AnaesthesiaUK Final Long Case - September 2012

MDMZ

A 64-year-old man presents for thoracic spine surgery. He has a history of hypertension and has recently been treated by his GP with antibiotics for a cough. He also reports having been very sick on morphine in the past.

Drug history
Bendroflumethiazide
Amlodipine

Examination/Observations
Pulse: 75 bpm
Blood pressure: 108/50 mmHg
Auscultation: widespread crepitations.
Blood results: urea 25 mmol/L, Creatinine 156 µmol/L, K+ 5 mEq/L, Na + 151 mEq/L, Hb 12.1 g/dl, white cell count 12 × 109/L, glucose 14 mg/dl, with raised neutrophils.
Arterial blood gases (on air): mixed acidosis with normal anion gap
Pulmonary function tests: peak expiratory flow rate and forced vital capacity (FVC) low, but within normal range; forced expiratory volume in one second (FEV1) 1.8 L; FEV1/FVC 43%
Chest X-ray: shows hyperinflated lungs with consolidation right lower lobe
ECG: sinus rhythm, left-axis deviation, first-degree heart block.

Questions
1. Summarise the case.
2. Discuss his arterial blood gas results. What are the causes of metabolic acidosis and what is the likely cause in this case?
3. What are the causes of acute renal failure? What do you think is the most likely cause in this case?
4. Discuss his ECG. Does first-degree heart block concern you?
5. What do his lung function tests show?
6. How would you optimise his chronic obstructive pulmonary disease treatment preoperatively?
7. How would you manage this case?
8. Assuming that he is now optimised from his recent chest infection, discuss your induction and airway management.
9. How do you insert a double lumen tube?
10. What type and size of tube would you use?
11. If he desaturated during the surgery, how would you manage this?
12. What would be your plan for analgesia?
13. What would be your plan postoperatively?
14. What would inform your decision about whether to extubate him or keep him ventilated?

jl2925

Drug history
Bendroflumethiazide
Amlodipine

随风远飘

2012年9月英国麻醉学期末考试疑难病例分析

一位64岁老年男性拟行胸椎手术。他有高血压病史，近期由于咳嗽接受了抗生素治疗。另外，他曾因为服用吗啡而发生严重眩晕。

用药史   
苄氟噻嗪
氨氯地平

体格检查和辅助检查
脉搏：75bpm
血压：108/50mmHg
肺部听诊：弥散性啰音
血液检查：尿素氮25mmol/l   肌酐156mol/l   钾5mEq/L   钠151mEq/L   血红蛋白12.1g/dl
               白细胞12×10⁹   血糖14mg/dl   中性粒细胞增高
动脉血气（呼吸空气）：混合型酸血症 阴离子间隙正常
肺功能：呼气峰流速和用力肺活量降低，但在正常范围内。第1秒用力呼气量是1.8L，FEV₁/FVC=43%
胸片：重度肺气肿 右下肺实变
心电图：窦性心律 电轴左偏 Ⅰ度房室传导阻滞

问题
1  对此病例作一总结。
2  分析血气结果：代酸的原因？最可能的原因？
3  急性肾衰的原因？最可能的原因？
4  分析心电图：1度方式传导阻滞提示了什么？
5  肺功能结果提示了什么问题？
6  术前应怎样处理COPD，得到最佳改善？
7  如何处理此患者？
8  假如肺部感染已控制，如何诱导？如何进行气道管理？
9  如何放置双腔管？
10  选择几号导管？
11  如果术中氧合不良，如何处理？
12  镇痛方案？
13  术后处理方案？
14  你根据什么来决定：术后拔管？还是带管继续机械通气？