BKA anaesthesia discuss

lumingfang003

A 68-year-old patient with insulin-dependent diabetes mellitus presents with septic shock and diabetic ketoacidosis for a below-knee amputation.

1. How would you proceed?
2. How would you resuscitate the patient?
3. What fluids would you administer?
4. How would you infuse insulin?
5. What investigations would you carry out and why?
6. Which antibiotics would you give?
7. Describe your management plan for the patient
8. You need to administer unilateral spinal anaesthesia; which drug would you use and at what dose?
9. If, 10 minutes after a successful block, the patient has convulsions, what would you do? What might be the causes?
10. Why might the patient suffer from hypoglycaemia during surgery?

maomaosmmu

没有能力用英文回答，就用中文尝试一下，希望能看到参考答案。
1. How would you proceed?
纠正休克、酸中毒，维持生命体征，病情稳定后再行手术；
进行必要的实验室检查，如血常规、尿常规、血糖、电解质、血生化、肾功能指导下一步治疗措施。
2. How would you resuscitate the patient?
补液以晶体液为主，酮症酸中毒病人最好输0.45%低张盐水，有条件的在CVP指导下补液，没条件就以血压变化为指导；
给予胰岛素＋葡萄糖，纠正酸中毒，如果PH<7.2，可考虑给予碳酸氢钠；
根据尿量和血钾情况给予补钾，这类病人一般都要补钾；
3. What fluids would you administer?
晶体液为主，最好输0.45%低张盐水
4. How would you infuse insulin?
先给予负荷剂量10～20U，1U/h持续静滴，血糖下降速度不超过2mmol/L/h，控制在8～10mmol/L即可。
5. What investigations would you carry out and why?
评估病人的心肺功能，能否耐受手术；查心电图，此类病人可能会伴有心肌缺血；
检查肾功能，此类病人往往伴有糖尿病肾病；
6. Which antibiotics would you give?
糖尿病足部坏疽一般是以厌氧菌为主的混合性感染，以广谱抗生素为主＋抗真菌药物
标本培养及药敏试验结果出来后，再选择针对性抗生素；
7. Describe your management plan for the patient。

8. You need to administer unilateral spinal anaesthesia; which drug would you use and at what dose?
重比重布比卡因（布比卡因10mg）
9. If, 10 minutes after a successful block, the patient has convulsions, what would you do? What might be the causes?
保护病人，防止跌落至地面；面罩给氧，给予咪唑安定或丙泊酚或硫喷妥钠，长时间抽搐且无法给氧，立即给予司可林气管插管。
可能原因有：低血压，低血糖，癫痫病史，高热等
10. Why might the patient suffer from hypoglycaemia during surgery?
病人肝糖原储备不足；术中使用胰岛素可能会过量；