case discussion--elderly woman for open cholecystectomy

MDMZ

A 90-year-old woman presents for elective open cholecystectomy. She has had recurrent bouts of abdominal pain over the past year. In her history, she says she has atrial fibrillation, a “bad chest” and arthritis.

Blood results
K+: low normal
Bilirubin: slightly raised
Alkaline phosphatase and alanine aminotransferase: normal
No clotting results supplied

Investigations
Lung function tests: forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) decreased (~ 60% predicted); FEV1:FVC ratio 120%
ECG: atrial fibrillation with left bundle branch block
Chest X-ray: obscured left diaphragm and visibly hyperinflated. Otherwise, nothing abnormal discovered.

Questions
1. How would you anaesthetise her and why?
2. How would you assess her airway?
3. What test do you know for assessing the airway?
4. How good are these tests?
5. What other tests would you want to perform?
6. What do the lung function tests show?
7. What does the chest X-ray show?
8. What does the ECG show?
9. What monitoring would you use?
10. How would you monitor her fluid status intra-operatively?

王麻子

1,GA(general anaesthesia):patient's age,AF.GA is better to adjust the patient's acid-base eqilibrium and to make her safe in the operation.
2,3,first:which degree of the patient's Mallanpati分级.the distance between jaw and thyroid;

王麻子

5:clotting test
8:no "P" wave in ECG.V5 and V6 "QRS" show "m" wave.
9:ECG,SpO2,noninvasive blood pressure,cvp
10:CVP and pcwp:maintain cvp in the normal round and if possible give the patient montoring the pressure of the pulmonary capillary.This is useful to assess fluid stasus and the function of left ventricular.

shenxiu2

回复 1# MDMZ


  The problems:

1.Elderly ---decreased pulmonary reserve; post operative atelectasis; decreased cough reflexes; increased sensitivity to anesthetic agents.

2.Open Cholecystectomy ----Big wound ; post-op pain  may prevent adequate breathing effort and lung expansion ,increase the possibility of atelectasis and pneumonia.

3." Bad Chest " --from history and lung function test , she has very  poor lung function ( Both FEV1 & FVC <70% are predictors for morbidity & mortality in abdominal surgery ) ( Can FEV1 :FVC =120%? What does this signify? )  At her  age , we must consider the possibility of difficult extubation, post op hypoxiemia, reintubation and possibility of prolonged ventilatory support .

4. Atrial Fibrillation and LBBB---What is the cause ? Is it pulmonary in origin ? Or cardiac ischemia ? Or endocrinal in origin? LBBB can be ischemia in origin.

5. Arthritis ---How severe ? What is the type ? If it is ankylosing spondylitis, she may present with  airway management difficulty .

6. Chest X ray --What is the cause of the obscured left diaphragm?


Discussion:

Besides Mallampathi classification and Thyromental distance , we need to assess the neck movement and mouth opening .

I would like to rule out cardiac ischemia and assess cardiac function ( Echocardiogram) , in view of the long standing lung problem and the ECG findings.

I would prefer to do regional anesthesia in this case , to avoid the pulmonary complications. For regional anesthesia ( Epidural ) , I will need to rule out coagulopathy , so a coagulation profile testing is needed.( PT / APTT, Platelet count ) .

She will need invasive monitoring intraoperatively .( Arterial BP , CVP at least ).