Case Discussions

Session 1 — long stem

Adult polytrauma with TBI for emergent craniotomy

A 35 y.o., 82 kg, 5'8" man is brought to the operating room for emergent left frontotemporal craniotomy and evacuation of an acute subdural hematoma.

HPIUnrestrained driver ejected from a motor vehicle collision approximately 90 minutes ago. EMS found him unresponsive at the scene and intubated him in the field with succinylcholine and etomidate. Brought to MGH ED where ATLS resuscitation was initiated. Two large-bore peripheral IVs in place. One unit of PRBC began infusing in the ED. CT scans completed. Now arriving in OR.

PMHMyocardial infarction 3 years ago, treated with two drug-eluting stents to the LAD. No anginal symptoms since. Hypertension. Hyperlipidemia. No prior surgeries.

MEDSAspirin 81 mg daily, atorvastatin 40 mg daily, lisinopril 20 mg daily. Last meal 5 hours prior to MVC.

PHYS EXAMHR 115; BP 95/55; assist control ventilation, FiO2 1.0; T 36.0°C; SpO2 92%. GCS 8T (E2, M4, intubated off sedation). Pupils: left 5 mm sluggish, right 3 mm reactive. Cervical collar in place. Chest auscultation: decreased breath sounds on the right. Abdomen soft. Right thigh and pubic region tender. Foley catheter in place.

CT HEADLarge left frontotemporal acute subdural hematoma with 8 mm midline shift. Effacement of the left lateral ventricle. No contralateral hemorrhage. No skull fracture.

CT C-SPINEUnstable C5-C6 ligamentous injury without fracture.

CT CHESTRight pulmonary contusion; small right pneumothorax, no chest tube; three right-sided rib fractures (4th, 5th, 6th).

CT PELVISRight superior and inferior pubic ramus fracture without retroperitoneal hematoma.

LABSHgb 9.8 gm/dL; platelets 198 K/uL; INR 1.3; K+ 3.2 mEq/L; glucose 220 mg/dL; lactate 5.2 mmol/L; creatinine 1.1 mg/dL. ABG on FiO2 1.0: pH 7.30; PaO2 88; PaCO2 38.

OR ARRIVALPatient is intubated and sedated on propofol 30 mcg/kg/min. Two 16 g peripheral IVs functioning. Arterial line not yet placed. Type and crossmatch sent; 4 units PRBC available in the OR. Surgeon is scrubbed and ready to incise.

Session 1 — long stem

Morbid obesity, OSA, prior failed neuraxial, repeat cesarean with placenta accreta

A 36 y.o. G3P2 at 39 weeks gestation, 152 kg, 5'4" (BMI 58), is scheduled for repeat cesarean delivery, her third. Obstetric ultrasound raises concern for placenta accreta over the prior cesarean scar.

HPIFirst cesarean under uncomplicated spinal at an outside hospital. Second cesarean at age 31: 90 minutes of attempted epidural placement, ultimately converted to general anesthesia after surgical incision under inadequate block; required two attempts at intubation. She recalls feeling pulling during the second cesarean but reports no nightmares or avoidance. On home CPAP at 14 cm H2O for severe OSA (AHI 65), uses it nightly. Has been doing prenatal pool exercise. BMI was 48 prior to pregnancy.

PMHClass III obesity. Severe OSA on CPAP. Gestational diabetes on insulin. Chronic hypertension on labetalol. Mild iron-deficiency anemia. GERD on PPI.

MEDSLabetalol 200 mg PO BID; insulin lispro sliding scale; omeprazole 40 mg PO daily; low-dose aspirin 81 mg; prenatal vitamins.

PHYS EXAMHR 88; BP 142/88; RR 18; SpO2 94% on room air; T 37.0°C. Neck circumference 47 cm. Mallampati IV, restricted neck extension, mouth opening 3 fingerbreadths, thyromental distance 4 cm. Bilateral end-expiratory wheezes. Redundant soft tissue over the lumbar back; bony landmarks not palpable on exam.

LABSHgb 10.5 g/dL; platelets 195 K/uL; INR 1.0; glucose 110 mg/dL; creatinine 0.7 mg/dL. Type and screen positive antibody (anti-E); four units crossmatched.

IMAGINGObstetric ultrasound suggestive of placenta accreta spectrum (lower segment, prior scar adherence). MRI confirms placenta increta with bladder involvement. Cardiology TTE: LV hypertrophy, mild diastolic dysfunction, EF 65%, RVSP 38 mmHg.

FETALEstimated fetal weight 4200 g. FHR baseline 140 with appropriate variability.

OR ARRIVALBariatric OR table with ramp pillows in place. After multiple attempts a single 18 g IV in the right forearm. Right radial arterial line attempted twice unsuccessfully. Ultrasound brought into the room. NICU and gynecologic oncology team notified for the accreta. IR notified for possible postpartum embolization.

Session 1 — long stem

Severe rheumatic mitral stenosis with new AF, planned cesarean

A 33 y.o. G2P1 at 36 weeks gestation, 58 kg, 5'3", is admitted for planned cesarean delivery tomorrow morning for known severe rheumatic mitral stenosis with progressive symptoms.

HPIProgressive exertional dyspnea since week 28, now NYHA class III to IV; orthopnea and paroxysmal nocturnal dyspnea for the past week. Two triage visits in 10 days for shortness of breath. Today walking from the parking lot left her breathless. No chest pain. Immigrated from Vietnam at age 19; first child delivered uneventfully at 24.

PMHChildhood rheumatic fever. Severe rheumatic mitral stenosis with mitral valve area 0.85 cm² and mean gradient 18 mmHg on echo this month. New-onset atrial fibrillation four weeks ago, rate-controlled. Mild gestational hypertension. No prior anesthetics other than uncomplicated spinal for first cesarean.

MEDSMetoprolol 50 mg PO BID; furosemide 20 mg PO daily; therapeutic-dose enoxaparin 1 mg/kg SC BID for AF (last dose 24 hours ago); prenatal vitamins.

PHYS EXAMHR 92 (atrial fibrillation, controlled); BP 118/72; RR 22; SpO2 95% on 2 L NC; T 36.8°C. Loud opening snap, low-pitched mid-diastolic murmur at the apex with presystolic accentuation lost in AF. Bibasilar crackles to the mid-zone. JVP elevated to the angle of the jaw. Mild pitting edema. Airway: Mallampati II, full mouth opening, full neck extension.

ECGAtrial fibrillation at 92 with diffuse repolarization changes; no ischemic features.

LABSHgb 10.2 g/dL; platelets 195 K/uL; INR 1.2; creatinine 0.7 mg/dL; BNP 1240 pg/mL; anti-Xa from yesterday morning 0.5 IU/mL. Type and screen positive for anti-K antibody (notified blood bank, two crossmatched units on hold).

IMAGING / TTE todayMitral valve area 0.85 cm², mean gradient 18 mmHg; estimated RVSP 60 mmHg; RV mildly dilated with preserved function; LV ejection fraction 60%; biatrial enlargement; no thrombus seen. CXR with cephalization and small bilateral pleural effusions.

FETALFHR baseline 140 with appropriate variability and accelerations.

OR ARRIVALTwo 16 g peripheral IVs and a right radial arterial line in. Cardiology and cardiac surgery on standby. NICU team present. Epidural cart in the room. ECMO consult notified the day before.

Session 1 — long stem

Idiopathic pulmonary arterial hypertension in active labor at term

A 26 y.o. G1P0 at 39 weeks gestation, 62 kg, 5'5", presents in active labor at 6 cm cervical dilation. She has known idiopathic pulmonary arterial hypertension and was scheduled for elective cesarean at 37 weeks but presented in spontaneous labor today.

HPIIdiopathic PAH diagnosed at age 22 after presyncope and progressive dyspnea on exertion; right-heart catheterization at that time showed mean PA pressure 56 mmHg, PVR 9 Wood units. Initial improvement on dual oral therapy. Pregnancy proceeded despite counseling; she elected to continue.

PMHIdiopathic PAH (WHO Group 1, functional class II to III). Multidisciplinary plan with cardiology, OB, and anesthesia for delivery at 37 weeks by elective cesarean. No prior surgeries, no prior anesthetics.

MEDSSildenafil 20 mg PO TID; selexipag 1600 mcg PO BID; low-dose aspirin 81 mg daily; prophylactic enoxaparin 40 mg SC daily (last dose 14 hours ago); prenatal vitamins.

PHYS EXAMHR 102, sinus; BP 110/68; RR 22; SpO2 92% on room air; T 37.0°C. Loud P2, parasternal RV heave. JVP elevated to 8 cm. Trace edema. Airway: Mallampati II, full mouth opening, full neck extension.

ECGSinus tachycardia, RV hypertrophy, right-axis deviation, T-wave inversions V1-V3.

LABSHgb 12.4 g/dL; platelets 220 K/uL; INR 1.0; BNP 980 pg/mL; creatinine 0.7 mg/dL; type and screen negative.

TTE (recent)RVSP estimated at 78 mmHg; RV moderately dilated with preserved function; septal flattening; moderate tricuspid regurgitation; reduced RVOT VTI; LV ejection fraction 60%.

IMAGINGCXR with enlarged central pulmonary arteries, no acute infiltrate.

FETALEstimated fetal weight 3500 g. FHR baseline 145 with appropriate variability, no decelerations.

OR ARRIVALAdmitted to L&D 90 minutes ago. Cardiology and adult cardiac anesthesia notified. ECMO team aware. 18 g antecubital IV. No arterial line yet. OB asks whether anesthesia is comfortable with assisted vaginal delivery versus moving to cesarean now.

Case Discussions

Why this exists Hide

Aortic valve replacement for bicuspid valve with chronic severe aortic regurgitation

Surgical aortic valve replacement for severe aortic stenosis

Urgent CABG for left main / three-vessel disease with failure to separate from bypass

Cardiogenic shock and mechanical circulatory support after a large anterior MI

Mitral valve repair for severe degenerative mitral regurgitation

Mitral valve replacement for severe rheumatic mitral stenosis

Post-CPB coagulopathy and massive transfusion after redo aortic root/ascending replacement under DHCA

Open repair of acute Stanford Type A aortic dissection

Pacemaker-dependent ICD patient for noncardiac surgery with EMI

Myasthenia gravis for abdominal hysterectomy

Adult polytrauma with TBI for emergent craniotomy

Morbid obesity, OSA, prior failed neuraxial, repeat cesarean with placenta accreta

Severe rheumatic mitral stenosis with new AF, planned cesarean

32-week parturient after MVC with hemorrhagic shock and fetal distress

Idiopathic pulmonary arterial hypertension in active labor at term

RUQ pain and abnormal labs in the third trimester (HELLP with hepatic rupture)

Severe preeclampsia with thrombocytopenia and morbid obesity, emergent cesarean

Stat cesarean in laboring parturient with epidural, conversion to general

Opioid use disorder on buprenorphine in labor

Active asthma flare in labor at term

Sickle cell disease in active labor after recent vaso-occlusive crisis

SICU postop perforated diverticulitis (Hartmann's), septic shock

Cervical mediastinoscopy and biopsy of a large anterior mediastinal mass

Right upper lobectomy with one-lung ventilation in severe COPD

Off-site navigational bronchoscopy and transbronchial biopsy in COPD

Right pneumonectomy with borderline pulmonary function and coronary disease

Tracheal resection and reconstruction for post-intubation stenosis