Melvin Jubber is a 77 year old male Caucasian, former farmer from rural Alberta. He was transferred to the Peter Lougheed Centre where he underwent radiologic investigation for suspected AAA (confirmed 6cm infra-renal, intimal aneurism). Co-morbidities include Type II diabetes, 20 pack year smoking history, (quit 25 yrs ago) diffuse atherosclerosis, and moderate obesity. Weight 117 Kg. Height 183 cm. Presenting complaint was lower back and leg pain.
实验室检查结果：
ABGs done the day before surgery are: pH -7.48, PCO2 -33, PaO2 -95, HCO3 -24, HbO2 -96%. --On an FiO2 of 0.28
PFTs: FEF 25-75 --83% of predicted, VC --95% of predicted, FEV1 –85 %.
Twelve Lead ECG: Moderate hypertrophy, R shifted axis, inverted T waves on lead II, Rate -54/m, occasional runs (1 every 5 minutes) of 3-4 uni-focal PVCs
Echo-cardiogram: Large 6 cm intimal aneurism in lower aorta, above renal branching
Heart Sounds: Normal S1 & S2, Mild S 4
Swan-Ganz Data: CVP 5 mmHg, PA pressure 20/9 mmHg, PCWP 6mmHg, CO 4.1 L/m
CH7: Na+ 139; K+ 4.9; Ca++ 9.1; Mg++ 2.7; HCO3 - 26: Cl- 101; HPO4- 2.6; BUN 21.5 mg/dL, Albumin 4.3 g/dL, Glucose 120 mg/dL
CBC: Hgb 14.7 gm%, HCT 42%; Platelets 210,000/mm3, WBC – 4,700 /mm3, 4 % bands.
Chest X-ray: Relatively normal chest film.
Physical Assessment:
Disagreeable, demanding gentleman, sitting back (HOB up 450), SOBOE, moderate accessory muscle use, no pedal edema, no JVD, no hepatomegaly, severe lower abdominal and leg tenderness, ENT unremarkable. Neuro exam unremarkable.
Height 183 cm. Weight 117 Kg
BP: 148/96 mmHg; R>L brachial
RR: 24, shallow
Temp: 37.9 0C --- tympanic
O/A: Scattered wheeze through out both lungs, scarce crackles mainly lower lobes.
Current medications:
ASA (one 81 mg tablet, daily)
Ibuprofen PRN
The Problem:
Mr. Jubber needs an AAA repair operation to prevent dissection and exsanguination. This procedure will include cross clamping of the aorta. He will be an emergent case so the surgical team wants to do the repair now. Time is of the essence. You are the head anesthetist and the final word about the surgical risk/procedure is yours.
这里是需要解答的，也是我求助的
What to do….what to do…?
Can he be safely and conservatively managed?
How can he be optimized for OR?
What special considerations does he require?
1。To determine how urgent is the surgery --whether the aneurysm is leaking , if it is not leaking , you may still have a few hours to optimize the patient's condition.
2. Make a diagnosis of his lung condition --he probably has exacerbation of COPD ( Since there is no signs of heart failure and chest X ray did not show any evidence of pneumonia, the use of Aspirin and NSAIDs may have precipitate the COAD exacerbation ).
3. Treat his lung condition --steroids, bronchodilators etc..
4. Control blood pressure to prevent further leaking or rupture of aortic aneurysm --by intravenous vasodilators. Establish invasive monitoring .
5. While optimizing the patient's condition --prepare for surgery ---crossmatching blood and blood products, meeting up with patient's family & explain the risk involved with surgery and anesthesia , including post operative ICU stay, obtain high risk consent, booking of ICU bed.
2。Can he be safely and conservatively managed?
If the aortic aneurysm is life threatening , he cannot be conservatively managed safely. He should go for surgical repair.
3。How can he be optimized for OR?
As above in 1.
4。What special considerations does he require?
1. Elderly with all issues associated with elderly patients undergoing anesthesia.
2. Diabetes with glucose control perioperatively.
3. COAD/ COPD with optimization and effective control perioperatively.
4. Obesity with all problem associated with obese patient undergoing anesthesia.
5. intraoperative Bleedinｇ .
6. Aortic cross clamping may cause cardiac ischemia in view of possible ischemic heart disease. ---cross clamping should be done in stages , and slowly, vasodilator infusion and epidural local anesthetics infusion may help to reduce the systemic vascular resistance during aortic cross clamping.
7.Suprarenal AAA repair may cause further deterioration of renal function and possibility of renal failure post operatively( because of Aortic cross clamping above renal arteries).
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发表于 2011-2-9 13:27:53
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发表于 2011-2-14 20:00:55
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