Self assessment case histories

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1. A 75-year-old woman has been admitted 24 hours previously with large bowel obstruction. She is warm and tachycardic and had been unwell at home for several days before coming to hospital. Her urine output per hour has slowly decreased throughout the day and is now < 0-5 mg kg-1 per hour. She is scheduled for theatre in a few hours. Outline your management.

2. A 70-year-old woman is due for a partial gastrectomy for stomach cancer but the surgeons have noted that her ECG has changed in the last 4 weeks. There is new T wave inversion in leads V1-V4. You are asked to decide whether or not she has had a myocardial infarction. She says she had an hour of chest discomfort 2 weeks ago, but did not seek medical attention. She does not suffer from angina or breathlessness, and is walking around the hospital with no symptoms. What is her perioperative risk, what can you do to reduce that risk, and what do you advise the surgeons?

3. A 60-year-old man comes to the Outpatient Department, referred by an orthopaedic surgeon. The patient has a history of ischaemic heart disease and has had a myocardial infarction many years ago. He does not have angina nowadays (on treatment). He arrives using a walking stick because of his painful knee, which is due to be replaced. The orthopaedic surgeon has asked whether it is safe to proceed with the planned surgery in view of his heart disease. What is the question you are being asked? How do you assess the patient?

4. A 75-year-old lady is admitted following a fall and a fractured left neck of femur. There is no past medical history. She has been lying on the floor for 18 hours at home. On examination her skin feels warm and dry. She has the following vital signs: in pain, pulse 110/minute, BP 110/60 mmHg, RR 26 per minute, temperature 38°C, SaO2 94% on air, urine output - has not passed urine since admission (not catheterised). There are coarse crackles at the left base of the lungs and a chest x ray film shows pneumonia. She is scheduled for theatre as soon as possible. What do you need to do before then?

5. You are asked to see a 60-year-old man who is being booked for an elective inguinal hernia repair. In the Outpatient Clinic it is noted that his oxygen saturations are 89% on air and he is breathless on exertion. You are asked to advise on his chest condition before surgery. Further history reveals that he is a lifelong smoker and used to be a miner. He has several years' history of breathlessness on exertion but has never seen a doctor about it. On examination he has hyperexpanded lungs and prolonged expiration with scattered wheeze. His chest x ray film shows clear lung fields and his arterial blood gases on air show: pH 7-4, PaCO2 6-0 kPa (46 mmHg), bicarbonate 27 mmol/l, BE + 1, PaO2 7-5 kPa (57-6 mmHg). What is your advice to the surgeons?

6. A 65-year-old lady is admitted with small bowel obstruction, which is being treated with a nasogastric tube and intravenous fluids. She has a history of stable angina and hypertension. Her usual medication includes atenolol 50 mg a day. You are asked to see her urgently because her pulse is 140 per minute (previously 60 per minute). The ECG shows atrial fibrillation. Why has this happened and what is your management?

7. A 60-year-old man on treatment for angina and heart failure is admitted with bowel obstruction. He has been unwell with vomiting for 4 days. On examination he has a pulse of 100 per minute, BP 100/50 mmHg, RR 24 per minute, temperature 37-5°C and SaO2 95% on air. His blood results show a raised white cell count and urea of 15 mmol litre-1 (BUN 41 mg dl-1), creatinine 300 ^mol litre-1 (3-6 mg dl-1). His urea and creatinine were normal 3 months ago. He is scheduled for theatre as soon as possible. Should he be "preoptimised"?

Self assessment - discussion

1. Looking back, preoperative aims were summarised as:

• airway secure

• respiratory rate 10-30

• well perfused with good cardiac output

• normal electrolytes (especially K+ and Mg2+)

Is this case due to simple hypovolaemia or is this patient developing SIRS? Management consists of A (giving a high concentration of oxygen), B (treating any breathing problems), and C (giving fluid). Hypoperfusion should be assessed further by measuring blood pressure, respiratory rate, skin temperature, and arterial blood gases. Invasive monitoring may be helpful. Particular attention should be paid to the possibility of electrolyte disturbances from nasogastric losses. Surgery should be postponed for a short time while resuscitation takes place - ask whether she should be preoptimised in a high dependency area.

2. Myocardial infarction is diagnosed from history, electrocardiogram changes, and a cardiac enzyme rise. Two out of three indicates a probable recent myocardial infarction. This, and the type of surgery, places the patient at high risk of perioperative cardiac complications but, as the surgery is for cancer, it would be impractical to postpone this for 6 months. In terms of function the patient is quite good with no angina, breathlessness, nor limitation of mobility. Post-myocardial infarction treatment is indicated (including a p blocker, which will also reduce perioperative risk). A discussion of the risks involved should take place between the surgeon, anaesthetist, and patient. High risk patient and high risk surgery should lead to consideration of perioperative invasive cardiac monitoring.

3. The questions being asked are:

• How significant is this patient's ischaemic heart disease?

• What is his perioperative cardiac risk?

• Can that risk be reduced by any specific measures?

The patient should be asked about cardiac symptoms and general function. The Goldman score can be used at this point. General cardiovascular risk factors should be sought and treated (for example, hypertension, high cholesterol, diabetes, and smoking). Perioperative p blockers would be indicated. He is an intermediate risk patient facing intermediate risk surgery with good function. However, his mobility may be limited by his painful knee, masking angina symptoms. Non-invasive cardiac testing may therefore be indicated to assess this further.

4. With the list of preoperative aims in Question 1 in mind, this patient needs oxygen therapy, treatment for pneumonia, and fluid for dehydration. Analgesia is required, but not with NSAIDs (oliguria). A urinary catheter and arterial blood gases are indicated. Blood should be sent for full blood count and electrolytes. In this case creatinine kinase levels should be measured, as the patient has been lying on the floor for a long time and has oliguria (possible rhabdomyolysis). Outcome is better after a fractured neck of femur if surgery is within 24 hours and regional anaesthesia is used. The dilemma here is that delaying surgery while waiting for the chest to improve may not help. Early surgery, good postoperative care, physiotherapy, and mobilisation may in fact be better for the chest.

5. This man has a new diagnosis of COPD. This can be confirmed by pulmonary function tests. He needs treatment for this condition under the supervision of a chest specialist. Once this is done and the patient is as fit as he can be (which may mean he is still breathless and hypoxaemic), the following recommendations should be made:

• the patient should stop smoking

• perioperative inhaled beta agonists should be prescribed.

Intravenous steroids can be considered. Early mobilisation and chest physiotherapy are indicated after surgery and a discussion should take place with the anaesthetist and surgeon as to whether or not a general anaesthetic can be avoided.

6. The abrupt withdrawal of this patient's p blocker and possible electrolyte disturbance (from bowel obstruction and intravenous fluid administration) have caused atrial fibrillation in this lady with ischaemic heart disease. Treatment still starts with A, B, C. Correction of any low potassium or magnesium and intravenous administration of a p blocker is a logical course of action in this case.

7. Yes! This patient has significant premorbid conditions and is about to undergo major surgery. He already has symptoms and signs of organ dysfunction. Volume depletion may be the cause of his acute renal failure. He requires aggressive but careful fluid resuscitation in order to maximise his compensatory responses to surgery. He should be referred to the ICU where fluid therapy can be titrated using more advanced forms of monitoring. "Goal-directed therapy" in this patient may stop the slide from SIRS to MODS. Goals should be set according to the monitoring available in your hospital (pressure-based or flow-based). Useful tests to monitor the success or failure of resuscitation are clinical status and biochemical markers of hypoperfusion (base deficit, lactate, and pHi). Inotropes should be commenced if appropriate. Dopexamine at a rate of 0-5-1-5 |ig kg-1 per minute can improve oxygen delivery and tissue perfusion. Monitoring should be continued during surgery and the immediate postoperative period. "Optimisation" after surgery is less effective in improving outcome.

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