Download 1) Björn is a 75 y/o male, and has smoked 1p/d of cigarettes since

1)
Björn is a 75 y/o male, and has smoked 1p/d of cigarettes since his teen years. He does not
attend annual medical check-ups and is not (because of that?) on any regular medications.
Fatigue for the last few months, with a marked worsening in the last month. Weight loss of
10kg (now 45kg). The last week dark loose stools and vomiting, abdominal pain and loss of
appetite. Refuses to see a doctor despite his wife´s concerns. Today he collapsed on the
floor of their apartment and his wife calls an ambulance. He arrives to the hospital where
you currently work as a doctor in the medical ED.
At arrival 12:45 on a Saturday, Björn is tired but still and talking. He is peripherally cold, the
skin on the arms and legs has purple irregular color and the pulses are difficult to palpate
peripherally. Respiratory frequency is 34 and saturation slightly below 90%. You are unable
to measure systolic BP. The pulse is irregular around 170 bpm.
a) What is the patients current condition?
b) You quickly establish that you have a free airway. What are the first three measures you
take?
c) How do you proceed with your clinical investigation?
d) Name two examinations can provide you with additional, useful information in the
emergency room
2)
You quickly establish that the patient is in chock, and start aggressive resuscitation. You
administer oxygen and after making sure the patient has venous access you order fluid
therapy with warm Ringer Acetate. You examine the patient according to ABCDE and notice
that the saturation now has increased to 94%, normal breathing sounds and the heart has no
murmurs. The abdomen is slightly extended but soft and with no signs of peritonitis, bowel
sounds are normal (abd examined together with a surgical colleague). ECG shows rapid atrial
fibrillation and some signs of increased work load, no signs of acute infarction.
ABG (w 8L O2 on mask): pH 7.42, pCO2 4.3, pO2 10.7, sat 94%, Na+ 134 (137-145), K 3.0 (3.64.6), Cl- 88 (98-107), Ca2+ (1.15-1.33), Lactate 6.6, Glucose 9.6, Hb 145, Krea 305, Anion gap
24.9 (8-16)
After 1 L of Ringers Acetate the pulse has decreased to 125, systolic BP is 110, respiratory
frequency 22.
a) What/which acid-base disturbance(s) are present?
b) What is the most probable cause of the high creatinine?
c) What underlying causes do you consider and what is your next step of action?
3)
You consider different possible reasons for chock. Presently you can not exclude infectious
cause and administer broad spectrum ab after blood cultures has been secured. You also
send venous blood samples and order a CT thorax and abdomen to further push the
diagnostics. Since you previously treated patients with chock you know that the patient may
well deteriorate again and should be considered unstable. You order another liter of fluid
and escort the patient to radiology department.
CT thorax and abdomen shows a strangulated inguinal herniation leading to a fulminant ileus
and a large ventricular retention (the hernia is located under the trousers that were not
taken of for the examination). Venous blood sampling shows CRP 52, albumin 30, krea 312,
otherwise electrolytes as on the ABG, INR, Tpc and Lpk within normal range.
Patient is transferred to the surgical emergency ward (KAVA) for continued fluid treatment.
You are now the anesthesiologist on call and get a page from the surgeon who has seen the
patient in the ward and planned acute surgery. The surgeon is however concerned as the
patient seems affected and now lacks a measurable blood pressure. The patient has now
been in the hospital for five hours and received half of the third liter of RA.
When you arrive to the ward ten minutes later the patient has received the entire third liter
of fluid and is now oriented and talking again.
a) How do you calculate the patient’s fluid deficit? How much of the original deficit has been
has been replaced?
b) How do you examine the patient and how do you want to optimize him before surgery?
4)
Considering the severe signs of dehydration with hypovolemia you assess that the patient
has had at least 10% (of bw) fluid deficit or 5L. However, it may well be slightly more as he
has received 3L and continues to be unstable. You re-examine the lungs and heart, which
sounds fine except maybe slightly weakened lung sounds. You palpate weak radial and tibial
pulses but cannot feel anything at a. dorsalis pedis bilaterally. He is still cold in his
extremities but not purple any more.
Björn says he previously has undergone surgery for a clavicular fracture a few years ago but
didn’t experience any difficulties during, or after, anesthesia. You judge the airway to be
uncomplicated.
You realize that the patient is still critically ill and needs surgery sub acute. Prior to the
surgery the patient requires a preoperative shower, a urinary catheter and a ventricular
tube. While the nurse tends to that, you go back to the surgical theater to prepare for the
anesthesia.
a) What possible problems do you see for this anesthesia?
b) What is your plan for this anesthesia (method, drugs)?
5)
After 30 minutes the nurse from the ward calls you. The patient is showered and has a
urinary cath. He has however deteriorated and has now an affected mental status and is
once again slightly purple on the limbs. The nurse doesn’t want to put in the ventricular tube
at this point and asks if she can bring the patient to the OR instead.
You agree that the patient in unstable and tell her to come on down to the OR instead.
When he arrives he is vomiting and still has some purple discoloration.
You assess there is a high risk of aspiration and are therefore preparing for RSI without mask
ventilation. You also realize that the patient is hypovolemic with high risk for unstable
hemodynamics, especially at induction. You also consider that his vessels are not all healthy
after a long time of smoking. You choose to put in a arterial catheter (for continuous blood
pressure measurements) prior to induction. This is however not that easy, when you hardly
can feel any pulses and the vessels are contracted. By the time the a-line is in place, the
fourth liter of RA is finished and you see a systolic BP of 95-100 and the patient is slightly
improved again.
a) It is difficult to place the ventricular tube and Björn thinks it is very uncomfortable and
slightly painful. The anesthesia nurse asks if you cannot wait until after the patients asleep
so it will be less uncomfortable. What do you think?
b) How do you adjust the induction to minimize the risk of further drops in BP?
Epilog:
With some good teamwork you get the v-tube down and empty the ventricle of 2.5L of
brown fluid. You induce the anesthesia with Ketalar with close surveillance of the blood
pressure. You use Celocurine (Succinylcholine) for muscle relaxation. After induction you put
in a double lumen central line as you think you might need to give Noradrenaline during
surgery and the patient may continue to be unstable afterwards.
The surgery is quick, and the bowel is not necrotic. During surgery the patient is stable with
low dose of epinephrine and some additional fluid therapy with RA and albumin.
Postoperatively Björn feels better and can start to eat and drink the day after surgery. POD
2, however, he gets some difficulties breathing and x-ray shows some excess fluid. After low
dose Lasix he is again fine and can go straight home from the ward POD 5. The kreatinine is
then 120 and CT had shown no signs of malignancy.
Well done!