Case Discussions

A 72 y.o., 80 kg man is admitted after a fall down a flight of stairs. The acute pain service is consulted for analgesia.

A 56 y.o., 82 kg, 5'10" man with a bicuspid aortic valve and chronic severe aortic regurgitation is scheduled for aortic valve replacement, with possible aortic root replacement.

A 78 y.o., 68 kg, 5'4" woman is scheduled for surgical aortic valve replacement for severe aortic stenosis.

A 64 y.o., 92 kg, 5'9" man is scheduled for urgent coronary artery bypass grafting for left main plus three-vessel disease.

A 64 y.o., 88 kg, 5'9" man with ischemic cardiomyopathy is in the cardiac ICU in decompensated cardiogenic shock after a large anterior MI, and the team is deciding on and placing mechanical circulatory support.

A 64 y.o., 82 kg, 5'10" man is scheduled for mitral valve repair for severe degenerative mitral regurgitation.

A 54 y.o., 60 kg, 5'3" woman is scheduled for mitral valve replacement for severe rheumatic mitral stenosis.

A 66 y.o., 92 kg, 5'10" man is undergoing a redo aortic root and ascending aortic replacement for an expanding root aneurysm at the site of a prior bioprosthetic aortic valve.

A 58 y.o., 92 kg, 5'11" man is brought emergently to the OR for open repair of an acute Stanford Type A aortic dissection.

A 79 y.o., 88 kg man with an implantable cardioverter-defibrillator placed for nonischemic cardiomyopathy and an episode of monomorphic VT is scheduled for an elective laparoscopic sigmoid colectomy. He is pacemaker-dependent, in permanent atrial fibrillation after an AV-nodal ablation, and his last device interrogation was 11 months ago. The surgical team plans extensive monopolar electrocautery, and the patient will be in steep Trendelenburg with the device generator on the left upper chest. He has an LVEF of 25% and chronic kidney disease; he takes carvedilol, sacubitril-valsartan, furosemide, and apixaban. He tells you he 'gets the device checked sometimes' and once 'felt a big jolt' a year ago, and he has brought no card or printout. P 70 (paced); BP 142/80; SpO2 95% on room air; K+ 5.1 mEq/l.

A 40 y.o., 50 kg, 5'2" woman is scheduled for abdominal hysterectomy for menorrhagia. History of myasthenia gravis and hiatal hernia with esophageal reflux. Medications: pyridostigmine (Mestinon) 360 mg/day, prednisone 15 mg/day, antacids. Vital signs: HR 80; BP 120/80; RR 18; T 37°C. Hgb 9.3 g/dL.

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.

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.

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.

A 27 y.o. G2P1 at 32 weeks gestation, 70 kg, 5'6", is brought to the trauma bay 30 minutes after a head-on motor vehicle collision. Trauma surgery plans emergent exploratory laparotomy for a positive FAST and hemodynamic instability; obstetrics is scrubbed for possible cesarean if fetal status worsens.

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.

A 29 y.o. G1P0 at 33 weeks gestation, 68 kg, 5'4", is admitted to labor and delivery for right upper quadrant pain, malaise, and decreased fetal movement. The obstetricians are asking whether she can go for urgent cesarean delivery.

A 32 y.o. G2P1 at 35 weeks gestation, 110 kg, 5'5" (BMI 41), is brought from L&D to the OR for stat cesarean delivery for non-reassuring fetal tracing.

A 28 y.o. G3P2 at 39 weeks gestation, 5'7", 78 kg, has been in active labor for 11 hours with a continuous lumbar epidural infusion of bupivacaine 0.1% with fentanyl 2 mcg/mL, placed six hours ago without difficulty. She has well-controlled asthma on albuterol prn and mild iron-deficiency anemia (Hgb 10.4). Her last meal was four hours ago, a sandwich and orange juice. Mallampati II at admission; HR 96; BP 128/76; RR 18; SpO2 99% on room air. The obstetric team has managed a prolonged second stage with intermittent variable and late decelerations. She is requesting a top-up because the obstetricians plan a bedside intrauterine pressure catheter and forceps trial.

A 30 y.o. G2P1 at 39 weeks gestation, 5'4", 72 kg, presents in active labor at 5 cm cervical dilation. She is on buprenorphine-naloxone 16 mg sublingual daily for opioid use disorder, with two years of stable treatment in recovery. She also takes sertraline for depression and uses cannabis two to three times per week. Smokes five cigarettes daily. Hgb 11.4; platelets 165; vital signs normal; Mallampati II; visible track marks bilaterally on the antecubital fossae.

A 31 y.o. G2P1 at 38 weeks gestation, 5'5", 74 kg, presents in active labor at 5 cm cervical dilation. She has steroid-dependent asthma with two prior ICU admissions and one intubation in the past three years; current peak flow is 60% of her personal best with audible wheezing, and she has been progressively short of breath over the past 24 hours. Aspirin sensitivity and penicillin allergy. Took prednisone 20 mg PO this morning per her chronic regimen. P 108; BP 132/82; RR 24; SpO2 93% on room air; Mallampati II.

A 24 y.o. G1P0 with hemoglobin SS sickle cell disease at 37 weeks gestation, 5'3", 58 kg, is in active labor at 4 cm dilation. She was discharged five days ago after a vaso-occlusive crisis requiring four days of IV hydromorphone PCA. She has bilateral femoral head avascular necrosis and chronic back pain. Hgb 7.6 g/dL (baseline 8.0), reticulocytes 18%, LDH 920. P 102; BP 118/72; RR 22; SpO2 95% on 2 L NC; mild crackles at bases; Mallampati II.

A 20-week-old, 4.7 kg former premature infant boy is scheduled for elective right inguinal hernia repair.

A 68 y.o., 95 kg woman is scheduled for elective right total knee arthroplasty. She has atrial fibrillation on apixaban, last taken three days ago per preoperative instruction, with normal renal function. A recent echo showed moderate aortic stenosis (valve area 1.1 cm2, mean gradient 30 mmHg). She has obstructive sleep apnea on home CPAP with a body mass index of 35, hypertension, and type 2 diabetes. She takes tramadol daily for osteoarthritis pain and had severe nausea and prolonged sedation after a previous joint replacement under general anesthesia. On exam she is Mallampati III with full neck motion. BP 150/85; HR 76 and irregular; SpO2 95% on room air; Hgb 12 g/dL; platelets 240 K/uL; creatinine 0.9 mg/dL.

A 64 y.o., 92 kg, 5'10" man is admitted directly to the SICU from the OR following emergent exploratory laparotomy with sigmoid resection and end colostomy (Hartmann's procedure) for perforated diverticulitis with feculent peritonitis.

A 34 y.o., 60 kg, 5'5" woman is scheduled for cervical mediastinoscopy and biopsy of a bulky mediastinal mass with anterior and right paratracheal extension for tissue diagnosis.

A 68 y.o., 70 kg, 5'9" man is scheduled for a right upper lobectomy for a 4 cm non-small-cell lung cancer.

A 64 y.o., 95 kg, 5'7" man is scheduled for electromagnetic navigational bronchoscopy with transbronchial biopsy and fiducial placement of a peripheral right-lower-lobe nodule, in the off-site interventional pulmonology suite.

A 66 y.o., 72 kg, 5'10" man is scheduled for a right pneumonectomy for a central non-small-cell lung cancer involving the right main bronchus.

A 55 y.o., 98 kg, 5'8" man is scheduled for tracheal resection and end-to-end reconstruction for a post-intubation tracheal stenosis.

A 71 y.o., 82 kg, 5'10" man is scheduled for elective open repair of a 6.2 cm infrarenal abdominal aortic aneurysm.