A
95yo male is brought to the OR for cystoscopy and TURBT. You've
seen his name on the add-on schedule for days, and you've prayed that
he
not come to your room, but alas there was no avoiding it...he's all
yours now! He lives alone and has a nurse that visits him
daily, and was doing well and managing to get around his apartment
with a walker until he developed painless hematuria. He was
admitted and treated for a UTI, developed urosepsis, went into
congestive heart failure, had an MI, and was ultimately found to have a
bleeding bladder tumor.
His past history is significant for hypertension, critical AS, a few
MIs (most recently the week prior to the proposed operation), and
CHF which is "fairly well controlled with prn Lasix" per the medicine
note. The cardiology note mentions an EF of 25% and states that
he is "at high risk of perioperative event even with a low risk
procedure". Cheerful and optimistic, isn't it?
Question 1: What are the
anesthetic goals of managing a patient with critical AS? Question 2: What are the
anesthetic goals of managing a patient with CHF?
Question 3: What are the anesthetic goals of managing a patient
with a recent MI?
He comes to the preop area slightly confused but looking pretty
good, and his BP is 95/50 with a HR of 70. He has slight rales on
bilateral lung exam, but seems to be in no respiratory distress while
laying flat in the gurney.
Question 4: OK smarty, so how are you going to reconcile all of
these goals in this patient? What's your detailed anesthetic plan
to include monitoring, induction and/or regional technique, airway
management, maintenance, pain control, fluid replacement, etc.
Extra Credit
Questions (required for full credit, so not really extra I
guess)
Question 5: How old is the oldest
documented patient to undergo an
operative procedure in the anesthetic (and I think all medical)
literature? Question 6: How old is the
oldest person alive today? How about the oldest person ever? Question 7: What is your
personal prescription for longevity?
The first person to
email me a COMPLETELY CORRECT answer at roy.soto@stonybrook.edu wins
a prize and the adoration of the entire department!