hour ago. He is alert, diaphoretic, tachycardic, and hypertensive. He is given oxygen, nitroglycerin, and morphine. He was found to have a dissecting thoracoabdominal aortic aneurysm (TAAA) on a computed tomography (CT) scan. There is absence of blood flow to the left kidney. Large peripheral intravenous access…

Thermally Injured Patients

Case Synopsis You are an anesthesiologist on call, and a surgical resident covering the burn unit books an emergency extremity fasciotomy. The patient, a 40-year-old homeless man, was rescued from a burning garage and admitted to the burn unit the night before. He was found unresponsive at the scene, with a toxic blood ethanol level and deep burns covering about 80% of his total body surface…

Spinal Cord Injury

Case Synopsis A 32-year-old man presents to the emergency department following a motorcycle accident in which he was thrown to the roadside. He is mildly obtunded, smells of alcohol, and is difficult to examine neurologically, but he appears to have loss of sensation and motor activity below the C5 dermatome. Lateral neck films fail to identify bony injury or subluxation. Vital signs reveal hypotension (90/40 mm…

Sedation of Pediatric Patients

Case Synopsis An obese 10-year-old child with enlarged tonsils and a history of sleep apnea is scheduled to undergo magnetic resonance imaging (MRI). She is sedated by the hospital sedation service, which is staffed by pediatric intensive care physicians. The child is given 2.5 mg/kg of propofol as a bolus, and a 200 μg/kg/min infusion is started. After falling asleep, the child is placed in the…

Retrobulbar Block

Case Synopsis Monitored anesthesia care is provided for an active 70-year-old patient undergoing phacoemulsion of a cataract with intraocular lens implantation. The patient has stable hypertension, coronary artery disease, mild emphysema, and renal insufficiency. Sedation with 1 mg midazolam is administered along with verbal reassurance while the anesthesiologist performs a retrobulbar block. Five minutes later the patient becomes unresponsive, is hypotensive with a heart rate of…

Pulmonary Hypertension

Case Synopsis A 55-year-old man with end-stage lung disease undergoes bilateral lung transplantation for usual interstitial pneumonitis. After reperfusion of the second lung the patient develops ischemia-reperfusion injury with acute graft dysfunction, pulmonary hypertension, and right ventricular failure. Problem Analysis Definition Pulmonary hypertension (PHT) is defined as an increase in mean pulmonary artery pressure (mPAP) greater than or equal to 25 mm Hg at rest. It…

Preterm Labor

Case Synopsis A 28-year-old woman, gravida 2, para 1, with an estimated gestational age of 28 weeks presents with a new onset of regular uterine contractions. She is admitted to the hospital for intravenous hydration and tocolytic therapy. Acknowledgment The author wishes to thank Dr. Craig Palmer for his contribution to the previous edition of this chapter. Problem Analysis Definition/Epidemiology Centers for Disease Control and Prevention…

Postpartum Hemorrhage

Case Synopsis A 29-year-old woman, gravida 4, para 2, has been delivered of a 4200-g infant. Her labor had been augmented after high maternal temperatures and foul-smelling liquor. The anesthesiologist is called 2 hours after delivery of the placenta when the patient is noted to be increasingly hypotensive, tachycardic, and pale. On arrival, the anesthesiologist is informed that she has had a heavier-than-normal lochia resulting in…

Posterior Fossa Surgery

Case Synopsis A 53-year-old woman undergoes posterior fossa craniotomy for removal of a right acoustic schwannoma. Preoperative symptoms included tinnitus, episodic vertigo, headache, facial asymmetry, and loss of coordination and balance. The surgeon will use a retrosigmoid approach and is planning for supine elevated right shoulder position and the intraoperative use of somatosensory evoked potentials (SSEPs); brainstem auditory evoked potentials (BAEPs); and facial, hypoglossal, accessory, and…

Pituitary Tumors : Diabetes Insipidus

Case Synopsis A 58-year-old man undergoes transsphenoidal hypophysectomy for resection of a prolactin-secreting pituitary adenoma with suprasellar extension. Ten hours after surgery, urine output exceeds 3 L/h, and the serum sodium level is 150 mEq Acknowledgment The authors wish to thank Dr. Patricia Petrozza for her contribution to the previous edition of this chapter. Problem Analysis You’re Reading a Preview Become a Clinical Tree membership for…

Peripheral Vascular Surgery

Case Synopsis A 74-year-old woman with a long-standing history of insulin-dependent diabetes, hypertension, chronic kidney disease, and a 50 pack-year smoking history requires right lower limb surgical revascularization due to lifestyle-limiting claudication. The patient is on carvedilol, simvastatin, lisinopril, and insulin. She describes chronic angina after ascending over two flights of stairs that resolves with rest. A dobutamine stress echocardiogram demonstrates a single segment of basal…

Perioperative Psychological Trauma

Case Synopsis A 4-year-old boy presents for inguinal hernia repair. In the preoperative holding area, he appears scared and agitated and refuses to leave his mother’s lap. On separation, he cries and tries to escape from the anesthesiologist. One week after surgery, the mother reports major behavioral changes in the boy since his operation, including nightmares and temper tantrums. Problem Analysis Definition The perioperative period is…