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Complications of Lithotripsy

Case Synopsis A 78-year-old woman with a history of severe coronary artery disease underwent extracorporeal shock wave lithotripsy with general anesthesia. Ten minutes after placement in the water bath, the patient’s heart rate increased from 78 to 138 beats per minute, and pink frothy fluid was noted in the endotracheal tube. The patient was removed from the water bath, and an immediate chest radiograph revealed congestive…

Complications of Laparoscopic Surgery

Case Synopsis A 75-year-old man with dyslipidemia and hypertension is scheduled for elective laparoscopic repair of hiatal hernia. He has been on nothing-by-mouth (NPO; from the Latin, nil per os ) status for 12 hours except for his antihypertensive medications (losartan and hydrochlorothiazide). During induction of general anesthesia, his systolic blood pressure drops to 85 mm Hg. The patient receives a 500-mL bolus of lactated Ringer’s…

Complications of Carcinoid Tumors

Case Synopsis A 55-year-old man is scheduled for emergency exploratory laparotomy for small bowel obstruction. Anesthesia is induced with intravenous (IV) fentanyl, lidocaine, propofol, and succinylcholine and maintained with sevoflurane in an air-oxygen mixture with vecuronium. During the surgery the patient becomes profoundly hypotensive. His blood pressure does not respond to boluses of IV fluid, ephedrine, and epinephrine. The patient’s face and neck appear flushed. Problem…

Complications of Adrenal Surgery

Case Synopsis 1 Pheochromocytoma A 38-year-old woman presents in the surgical outpatient department with recurrent attacks of palpitations, headache, diaphoresis, occasional right-sided abdominal pain over the last year, and a neck swelling for the last 2 months. On examination she is severely hypertensive (220/130 mm Hg); a 3-cm thyroid nodule is present in the front of the neck. An ultrasound of the abdomen reveals a right-sided…

Complications After Pneumonectomy

Case Synopsis A 72-year-old man is scheduled for a right-sided pneumonectomy for non–small-cell lung cancer. He has a past medical history of long-standing smoking, diabetes mellitus, and hypertension. He has a remote history of non–Q-wave myocardial infarction with a coronary artery stent placed in his left anterior descending artery. He had a nuclear medicine stress test performed 1 year previously that was negative for myocardial ischemia.…

Chronic Nonsteroidal Antiinflammatory Drug Use

Case Synopsis A 60-year-old man with a history of osteoarthritis has been taking naproxen for the past 3 years without complications or side effects. He experienced sudden severe nausea and vomited frank blood. He was taken to the emergency department and underwent an urgent upper gastrointestinal (GI) endoscopy, which revealed a bleeding gastric ulcer. Problem Analysis Definition Nonsteroidal antiinflammatory drugs (NSAIDs) are widely used drugs that…

Carotid Endarterectomy

Case Synopsis An 82-year-old woman with a significant past medical history of hypertension and coronary artery disease undergoes carotid endarterectomy (CEA) under regional anesthesia. She experienced an episode of dysphasia and transient weakness affecting her left side 3 days previously. Investigations revealed an 80% stenosis of the right internal carotid artery. Her blood pressure is 180/95 mm Hg before surgery. Surgery proceeds uneventfully, although she remains…

Cardioversion

Case Synopsis An 88-year-old woman with a background of hypertension, angina, and mild asthma presented to the emergency department (ED) with a 10-day history of abdominal pain, nausea and vomiting, and reduced oral intake. She was initially being treated for acute dehydration secondary to gastroenteritis. On further questioning, she had a significant history of ischemic heart disease (IHD) limiting exercise tolerance, having suffered from a previous…

Cardiomyopathies

Case Synopsis A 3-year-old boy presents for inguinal hernia repair. His past medical history is unremarkable except for an upper respiratory infection 3 weeks ago that was characterized by a low-grade fever, thin rhinorrhea, and a mild cough that resolved last week. His physical examination and vital signs are normal. On anesthetic induction with nitrous oxide, oxygen, and sevoflurane his heart rate increases to 180 beats…

Bleeding After Cardiac Surgery

Case Synopsis A 73-year-old man presents with a history of aortic stenosis, coronary artery disease, peripheral vascular disease, dyspnea at rest, and chronic renal failure (creatinine level 1.6 mg/dL). Myocardial function is moderately reduced (left ventricular ejection fraction is 35%). Combined aortic valve replacement and coronary artery bypass graft surgery is performed. Total cardiopulmonary bypass (CPB) time is 142 minutes. Postoperative bleeding as measured by chest…

Arteriovenous Malformation : Normal Perfusion Pressure Breakthrough

Case Synopsis A healthy, 41-year-old man presented to his primary care physician with a 3-month history of right-sided temporal-occipital headaches. He was initially treated conservatively with oral analgesics and subsequently an occipital nerve block without significant improvement. Magnetic resonance imaging (MRI) was eventually obtained demonstrating the presence of a 2 × 3 cm arteriovenous malformation (AVM) located in the right temporal lobe ( Fig. 37.1 ).…

Anticoagulation Initiation and Reversal for Cardiac Surgery

Case Synopsis An 81-year-old woman with dyspnea at rest due to aortic stenosis (valve area 0.4 cm 2 , mean gradient 50 mm Hg) presents for aortic valve replacement. Past medical history is significant for a recent pulmonary embolism, for which she received intravenous heparin therapy. At the time of operation, antithrombin III (AT-III) levels are low and the activated partial thromboplastin time is elevated. After…

Anticoagulants and Peripheral Nerve Block

Case Synopsis A 70-year-old man with a history of valvular heart disease, peripheral vascular disease, and diabetes mellitus is scheduled to undergo a below-the-knee amputation. The patient has been receiving daily anticoagulation with warfarin since his aortic valve replacement 5 years ago. Five days before surgery, the patient’s warfarin was discontinued by his primary care physician, at which time he began therapeutic anticoagulation bridging therapy with…

Anterior Mediastinal Mass

Case Synopsis An 8-year-old, previously healthy girl is admitted with respiratory distress, wheezing, and stridor. Her symptoms have been slowly progressive over 2 weeks and are associated with nocturnal fever and exercise intolerance. The chest radiograph demonstrates a widened mediastinum and a retrosternal mass ( Fig. 34.1 ). A computed tomography (CT) scan of the chest confirms the presence of an anterior mediastinal mass ( Fig.…

Antepartum Hemorrhage

Case Synopsis A 30-year-old woman, gravida 3, para 2, presents at 28 weeks’ gestation with vaginal bleeding. She has had a previous myomectomy and two previous cesarean deliveries. This is her first episode of bleeding in pregnancy. The estimated blood loss is about 200 mL. She is hemodynamically stable and her hematocrit is 30%. Ultrasonography reveals evidence of placenta accreta. Problem Analysis Definition Antepartum hemorrhage is…

Anesthetic Complications of Fetal Surgery : EXIT Procedures

Case Synopsis A 28-year-old gravida II, para I woman at 36{2/7} weeks’ gestation presents with a fetus prenatally diagnosed with a large cystic left lung mass. Ex utero intrapartum therapy is planned to establish an airway before delivery and possibly transition the fetus onto extracorporeal membrane oxygenation. Acknowledgment The authors wish to thank Dr. Marnie Robinson for her contribution to the previous edition of this chapter.…

Anesthesia for Electroconvulsive Therapy

Case Synopsis A 65-year-old man with a major depressive illness is scheduled to commence his first course of electroconvulsive therapy (ECT). Medical assessment before commencing treatment reveals he is otherwise well, apart from being hypertensive (serial readings in the order of 180/95). For management of his psychiatric condition he is currently taking tranylcypromine, lithium, and sodium valproate. Following anesthesia with thiopentone and suxamethonium and a period…

Adenotonsillectomy

Case Synopsis An obese 3-year-old boy (body mass index 30) with obstructive sleep apnea (apnea hypopnea index 10) presents for tonsillectomy and adenoidectomy. In the postanesthesia care unit, his respiratory rate is 10 breaths per minute with significant respiratory pauses, and his heart rate is 140 beats per minute. A small amount of blood is noted in the oropharynx, and he has bilateral rales on auscultation.…

Abdominal Aortic Aneurysm Repair

Case Synopsis A 74-year-old man with chronic stable angina, hypertension, and a previous myocardial infarction is undergoing an endovascular aneurysm repair (EVAR) of an infrarenal para-anastomotic aortic aneurysm under general anesthesia. Previous dipyridamole thallium testing revealed a large, fixed myocardial defect with no evidence of reversible disease. It has been 4 months since his prior open abdominal aortic aneurysm (AAA) repair in which his postoperative recovery…

Upper Respiratory Tract Infection

Case Synopsis A 4-year-old girl with a history of recent upper respiratory tract infections (URIs) and symptoms of clear rhinorrhea and occasional nonproductive cough and a history of low-grade fever 3 days ago presents for a tonsillectomy and adenoidectomy under general anesthesia. She has a history of frequent URIs and has had four episodes in the last 3 months. Laryngospasm occurs during inhalation induction of anesthesia…