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 58 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 66 y.o., 78 kg, 5'3" woman is scheduled for posterior cervical decompression and instrumented fusion, C3 to C6, prone, with somatosensory and motor evoked potential monitoring.

A 47 y.o., 96 kg, 5'9" man is scheduled for right suboccipital craniotomy and resection of a cerebellopontine-angle tumor.

A 52 y.o., 68 kg, 5'4" woman is scheduled for craniotomy and clipping of a ruptured anterior communicating artery aneurysm.

A 38 y.o. right-handed man, 5'10", 110 kg (BMI 34), is scheduled for awake craniotomy with intraoperative language mapping for a presumed low-grade glioma of the left inferior frontal region. He has had two breakthrough focal seizures in the past month despite a recent increase in his levetiracetam dose. His wife reports loud nightly snoring; he has never had a sleep study. He is markedly anxious about the operation and has asked repeatedly whether he will feel it. Mild hypertension is treated with lisinopril. His neurologic exam is intact apart from occasional word-finding pauses. MRI shows a non-enhancing 3 cm left frontal-opercular lesion without midline shift. P 84; BP 148/88; RR 14; SpO2 96% on room air; Mallampati III.

A 79 y.o., 68 kg man is scheduled for burr-hole evacuation of a left chronic subdural hematoma later today. He has had two weeks of progressive confusion, headache, and gait unsteadiness after a minor fall from standing; CT shows an 18 mm left chronic subdural collection with 6 mm of midline shift. He takes apixaban 5 mg BID for atrial fibrillation and took this morning's dose before the CT result was back. A systolic murmur was worked up last year: echocardiogram showed moderate aortic stenosis with a valve area of 1.2 cm² and mean gradient 28 mmHg. He has baseline mild cognitive impairment, now worse — he repeats questions, and his daughter is at the bedside. P irregular, ~88; BP 158/84; RR 16; SpO2 96% on room air. Creatinine 1.4 mg/dL; Hgb 13.1 g/dL; platelets 214 K/uL.

A 61 y.o., 80 kg, 5'7" woman is scheduled for elective right frontal craniotomy for resection of a 4 cm meningioma with surrounding vasogenic edema. For two weeks she has had headaches on waking with nausea, and she reports her left hand has become clumsy; in clinic her outstretched left hand drifts. One week ago she was started on dexamethasone 4 mg BID and levetiracetam 500 mg BID. Type 2 diabetes treated with metformin; her home glucoses have run 180-240 since starting the dexamethasone. GERD, asymptomatic on daily omeprazole; hypertension treated with amlodipine. P 76; BP 152/88; RR 14; SpO2 98% on room air; T 36.9°C. Airway exam: Mallampati II, full neck extension, good mouth opening.

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 36 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 went into spontaneous labor today, a few days before the planned date.

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 71 y.o., 5'9", 96 kg man is scheduled for right total shoulder arthroplasty in the beach chair position. He has severe COPD on tiotropium and budesonide-formoterol, uses oxygen at night, and was hospitalized six weeks ago for an exacerbation treated with a prednisone course. He has obstructive sleep apnea and does not tolerate his CPAP, hypertension on amlodipine and lisinopril, and type 2 diabetes. He quit smoking two years ago after a 55 pack-year history. The surgeon has requested "a block so we can avoid a general." BP 168/92; P 84; RR 20; SpO2 91% on room air; T 36.9°C. On exam he has a barrel chest with scattered expiratory wheezes, a Mallampati III airway, and a thick neck with full range of motion.

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.