Oxford Case Histories in Anaesthesia by McCormack, Jon -- Read -- Imperial Library of Trantor

Index

Cover Title page Copyright Preface Contents Symbols and abbreviations Contributors Chapter 1. General anaesthesia

Case 1.1 Waiting times: improving theatre productivity and minimizing expenditure

Background Learning outcomes CPD matrix matches Case history

Using the data

‘88% theatre utilization and 99.9% time used—time to celebrate?’ How do we use our time better? Three-session days?

Any other factors that may reduce efficiency?

Further Reading

Case 1.2 Assessing and explaining risk and predicting outcome

Background Learning outcomes CPD matrix matches Case history

Introduction to risk assessment What is fitness for anaesthesia? What is the purpose of risk assessment? What means/tools are available to assess risk? Key elements of a preoperative scoring system How can we communicate predicted risk effectively? What influences a patient’s decisions?

Further Reading

Case 1.3 ‘Did I really do that?’ Managing the aftermath of a serious adverse event

Background Learning outcomes CPD matrix matches Case history

How would you deal with breaking the bad news to the family? How would you deal with the management of the team and its members? How would you deal with the debriefing and/or morbidity and mortality meetings? Further follow-up—how should the anaesthetist in the team be supported in the longer term by the anaesthetic department and the hospital trust, if identified to have psychological distress? How might you be affected by your involvement in a serious traumatic adverse event? What guidelines are available for the medical personnel to deal with consequences of major catastrophes in the workplace? Who should be informed and what steps should be taken by the individuals when dealing with potential complaints in this scenario?

Further Reading

Case 1.4 Current approaches to complex colorectal surgery

Background Learning outcomes CPD matrix matches Case history

How should perioperative care be managed? What are the key aspects of the preoperative assessment in this case history?

Case update: relevant clinical history and investigations

Comments on these results Comments on medications and suggested plan for perioperative management What are the important points to consider in this patient’s preoperative preparation? What interventions should be considered for this patient’s thrombocytopenia? Should there be active management of this patient’s ascites? Given that you anticipate the potential for major blood loss, what blood conservation strategies can you employ to reduce blood loss and transfusion requirement? Discuss your anaesthetic technique for this patient Which analgesic regimen will you use? Monitoring What are your concerns about haemodynamic management? What potential problems, specific to this patient, should you anticipate in the post-operative period? What would alert you to an episode of graft rejection?

Further Reading

Chapter 2. Trauma and resuscitation

Case 2.1 Major haemorrhage

Background Learning outcomes CPD matrix matches Case history

What features of this case suggest haemorrhage, and how can its severity be graded?

Case update

What are the pathophysiological features of a major haemorrhage? What are the priorities in managing this patient with suspected pelvic fracture and major haemorrhage? How should this patient be resuscitated in terms of fluids, blood products, and drugs?

Initial fluid and patient response Blood pressure target Blood product use Red cell replacement Clotting factors and platelets Drugs A new approach

Case update

What are the options for definitive haemorrhage control in trauma?

Case update

How has the introduction of a major haemorrhage protocol influenced management and outcome?

Case update

What is ‘damage control’ surgery?

Case update Further Reading

Case 2.2 Burns

Background Learning outcomes CPD matrix matches Case history

What are your immediate management priorities? How would you assess and manage this patient’s airway? How do you proceed? What drugs would you use? His pulse oximetry reading is 100% on air. Are you satisfied with this? How would you further assess breathing and respiratory function? How might the circulation in a burns patient be compromised? This patient has estimated 28% BSA full-thickness burns. His weight is approximately 85 kg. What is his fluid requirement in the first 24 hours post-burn injury? What other immediate management steps do you initiate in the emergency department? Should this man be transferred to a specialist burns centre? The patient is now intubated and ventilated in the intensive care unit of the regional burns centre. What would make you suspect he had an inhalation injury? How should this man’s nutritional needs be addressed?

Further Reading

Case 2.3 Sepsis

Background Learning outcomes CPD matrix matches Case history

What are your immediate treatment priorities? Going through the ‘Sepsis Six’ bundle, what would be an appropriate choice of antibiotic for this patient? How much fluid do you give him, and what fluid do you give? What is the rationale behind measuring Hb and lactate in patients with severe sepsis?

Case update

Comment on his chest X-ray and arterial blood gases What ventilator settings would you use in this man? What strategies are used in your intensive care unit to reduce the incidence of ventilator-associated pneumonia?

Further Reading

Case 2.4 General anaesthesia for major trauma

Background Learning outcomes CPD matrix matches Case history

Why is the anaesthetist crucial for the management of a trauma patient?

Case update

How should the treatment of these injuries be prioritized?

Case update

What are the issues when considering anaesthetizing this patient? How should the airway be managed for this general anaesthetic? Are there any anticipated difficulties? How should general anaesthesia be induced and maintained?

Induction agents Neuromuscular blockade

What are the issues with ventilation of this patient? What influence does a head injury have on the management of a trauma patient?

Case update

Should this patient be extubated following the surgical procedure, or should ventilation continue in the post-immediate post-operative period?

Case update Further Reading

Chapter 3. Day case anaesthesia

Case 3.1 Post-operative nausea and vomiting

Background Learning outcomes CPD matrix matches Case history

What further information would you like during the preoperative assessment?

Case update

Will her fasting status delay her operation? Would you consider her recent cup of coffee or gum chewing in breach of fasting guidelines? She does not have a carer at home. Is she suitable for day case surgery? Is her history of post-operative nausea and vomiting significant? Is there any other information you would like? Can this procedure be carried out under local or regional anaesthesia? How are you going to provide anaesthesia and analgesia for this lady, given she refuses a regional technique?

Preoperatively Intraoperatively Post-operatively

Would you give IV fluids? Are you aware of any other effective antiemetic drugs? In what way might they be beneficial? Would the administration of this combination of drugs give you any concerns about post-operative sedation? If this lady manages to arrange for a carer at home, would she be suitable as a day case?

Further Reading

Case 3.2 Day case dental anaesthesia

Background Learning outcomes CPD matrix matches Case history

What is Eisenmenger’s syndrome? What problem does this present? How would you go about anaesthetizing this gentleman? You are the consultant. How would you go about anaesthetizing this gentleman? Does he need this surgical procedure? Does he need a general anaesthetic?

Case update

Is a remote dental hospital a suitable site? Would you provide conscious sedation for this gentleman in this location if all the dental extractions were thought to be straightforward? What anaesthetic would you give this gentleman? What induction agent would you use? What analgesia would you use? Would you intubate and ventilate this gentleman? What monitoring would you use? Are there any other features of your anaesthetic you wish to mention? Would you use antibiotic prophylaxis? Is this gentleman suitable as a day case patient?

Further Reading

Chapter 4. Regional anaesthesia

Case 4.1 Lower limb anaesthesia

Background Learning outcomes CPD matrix matches Case history

What are the benefits and risks of regional anaesthesia?

Analgesia Rehabilitation Mortality and morbidity Risks

Case update

Describe the main nerves innervating the lower limb

Case update

Which nerve blocks can be considered to provide regional anaesthesia and analgesia for this type of surgery? Which blocks are the most appropriate for this patient?

Case update

What methods are available for locating the target site for local anaesthesia injection in order to obtain a successful block? Which methods would be suitable in this case?

Case update

How do you go about safely administering regional anaesthesia?

Preoperatively Perioperatively Post-operatively

Further Reading

Case 4.2 Upper limb regional anaesthesia

Background Learning outcomes CPD matrix matches Case history

Which intraoperative anaesthetic options are available? Describe the origins of the nervous supply of the upper limb

Trunks Divisions Cords

Case update

Which regional blocks are possible for upper limb anaesthesia? Which are suitable for elbow surgery? Which technique would you choose for this patient and why?

Case update

How do you place a nerve catheter, and how can you ensure good intra- and post-operative analgesia?

Preparation Preoperatively Post-operatively

Further Reading

Case 4.3 Regional anaesthesia in the elderly patient

Background Learning outcomes CPD matrix matches Case history

What are the relevant physiological changes seen in elderly patients?

Cardiovascular Respiratory Renal Central nervous system

Case update

Outline the key principles in your preoperative work-up for this patient

Case update

Describe your intraoperative plan

Case update

What measures can be taken to care for the insensate limb?

Further Reading

Chapter 5. Obstetric anaesthesia

Case 5.1 Major obstetric haemorrhage

Background Learning outcomes CPD matrix matches Case history

What other investigations should this lady have had? How would you anaesthetize this lady? What medications would you have ready?

Case update

How do you assess the amount of blood lost? The blood loss is 1200 mL. What actions should now be taken? Despite the measures taken, the uterus remains atonic and the blood loss is now 1800 mL. Which drugs are used as uterotonics during a Caesarean section, and what are their dosages and contraindications/major side effects?

Case update

What are the recommended types and volumes of fluid for resuscitation? What actions should be taken in view of the ongoing blood loss?

Case update

What actions could the obstetricians take to stop the bleeding?

Case update

What management should be initiated, based on these blood results?

Case update

Comment on what these blood results show. What should be done to treat these results?

Case update

What action should the obstetricians take? The surgery is completed with a total blood loss of 6.4 L. What is your post-operative plan?

Further Reading

Case 5.2 Pre-eclampsia

Background Learning outcomes CPD matrix matches Case history

What is the most likely diagnosis and risk factors for this condition? What investigations would be appropriate and why? At what level of systolic and diastolic pressures should antihypertensives be initiated? The obstetricians want to commence antihypertensive therapy. Which drugs are commonly used?

Case update

What are the common symptoms and signs associated with her condition?

Case update

What other treatments are available to manage her BP? What additional interventions should be considered for the optimal management of this patient’s condition?

Case update

What treatment would you consider at this stage, and how should this be given?

Case update

How would you manage this lady for her operation?

Conduct of general anaesthesia for an emergency Caesarean section

What would be your post-operative plan? Post-operatively, she is oliguric. How should this be managed? She fails to respond to your treatment. What would you do next?

Further Reading

Case 5.3 Morbid obesity in obstetrics

Background Learning outcomes CPD matrix matches Case history

How would you classify her BMI? The midwife carries out a routine booking and arrangesfor a booking ultrasound. What other appointments should be arranged for this lady? What are the adverse outcomes associated with obesity in pregnancy?

Fetal/neonatal Maternal

What pre-existing conditions are more likely in obese parturients? What screening should be performed on this lady between 24 and 28 weeks? At 32 weeks, this lady attends the antenatal anaesthetic clinic at the hospital. What should be assessed in this clinic? What should be discussed with this lady at this stage, and what would you recommend?

Case update

Who should be informed of this patient’s admission?

Case update

What problems are there in siting and managing an epidural in a woman with a raised BMI?

Case update

What are the differences in the management of an epidural top-up in this lady, compared to someone with a normal BMI? What are the anaesthetic problems of managing this lady in theatre? What post-operative complications is this woman more at risk of, and how are these prevented?

Further Reading

Case 5.4 Peripartum cardiomyopathy

Background Learning outcomes CPD matrix matches Case history

What is the differential diagnosis? What other investigations should be performed? What is the most likely diagnosis? Which individuals should be involved in her care? How would you manage her symptoms?

Case update

How should she be managed? Your patient is keen for a vaginal delivery. What would be the benefits of this? How should this be managed by the anaesthetic team?

Case update

What should be your management of this situation? What should be her post-operative management? What is her long-term prognosis? Your patient is keen for more children. What should she be advised?

Further Reading

Case 5.5 Severe sepsis in pregnancy

Background Learning outcomes CPD matrix matches Case history

Comment on these observations. What is the diagnosis? What investigations should be performed? What treatment should be given?

Case update

What would be your choice of anaesthetic for this patient? What is the likely diagnosis? What are the risk factors for peripartum sepsis? What are the likely organisms? Following delivery in theatre, the patient’s heart rate increases to 150 bpm and blood pressure is 82/40 mmHg. What is the likely differential diagnosis of this altered physiology? What treatment would you give in the first instance?

Case update

How would you define her condition? How would you manage this patient?

Case update

Comment on these results. Why is the patient ‘oozy’? How would you manage this situation? The surgery is completed with a total of 3.5 L blood lost. What would be your post-operative plan for this patient?

Further Reading

Chapter 6. Paediatric anaesthesia

Case 6.1 Prematurity

Background Learning outcomes CPD matrix matches Case history

Using a systems-based approach, outline the problems relating to prematurity

Respiratory Cardiovascular Neurological Thermoregulation Glycaemic control Fluid and electrolyte balance Haematological Sepsis Gastrointestinal

If baby J had chronic lung disease and an ongoing oxygen requirement, how might you modify your anaesthetic technique? What measures can be taken to maintain normothermia perioperatively? What are the analgesic options? You decide to perform a caudal. How do you explain this to baby J’s parents? What is a caudal? How is a caudal epidural block performed? Who will perform this procedure? What are the advantages and disadvantages of caudal anaesthesia?

Advantages Disadvantages

Is this patient suitable for day case admission? His operation proceeds uneventfully and he is comfortable, following the caudal. In addition to apnoea and oxygen saturation monitoring, what additional post-operative instructions would you give?

Further Reading

Case 6.2 Intravenous fluid for children

Background Learning outcomes CPD matrix matches Case history 1

What fasting instructions would you give his parents?

Case update

Is this the optimal fasting regimen for this patient? Your patient is the only case on the afternoon list starting at 1.30 p.m. It is now 11.15 a.m. How would you proceed with his fasting status and fluid management? Your patient is taken to theatre at 1.30 p.m. His surgery will take approximately 3.5 hours, and he has an epidural sited for analgesia. Calculate his maintenance fluid requirements. What type of maintenance fluid would you use? What is this patient’s fluid deficit? What fluids would you use in the post-operative period?

Case history 2

How would you assess her dehydration preoperatively? If her vital signs were unstable at presentation (e.g. tachycardic, tachypnoeic, with a prolonged CRT), how would this have altered your management?

Case history 3

What is the appropriate fluid for this child?

Further Reading

Case 6.3 The uncooperative child

Background Learning outcomes CPD matrix matching Case history 1

How do you proceed?

Case update

What techniques can be used by the play specialist?

Case update

What premedication would you prescribe?

Case update

This was your patient’s first visit to hospital. Is there any other way she could have been prepared?

Case history 2

What do you tell this patient and his mother? How do you proceed? What do you do now? What would you do if this boy refused to take the premedication? What differences are there in preparing an older child for theatre, compared to a younger child? What if you need to perform a rapid sequence induction in an uncooperative child?

Further Reading

Case 6.4 Pyloric stenosis

Background Learning outcomes CPD matrix matches Case history

What are the differential diagnoses? What is your initial management plan? Comment on the initial results

Case update

What is the likely diagnosis? What is the initial management of this condition?

Case update

Comment on this CBG What IV fluid regime would you prescribe? Outline the ongoing management for your patient

Case update

How would you interpret this CBG? Would you change the management plan?

Case update

What is your interpretation of these results? Describe the anaesthetic management of surgical pyloromyotomy How would you control post-operative pain? What post-operative instructions would you give?

Discussion

What are the clinical signs of dehydration in infants?

Further Reading

Chapter 7. Neuroanaesthesia

Case 7.1 Principles of neuroanaesthesia

CPD matrix matches Principles of neuroanaesthesia

What are the specific considerations in patient positioning in neuroanaesthesia? What is the anaesthetist’s role in preventing a raised intracranial pressure when managing the airway? The sitting position

Further Reading

Case 7.2 Acute subdural haematoma

Learning outcomes CPD matrix matches Case history

What is the likely cause of the patient’s subdural haematoma? What should be the initial management of this patient?

Case update

How may a subdural haematoma be differentiated from an extradural haematoma? Discuss which anaesthetic techniques could broadly be used for this patient. What are the relative advantages and disadvantages?

Total intravenous anaesthesia with propofol Volatile technique

Case update (anaesthetic technique used)

What do you think may have caused this increase of the INR? How may you treat this?

Case update Further Reading

Case 7.3 Endovascular treatment of subarachnoid haemorrhage due to ruptured berry aneurysm

Learning outcome CPD matrix match Case history

What is the aetiology and incidence of subarachnoid haemorrhage (SAH)? What are the independent risk factors for an aneurysmal subarachnoid haemorrhage?

Independent predictors of poor outcome after an aneurysmal subarachnoid haemorrhage Non-independent predictors

What is the usual current intervention for this disease? In the light of ISAT, are there still indications for the clipping of aneurysms? If so, what are they? What are the problems associated with a subarachnoid haemorrhage, and what may be done to lessen them?

Hydrocephalus Haematoma Vasospasm

What are the anaesthetic issues regarding anaesthetizing for endovascular coiling of a subarachnoid haemorrhage?

Case update

What do you think has happened, and how should this patient be managed? Which problems may present around the time of the procedure? How should these problems be managed?

Case update Further Reading

Case 7.4 Clipping of aneurysm

Learning outcomes CPD matrix matches Case history

What are the principles behind the use of temporary clips? How may the anaesthetist facilitate this technique? Which other methods of neuroprotection have been tried?

Further Reading

Case 7.5 Posterior fossa craniectomy

Learning outcomes CPD matrix matches Case history

What are the major features of an intracranial haemangioblastoma? How should this patient be worked up for theatre?

Case update

What are the problems especially associated with posterior fossa procedures? How may a patient be kept comfortable after a craniotomy? What are the salient points for this? The old-fashioned prejudice was that the only safe opiate to give after intracranial surgery was codeine. This has been challenged. Now some colleagues prescribe morphine. Discuss this point.

Case update Further Reading

Case 7.6 Awake craniotomy

Learning outcomes CPD matrix matches Case history

What are the major indications for an awake craniotomy?

Case update

What are the goals of the anaesthetic technique used for an awake craniotomy? Which anaesthetic techniques may be used for an awake craniotomy?

Case update

Technique Post-operative course

Further Reading

Chapter 8. Ear, nose, and throat anaesthesia

Case 8.1 Bleeding tonsils

Background Learning outcomes CPD matrix matches Case history

Is the child bleeding? When and where is the bleeding? How much has the child bled?

Case update

How much and what type of fluid for resuscitation?

Case update

Who should be involved with a second general anaesthetic on a resuscitated child? What are the specific anaesthetic concerns for a bleeding child? What anaesthetic equipment is required? What induction technique should be employed—a rapid sequence induction or an inhalational induction? What are the intraoperative considerations? What are the appropriate post-operative care instructions?

Further Reading

Case 8.2 Acute epiglottitis

Background Learning outcomes CPD matrix matches Case history 1 Case history 2

What is the diagnosis? What is the severity of respiratory distress? Discuss the management of acute epiglottitis Which team members should be involved? Discuss the options for induction and intubation What are the appropriate post-intubation care instructions?

Further Reading

Case 8.3 Inhaled foreign body

Background Learning outcomes CPD matrix matches Case history 1 Case history 2 Case history 3

Is there evidence of an inhaled foreign body in these cases? What are the differential diagnoses? What are the foreign bodies, and where do they end up? What investigations should be performed? What urgency of intervention is indicated? How should you manage the full stomach? Which staff should be involved? Which drugs should be considered? Should intravenous access be secured prior to induction of anaesthesia? What equipment is required? What monitoring should be applied? How should you conduct the induction of anaesthesia? What are the potential intraoperative complications? What post-operative care instructions are recommended?

Further Reading

Case 8.4 Airway obstruction

Background Learning outcomes CPD matrix matches Case history 1 Case history 2

What is causing the airway obstruction? What is the level of the obstruction? Can you quantify the severity of the obstruction? Describe the appropriate anaesthesic technique Is there a role for awake tracheostomy?

Further Reading

Chapter 9. Vascular anaesthesia

Case 9.1 Ruptured abdominal aortic aneurysm

Background Learning outcomes CPD matrix matches Case history

You are the on-call anaesthetist who is called to the A&E department to help with his management. What is your initial approach? Describe a suitable anaesthetic induction plan for this patient The operation begins, and the surgeon manages to clamp the infrarenal aorta. However, there is still ongoing haemorrhage, and the estimated blood loss by this point is 3500 mL. Describe the management of haemorrhage in this case Comment on the following ROTEM® results, and describe an appropriate management What are the adverse effects associated with a massive transfusion? What are the physiological consequences of aortic cross-clamping and subsequent unclamping? How is intraoperative myocardial ischaemia detected? Suggest appropriate treatments How should this patient be cared for in the immediate post-operative period? What are the main issues following surgery for a ruptured abdominal aortic aneurysm?

Further Reading

Case 9.2 Carotid endarterectomy

Background Learning outcomes CPD matrix matches Case history

What investigative imaging would you expect this patient to have undergone prior to listing for surgery? What are the important features of your preoperative assessment in this case?

History Medications Investigations

What are the anaesthetic options for carotid endarterectomy? What are the advantages and disadvantages of each? What are the common goals of anaesthesia for carotid endarterectomy?

Local anaesthesia

Advantages of local anaesthetic techniques Disadvantages of local anaesthetic techniques

General anaesthesia

Advantages of general anaesthesia Disadvantages of general anaesthesia

What methods are available for monitoring cerebral perfusion during carotid endarterectomy? A local anaesthesia technique is chosen. Unfortunately, the patient becomes unresponsive following cross-clamping of the internal carotid artery. Describe the subsequent management Prior to closure, the surgeon complains of excessive bleeding from the suture line of the arteriotomy. What are the possible causes, and how would you investigate and manage this situation? You are called to the ward by a junior doctor 2 hours following surgery, because the patient is finding it difficult to breathe. On examination, the patient is tachypnoeic and cyanosed, with a large swelling on the left side of the neck. There is audible stridor. What is the diagnosis, and what is your management?

Further Reading

Case 9.3 Elective aorto-femoral arterial revascularization

Background Learning outcomes CPD matrix matches Case history

What alternative treatments might be considered, rather than aorto-bifemoral bypass grafting? What is the role of the anaesthetist in this decision-making process? What is the revised cardiac risk index? How might it be used in the preoperative assessment of this patient? How else could you quantify the perioperative risk for this patient? What further investigations might be useful?

Assessment of functional capacity Cardiopulmonary exercise testing Dobutamine stress echocardiography Myocardial perfusion scanning Biomarkers

Would you recommend repeat coronary angiography? Would you recommend any changes to medication prior to surgery?

Antiplatelet drugs

Further Reading

Chapter 10. Cardiothoracic anaesthesia

Case 10.1 Lung isolation techniques

Background Learning outcomes CPD matrix matches Case history

How would you assess this patient’s fitness for surgery? What information would you like to obtain from this patient in the pre-admission clinic? What examination will you undertake? What investigations will you request?

Case update

What are the principles of anaesthetic management for patients undergoing a pneumonectomy? What techniques are available to facilitate one-lung ventilation? Can you list the indications for one-lung ventilation?

Absolute indications Relative indications

Case update

How would you establish one-lung ventilation? What ventilator strategy would you employ?

Case update

How would you approach the management of hypoxia and one-lung ventilation?

Further Reading

Case 10.2 Off-pump cardiopulmonary bypass

Background Learning outcomes CPD matrix matches Case history

What are the indications for coronary artery bypass grafting? What do you understand by the term ‘off-pump’? What are the perceived potential advantages of off-pump coronary artery bypass grafting? What makes off-pump coronary artery bypass grafting technically possible? What complications should you be aware of when anaesthetizing patients for off-pump coronary artery bypass grafting? What information would you like to obtain during your preoperative visit?

History Examination

Case update

What investigations would you wish to have been performed? What information would you like to provide to the patient during your preoperative visit? How would you conduct anaesthesia for this patient? When compared to on-pump coronary artery bypass grafting, does off-pump coronary artery bypass grafting result in reduced incidence of morbidity and mortality?

Further Reading

Case 10.3 Valve replacement surgery

Background Learning outcomes CPD matrix matches Case history

What are the three main causes of aortic stenosis? What are the signs and symptoms of aortic stenosis? You note that your patient is documented to have severe aortic stenosis. How do you classify the degree of severity in aortic stenosis? What information would you look to elicit in the preoperative visit?

History Examination

Case update

What investigations would you wish to have been performed? How would you quantify this patient’s operative risk for aortic valve replacement surgery? What information will you give to the patient during your preoperative visit? How would you prepare for the conduct of anaesthesia for aortic valve replacement surgery? What are the haemodynamic goals in anaesthetizing someone with aortic stenosis? This patient is undergoing aortic valve replacement surgery through a midline sternotomy incision and will require a period of time on cardiopulmonary bypass. What are the main reasons for using cardiopulmonary bypass for cardiac surgery? What does a cardiopulmonary bypass circuit consist of? What steps will you have to take in order to prepare your anaesthetized patient for cardiopulmonary bypass? What are the forms of myocardial protection available for use, in conjunction with cardiopulmonary bypass, and why are they required? Why do we use systemic hypothermia for patients undergoing cardiopulmonary bypass? What are the potential problems associated with cardiopulmonary bypass? Your patient has had an uncomplicated procedure. Where should he be cared for post-operatively? What should the aims of post-operative care in this patient be? What are the common post-operative complications associated with this type of aortic valve replacement surgery?

Further Reading

Case 10.4 Transcatheter cardiac valve surgery

Background Learning outcomes CPD matrix matches Case history

What are the indications for performing an aortic valve replacement using the transcatheter aortic valve insertion technique? What are the contraindications to transcatheter aortic valve implantation? Your patient has met the above criteria for aortic valve replacement using a transcatheter aortic valve implantation technique. What are the potential advantages to her of having her procedure in this manner? Your patient has severe respiratory disease in the form of chronic obstructive pulmonary disease. She has symptomatic aortic stenosis, chronic kidney disease stage 3, and a EuroSCORE of 23. How would you approach this patient’s perioperative care?

Preoperative assessment

How would you prepare to anaesthetize your patient for her transcatheter aortic valve implantation? Can you outline the intraoperative management of this patient? Outline the post-operative plan No procedure is without risk, and it is imperative that you are aware of the potential risks associated with a transcatheter aortic valve implantation in order to identify and manage them swiftly. Can you identify the major risks of the transcatheter aortic valve implantation procedures?

Further Reading

Chapter 11. Hepatobiliary and transplant anaesthesia

Case 11.1 Anaesthesia for major liver resection

Background Learning outcomes CPD matrix matches Case history

What important factors must be considered during the preoperative assessment? Which investigations are recommended? What are the potential major intraoperative problems? Which anaesthetic technique should be used? How is blood loss minimized?

Case update

What are the next appropriate management steps?

Case update

What should be done next?

Case discussion

Perioperative anaesthetic considerations Post-operative complications

Further Reading

Case 11.2 Acute liver failure

Background Learning outcomes CPD matrix matches Case history

What would your initial assessment points be?

Case update

Where should she be managed? At what stage should intubation be considered? What precautions are necessary around the time of intubation and transfer? The patient is intubated, mechanically ventilated, and transferred to the intensive care unit of a centre with a liver transplantation programme. Which criteria can be used to determine whether or not liver transplantation will be necessary? What should the basic goals of intensive care be in patients with acute liver failure? Your patient reaches the King’s College criteria and is listed for a super urgent liver transplantation. Should she have an intracranial pressure monitoring device placed? What are the risks and benefits of this? Mrs L has an intracranial pressure monitoring device placed. The opening pressure is 30 mmHg. Which treatments can be used to control her intracranial pressure? Mrs L receives an offer of a liver within 24 hours of being listed for transplantation. What are the stages of this operation, and what challenges do these present to the anaesthetist? Mrs L goes on to receive an orthotopic liver transplant. She returns to the intensive care unit after an 8-hour operation. What are the important post-operative considerations?

Case discussion Further Reading

Case 11.3 Anaesthesia following renal transplantation

Background Learning outcomes CPD matrix matches Case history

What are the main considerations in the preoperative assessment of a patient with a previous renal transplant? How does chronic rejection present? What issues relating to the renal function are important to obtain from the history? What investigations would you perform? What should be done regarding this patient’s immunosuppression perioperatively? What anaesthetic technique should be used, and is invasive monitoring essential? How should analgesia be provided? What issues must be addressed post-operatively?

Case discussion

Intraoperative issues

Further Reading

Case 11.4 Management of the brainstem-dead organ donor

Background Learning outcomes CPD matrix matches Case history

What are the physiological changes associated with brainstem death? How should you assess this patient prior to anaesthesia for a multiorgan retrieval procedure?

Case update

What can be done to optimize his pulmonary function?

Case update

How can he be optimized from a cardiovascular point of view?

Case update

What condition has likely developed? What are the other endocrine changes that occur following brainstem death? What drugs can be given as part of ‘hormonal resuscitation’? You transfer Mr T through to theatre. What are the key considerations before the retrieval procedure commences? What anaesthetic technique should be used? What are the surgical stages of a multiorgan retrieval procedure?

Case discussion Further Reading

Chapter 12. Urology

Case 12.1 Laparoscopic radical prostatectomy

Background Learning outcomes CPD matrix matches Case history

How would you adapt your preoperative assessment to this patient? Your patient denies any respiratory or cardiovascular symptoms; he is independent for all activities of daily living and walks his dog daily. His latest HbA1c is 75 mmol/mol (9%), and his capillary blood gas is 13.3 mmol/L. How would you manage his diabetes on the morning of surgery? How would you conduct an anaesthetic for your patient?

Case update

Explain the pathophysiology of the fluctuations in blood pressure and another intervention that could restore cardiovascular stability

Case discussion Further Reading

Case 12.2 Total cystectomy with ileal conduit formation

Background Learning outcomes CPD matrix matches Case history

Which preoperative investigations are required? What are the issues to discuss with the patient preoperatively?

Post-operative analgesia Invasive vascular access and monitoring Cardiac output monitoring Possible blood transfusion Post-operative high dependency care environment

What other alternative analgesic techniques could be discussed? What is the sequence of events in the anaesthetic room? What drugs do you want to use in your epidural? How will the patient be positioned? What else is to be done before the operation starts?

Case update

What post-operative complications may be expected?

Further Reading

Case 12.3 Percutaneous nephrolithotomy

Background Learning outcomes CPD matrix matches Case history

What are the important investigations for this man at pre-admission clinic?

Case update

What must the staff in the pre-admission clinic do after seeing the urinalysis result?

Case update

What are the main issues for the anaesthetist for this type of procedure? What is your plan for managing the airway for this procedure? What drugs will you draw up for the case? What is the standard antibiotic prophylaxis for urological procedures? What are the issues in positioning for this case? Are there any other perioperative interventions and monitoring to consider? What would you prescribe for post-operative medication?

Case update

What is the most likely cause of hypotension for this patient, and what should the anaesthetist do next?

Case update

What should be the next course of action?

Case update Further Reading

Case 12.4 Transurethral resection of the prostate

Background Learning outcomes CPD matrix matches Case history

What is your differential diagnosis for the delayed recovery of consciousness? What would be your initial management?

Case update

What is your diagnosis? What is your management?

Case discussion

Anaesthetic considerations

Further Reading

Chapter 13. The difficult airway

Introduction: the difficult airway Case 13.1 Cervical spine injury

Background Learning outcomes CPD matrix matches Case history

What should be the initial management strategy in the emergency department? What are the airway considerations in cervical spine trauma?

Case update

What are the options for airway management?

Rapid sequence induction and direct laryngoscopy Awake fibreoptic intubation Asleep fibreoptic intubation Surgical airway

Case update Further Reading

Case 13.2 Acromegaly

Background Learning outcomes CPD matrix matches Case history

What are the characteristic features of acromegaly?

Musculoskeletal Airway

What are the other associated conditions?

Cardiovascular Other

What are the potential difficulties with airway management? What are the options for airway management?

Case update

What is the plan for extubation? Post-operative airway care

Further Reading

Case 13.3 Thyroid tumour

Background Learning outcomes CPD matrix matches Case history

What is your initial management?

Case update

What are the problems? What are the options to secure the airway? What are the problems of an awake fibreoptic intubation in this case? How are you going to perform the procedure? What size and type of endotracheal tube should be selected? What is your plan B?

Case update Further Reading

Case 13.4 Morquio’s syndrome

Background Learning outcomes CPD matrix matches Case history

What are the key features of Morquio’s syndrome? What are the general skeletal abnormalities? What are the spinal abnormalities? What are the other features?

Case update

What are the general problems in anaesthetizing this patient? What are the specific airway problems? What are the options available to secure the airway?

Equipment Local anaesthesia of the airway Sedation

Case update

How are you going to extubate this patient? What is the appropriate post-operative care plan for this lady? What was your plan B if a fibreoptic intubation was not achievable?

Further Reading

Chapter 14. Transport and retrieval medicine

Case 14.1 Pre-hospital management of a multiply injured trauma victim

Background Learning outcomes CPD matrix matches Case history

What are the key principles relating to responding safely and effectively to a pre-hospital request like this?

Team composition Equipment Communication Personal protective equipment

Case update

What life-threatening injuries should your primary survey aim to identify at this stage?

Airway Breathing Circulation Disability

Case update

Outline the immediate management priorities for this patient

Intubation Location Equipment Team resource management Chest decompression Vascular access Fracture immobilization Packaging

Case update

How should this patient’s transfer to definitive care be undertaken?

Speed Patient management Safety Handover

Further Reading

Case 14.2 The collapsed neonate

Background Learning outcomes CPD matrix matches Case history: presenting features and common diagnoses

What are the likely differential diagnoses that may explain this collection of symptoms?

Case update: resuscitation and treatments

Comment on these findings, and discuss the interventions required

Case update: stabilization

What measures should be instituted whilst awaiting the retrieval team’s arrival?

Further Reading

Case 14.3 Time-critical transfers by referring clinicians

Background Learning outcomes CPD matrix matches Case history: identifying the advantages and disadvantages of retrieval team transport

What are the options for the emergency management of this child’s life-threatening injury?

Case update: outlining the principles of equipment for referring team transport

What equipment is required for the safe transport of this patient?

Case update: outlining the logistical processes for referring team transport

What are the necessary logistical processes to be implemented in order to effectively transfer this patient?

Discussion

Further Reading

Case 14.4 The stridulous infant

Background Learning outcomes CPD matrix matches Case history: identifying the signs and symptoms suggestive of impending respiratory failure

What clinical features are suggestive of severe respiratory compromise?

Case update: having an awareness of the underlying pathologies

What is the differential diagnosis for this patient’s underlying pathology?

Case update: outlining a management plan for the stridulous infant

What investigations, staff, and equipment will be required to manage this patient?

Investigations Staff Equipment

Case update: prepare for emergency anaesthesia of the stridulous infant

You are likely to need to anaesthetize this patient to secure their airway and support the respiratory function. Outline the ongoing management of this child

Inhaled therapies Systemic treatments

Anaesthestic management

When to get IV access? In what position should the child be induced?

Further Reading

Case 14.5 Aeromedical transport considerations in acute lung injury

Background Learning outcomes CPD matrix matching Case history: understanding the indications for aeromedical transport

What are the advantages and disadvantages of aeromedical vs road transport for this patient?

Case update: understanding the physiological effects of altitude and forces of flight

What physical factors during the flight may influence the patient’s physiology, and what can be done to minimize disturbances to the patient?

Barometric pressure

Case update: logistical considerations of aeromedical transfer

What are the logistical considerations to transferring this patient by helicopter?

Clinical environment Communication Weather

Further Reading

Chapter 15. Pain medicine

Case 15.1 Complex regional pain syndrome

Background Learning outcomes CPD matrix matches Case history

What are the key points you would assess from this patient’s history? What clinical features may you elicit on examination? How is the diagnosis confirmed? Discuss the pathophysiology of complex regional pain syndrome Outline a management strategy for this patient

Further Reading

Case 15.2 Phantom limb pain

Background Learning outcomes CPD matrix matches Case history

What is phantom limb pain? What is the incidence? What are the risk factors for developing phantom limb pain? Your patient asks why phantom limb pain happens and if there is anything that can be done to prevent it What is the role for central neuraxial blockade in the development of phantom limb pain? Is peripheral neural blockade beneficial? Are there any adjunctive medications that might impact on phantom limb pain?

Case update

What more do you want to know about the history? What other factors in the history may influence your management plan? Does his pain affect his mood or his outlook on life? What concerns does he have about his pain? What does he hope to gain from the pain clinic? What is the prognosis of phantom limb pain? What therapies are available for phantom limb pain?

Pharmacology Physical therapies Surgery Other pain management strategies

Further Reading

Case 15.3 Chronic post-surgical pain

Background Learning outcomes CPD matrix matches Case history

How is chronic post-surgical pain defined? Outline the risk factors for patients having major procedures developing chronic post-surgical pain and how these can be predicted What are the risk factors for chronic post-surgical pain? What are the patient factors that may influence the development of chronic post-surgical pain?

Demographic factors Psychosocial factors Genetic factors Preoperative pain Acute post-operative pain Surgical factors

Do different anaesthetic and analgesic strategies minimize the risk of chronic post-surgical pain? Can you predict patients at risk of chronic post-surgical pain preoperatively?

Further Reading

Case 15.4 Regional vs systemic analgesia

Background Learning outcomes CPD matrix matches Case history

Outline the evidence regarding those mentioned techniques Comment on the epidural use in elective and emergency abdominal surgery Do epidurals influence post-operative pulmonary morbidity? How does epidural use influence post-operative pain? Discuss the implications of regional analgesia techniques in cardiothoracic surgery Discuss the benefits of epidurals in major lower limb orthopaedic surgery Can epidurals be used in trauma patients? Outline the differences between continuous epidural analgesia and patient-controlled epidural analgesia

Further Reading

Case 15.5 Managing chronic pain patients for elective surgery

Background Learning outcomes CPD matrix matches Case history

What needs to be considered when managing this patient’s pain?

Pre-assessment

Case update

Who may be able to assist you with planning this patient’s analgesia? How would you manage this patient’s opioid therapy through the perioperative period? Discuss the oral to intravenous opioid conversion equivalences What are the general guidelines for dealing with any patient requiring opioids? What non-opiate analgesia may be of use for this patient? Is intravenous or oral opioid analgesia optimal?

Case update

Appendix 1 Royal College of Anaesthetists CPD matrix: level 2 Appendix 2 List of cross-references between chapters Index

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