Case Synopsis A 35-year-old man presents to the emergency department complaining of left eye pain and loss of vision after being hit by a nail in the left eye while working in a construction project. He had eaten a full lunch 1 hour before the accident. Acknowledgment The author wishes to thank Dr. Stacey L. Allen and Dr. Ellen Duncan for their contributions to the previous…
Case Synopsis A 72-year-old man is scheduled for robotic-assisted right upper lobe wedge resection for adenocarcinoma. His medical history is notable for stable coronary artery disease treated with coronary artery bypass grafting and a bare metal stent and hypertension treated with an angiotensin-converting enzyme (ACE) inhibitor. Preoperative pulmonary function testing reveals a forced expiratory volume in 1 second (FEV 1 ) of 85% predicted, a diffusing…
Case Synopsis A 75-year-old woman presents for hemiarthroplasty after a femoral neck fracture. She has a history of hypertension, coronary artery disease, moderate pulmonary hypertension, and osteoporosis. Her medications include lisinopril and clopidogrel. The patient undergoes induction of general anesthesia, and the surgery proceeds uneventfully. During cementing of the prosthesis the patient develops severe hypotension, hypoxemia, and tachycardia. Acknowledgment The authors wish to thank Dr. Kathryn…
Case Synopsis A 23-year-old previously healthy man is scheduled for cervical mediastinoscopy for tissue diagnosis of a mediastinal mass. He presents with a 3-month history of fatigue and dyspnea on exertion and reports that he cannot sleep on his left side because it makes him feel short of breath. Chest computed tomography (CT) demonstrates a 10 × 8 × 5 cm mass adjacent to the right…
Case Synopsis A 67-year-old man with critical aortic valve stenosis (aortic valve area of 0.5 cm 2 ), severe mitral regurgitation, coronary artery disease, left ventricular systolic dysfunction (ejection fraction of 30%), and chronic renal insufficiency (serum creatinine concentration of 1.89 mg/dL) underwent aortic valve replacement, mitral valve annuloplasty, and two-vessel coronary artery bypass graft (CABG) surgery. Cardiopulmonary bypass (CPB) time was 235 minutes. The patient…
Case Synopsis A 62-year-old obese man (body mass index 41) with a history of laryngeal cancer presents for microdirect laryngoscopy, esophagoscopy, and bronchoscopy to evaluate a positron emission tomography (PET)–positive lesion on recent surveillance scanning. He has a history of chronic obstructive pulmonary disease on 2 L home oxygen, hypertension, hyperlipidemia, 35 pack-year smoking, and laryngeal cancer for which he underwent transoral robotic surgery and subsequent…
Case Synopsis A 58-year-old female patient with a past medical history significant for hypertension, type 2 diabetes, and smoking developed a severe headache and was admitted to the emergency department. Computed tomography (CT) of her head showed a subarachnoid hemorrhage Fisher grade 3. The patient’s cerebral angiogram showed a ruptured wide neck aneurysm in the anterior communicating artery region. The patient underwent endovascular occluding of the…
Case Synopsis A 55-year-old man undergoing craniotomy for clip-ligation of a right anterior communicating artery aneurysm 12 hours after initial subarachnoid hemorrhage becomes acutely hypertensive and experiences bradycardia during the induction of anesthesia. Acknowledgment The authors wish to thank Dr. Philippa Newfield for her contribution to the previous edition of this chapter. Problem Analysis Definition Intracranial aneurysms are outpouching of arteries developing secondary to turbulent flow…
Case Synopsis A 61-year-old, 80-kg man is scheduled for removal and replacement of a total hip prosthesis. He is concerned about blood transfusion and the transmission of infectious diseases, particularly human immunodeficiency virus (HIV). He requests that transfusion of homologous blood be avoided, if possible. He predonated 2 units of autologous blood. During surgery, blood loss is more than 2000 mL, and the hemoglobin level is…
Case Synopsis A 22-year-old previously healthy man sustained a head injury, as well as an unstable pelvic and femur fracture, following a motorcycle accident. He was initially combative but quickly became obtunded with a Glasgow Coma Scale (GCS) score of 9 (E3V3M3; see Table 58.1 ). His blood pressure was 95/40 mm Hg, and his heart rate was 100 beats per minute. He had a dilated,…
Case Synopsis A 3-year-old boy is booked for an urgent rigid bronchoscopy for evaluation and removal of a suspected aspirated foreign body. He has previously been treated unsuccessfully with bronchodilators and antibiotics for a week-long history of coughing, wheezing, and mild tachypnea. The parents thought they recalled a prior episode of choking while he was eating peanuts. Chest x-ray showed localized right-sided air trapping and emphysema.…
Case Synopsis A 38-year-old, 120-kg primigravida with poorly controlled type 2 diabetes presents at 35 weeks’ gestation with ruptured membranes and a temperature of 38.5°C. The decision is made to induce labor. During labor the obstetrician declares that the electronic fetal heart rate monitor indicates fetal distress ( Fig. 56.1 ) and urgent cesarean delivery is required. Acknowledgment The author wishes to thank Dr. Brenda Bucklin…
Case Synopsis A 75-year-old woman is undergoing a revision of a left total knee arthroplasty under spinal anesthesia and intravenous sedation. She is morbidly obese, on chronic opioids for pain relief, and an insulin-dependent diabetic. A continuous adductor canal catheter is placed for postoperative pain control before the placement of a single-shot spinal anesthetic. A conventional rectangular thigh tourniquet is placed for surgical hemostasis. After limb…
Case Synopsis A 62-year-old man undergoing ankle arthrodesis has adductor canal and popliteal-sciatic perineural catheters placed under ultrasound guidance. He initially received 0.5% ropivacaine for surgical anesthesia and then 0.2% ropivacaine infusion through both catheters for postoperative analgesia. In the recovery room he was pain free, but during the first postoperative night he complained of pain throughout his ankle. He was bolused 0.5% ropivacaine through both…
Case Synopsis A 23-year-old man arrives in the emergency department with a gunshot wound to the right upper quadrant of the abdomen. He is combative and confused. His vital signs include systolic blood pressure, 70 mm Hg; heart rate, 119 beats per minute; and respiratory rate, 22 breaths per minute. Problem Analysis Definition Trauma-related injury (TRI) is the leading cause of death in the United States…
Case Synopsis An otherwise healthy 70-year-old man undergoes combined transurethral resection of the prostate (TURP) and transurethral resection of a bladder tumor (TURBT) under spinal anesthesia with sedation. His blood pressure is 130/90 mm Hg, heart rate is 68 beats per minute, respirations are 16 breaths per minute, and hematocrit is 38%. Ninety minutes into surgery, the patient becomes restless. His blood pressure is 180/100 mm…
Case Synopsis 1 A 55-year-old woman with a 5-year history of swelling in the front of the neck presented for subtotal thyroidectomy. She has a history of palpitations on minimal exertion. She gives a history of shortness of breath on lying supine and prefers to sleep on her side. She also has an altered voice. A prominent thyroid gland is palpated on physical examination. The chest…
Case Synopsis A 78-year-old man with morbid obesity (body mass index [BMI] 43), chronic atrial fibrillation on dabigatran (discontinued 5 days prior), and metastatic renal cell carcinoma to T8 is undergoing corpectomy and multilevel instrumented fusion using propofol-based total intravenous anesthesia (TIVA) with intraoperative somatosensory evoked potentials (SSEPs) and transcranial motor evoked potentials (tcMEPs). Intraoperatively, major blood loss ensues requiring massive transfusion of all blood components.…
Case Synopsis A 44-year-old man with treated hypertension and an extensive smoking history presents with malaise, weight loss, and painless hematuria. Computed tomography (CT) reveals a right-sided renal tumor with thrombus extending into the right renal vein and minimal extension into the inferior vena cava (IVC). He is listed for angioembolization of the kidney, radical nephrectomy, cavotomy, and IVC repair. On admission he is found to…
Case Synopsis A 50-year-old man presents to the emergency department after falling from the roof of his house. He is tachycardic (heart rate of 120 beats per minute) and normotensive (blood pressure of 130/88 mm Hg), with a grossly distended abdomen on arrival. His Glasgow Coma Scale score is 15, and computed tomography suggests intraabdominal bleeding. The decision for emergency laparotomy is made and, on opening…