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PhysioloGy And AnesthesiA for GenerAl And BAriAtriC surGery ● 337 Pancreatic Surgery Pancreatic surgery is usually performed for pancreatitis, pancreatic cysts, or tumors. Patients with pancreatitis may have respiratory compromise and sepsis. Severe dehydration and electrolyte imbalance, especially hypocalcaemia, is also common. The need for invasive monitors should be individualized. Hernia Surgery Increased intra-abdominal pressure from COPD and chronic cough, bladder outlet obstruction (BPH) or ascites may be some of the predisposing factors for hernias and should be addressed before repair to prevent recurrence. Common hernia types include inguinal, umbilical, and incisional. General, regional or local anesthesia may be used for uncomplicated cases and is usually individualized based on underlying disease, hernia size and location, and patient’s and surgeon’s preferences. Case Study A 38-year-old female is scheduled for laparoscopic Roux-en-Y gastric bypass. She is 5 feet, 6 in. tall and weighs 300 pounds. She has tried various diet and exercise plans to lose weight without success. She has hypertension treated with an ACE inhibitor. She wheezes on exertion or in hot weather and uses an albuterol inhaler as needed. She snores loudly while sleeping but has not had a formal sleep study and is not interested in CPAP at home due to a poor experience related by a friend. She does not exercise regularly but she is able to walk on level ground for a few minutes at a time in her work as an office postal worker. She has been told she has “borderline diabetes” but is not currently taking any medication for it. Preoperatively, her examination shows BP 180/95, HR 90, RR 24, scattered end expiratory wheezes, which clear with cough, airway Mallampati class II, thyromental distance 4 fingerbreadths. How severe is her obesity? Does it matter? Can any other obesity measures help you characterize her health risk further? Her BMI is 48.4, putting her in the morbidly obese category. Although risk is not linearly related to BMI, risk is higher for more obese individuals.
338 ● AnesthesiA student survivAl Guide The pattern of obesity, however, may be even more important than the absolute magnitude of her obesity. You could ask her waist size, and if >35 it would correlate with higher risk. Other obesity-related risk factors for perioperative morbidity include her relative inactivity and glucose intolerance. Interestingly, sleep apnea per se probably is not such a risk factor but it has significant anesthetic implications regarding difficulty with intra- and postoperative airway management. What concerns do you have about her respiratory status? How will these impact your anesthetic plan? You should be quite concerned. First, she may desaturate with positioning, even before sedative drugs are given, due to lower FRC relative to closing capacity, leading to ventilation–perfusion mismatching. This may worsen with induction of anesthesia, due to limited apneic reserve of oxygen in the lowered FRC. Second, her questionable history of obstructive sleep apnea (snoring) are concerns for possible difficult mask ventilation. Third, you may be concerned that she could have a possibly difficult intubation despite the reassuring airway exam, due to obesity itself. Fourth, she has a history of wheezing, implying she may have reactive airways and thus prone to intraoperative bronchospasm. Finally, though controversial, some consider morbid obesity to be a risk factor for aspiration of gastic contents during induction. In response, you will position her slightly head-up with blankets under her shoulders or a specialized pillow such as the Troop elevation pillow. You will carefully preoxygenate to ensure the longest possible time for intubation. You will have a selection of adjunctive devices available to assist with possibly difficult mask ventilation as well as alternative intubation devices such as a video laryngoscope, which may shorten the time to intubation in obese individuals. Finally, you should have help immediately available should ventilation or intubation prove to be challenging. How will you monitor her during the anesthetic? Will your plan differ from a normally proportioned patient having laparoscopic surgery? All ASA standard monitors should be used and will not differ markedly from those used in a normally proportioned patient. The BP cuff must be of appropriate size or you will overestimate blood pressure. An alternative is to place a cuff on the forearm, or consider an arterial line if noninvasive pressure monitoring proves too technically difficult. Depending on your
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Anesthesia Student Survival Guide
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Editors Jesse M. Ehrenfeld, MD, MPH
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Foreword As anesthesiologists and H
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Contents Case Studies xvii Section
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ContEntS ● xi 19 Physiology and A
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Contributors Basem Abdelmalak, MD S
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David C. Lai, MD Partner, Allenmore
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CASE STUDIES In order to focus your
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CASE StUDIES ● xix inhalation ane
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CASE StUDIES ● xxi around the job
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CASE StUDIES ● xxiii ● Although
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CASE StUDIES ● xxv ● You plan a
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CASE StUDIES ● xxvii ● What oth
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CASE StUDIES ● xxix Chapter 23 Ca
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CASE StUDIES ● xxxi of her left h
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CASE StUDIES ● xxxiii speechless.
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CASE StUDIES ● xxxv things go ver
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How to Be a “Star” Student, Car
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hOw tO Be A “stAr” student, CAr
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Pre-Op Holding Area Preoperative Ev
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History of Anesthesia and Introduct
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history of AnesthesiA And introduct
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Pharmacology Section II
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The Preoperative Patient Evaluation
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THe PreoPerATIve PATIenT evAluATIon
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Therapy-based indications radiation
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Table 8.5 Formulation an anesthetic
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Anesthesia Equipment and Monitors B
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AnesthesiA eQuiPment And mOnitOrs
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● ● ● AnesthesiA eQuiPment An
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Table 11.3 Data typically obtained
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Anesthetic Techniques: General, Sed
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Anesthetic techniques: GenerAl, sed
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Table 12.2 Stages of general anesth
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Table 12.6 (continued) Anesthetic t
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Anesthetic Techniques: Regional Ant
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Figure 13.2 Surface anatomy for neu
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Table 13.1 Risks of neuraxial anest
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Anesthetic techniques: reGionAl ●
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Table 14.6 Advantages, disadvantage
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Table 14.11 Transfusion of bloodpro
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Chapter 15 IV, Gastric Tube, Arteri
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iv, GAstric tube, ArteriAl & centrA
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Common Intraoperative Problems Fran
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Pneumothorax Uncommon, but may spon
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COMMON INTRAOPERATIVE PROBLEMS ●
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Table 16.3 Common intraoperative dy
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Table 16.3 (continued) Problem Diff
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Systems Physiology and Anesthetic S
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AmbulAtOry Surgery ANd Out-Of-Or (O
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Perioperative Acute and Chronic Pai
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PerioPerAtive ACute And ChroniC PAi
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Chapter 27 Postoperative Anesthesia
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POstOPerAtive AnesthesiA CAre unit
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Introduction to Critical Care Bever
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introduction to criticAl cAre ● 4
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SVR = [(MAP - CVP)/CO] ´ 80 introd
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● ● ● ● ● introduction to
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Chapter 29 Professionalism, Safety,
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ProfessionAlism, sAfety, And teAmwo
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Chapter 30 Quality Assurance, Patie
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QuAlity AssurAnce, PAtient And Prov
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Chapter 32 Clinical Simulation in A
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Table 32.1 Matrix of categories of
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CliniCAl simulAtion in AnesthesiA e
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ASA Difficult Airway Algorithm Appe
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518 ● ANESTHESIA STUDENT SURVIVAL
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