Anesthesia Student Survival Guide.pdf - Index of

170 ● AnesthesiA student survivAl Guide
Case Study
A 78-year-old ASA III male with a Mallampati class III airway presents for a
cerebral angiogram due to a recent episode of severe headache and transient
neurological deficit. He has a history of stable coronary artery disease, poorly
controlled hypertension, hyperlipidemia, and type II diabetes mellitus. He is
a former heavy drinker and smoker but quit both last year. He has no known
drug allergies and takes atorvastatin, lisinopril, metoprolol, and roziglitazone
(Avandia). You plan monitored anesthesia care (MAC).
The case will be done in the angiography suite, not the OR, and you plan
MAC, not general anesthesia. How will this alter your anesthetic equipment
set up?
The short answer is, it won’t! In any anesthetizing location, you should have
all of your usual tools, drugs, and equipment. Any case planned for monitored
anesthesia care could potentially require advanced airway management
or conversion to general anesthesia. The remote location of an increasing
fraction of anesthesia cases poses a challenge and requires flexibility, since
the geometry of the radiology, endoscopy, and cardiac catheterization
laboratory suites will differ from the operating room. But the basic elements
should always be present.
What drugs will you select for the case?
Midazolam and fentanyl are often used for light sedation, but they can produce
respiratory depression and may have a greater effect in the elderly or
those with cardiopulmonary disease. You might consider instead the use
of shorter acting drugs with predictably short offset, such as a low-dose
propofol infusion (25–75 mcg/kg/min) or a dexmedetomidine infusion
(0.2–0.5 mcg/kg/h).
After imaging the patient, the radiologist discovers an aneurism and small
intracerebral hemorrhage and wishes to coil embolize it to prevent further
bleeding. She requests that you alter conditions to completely immobilize the
patient for the procedure. What are your options?
You could deepen the sedation but given his comorbidities and age you
might prefer to induce general anesthesia instead. This also lets you use
neuromuscular blocking drugs to provide immobility without the fear that