I am now 6 weeks into my 6 month anaesthetic secondment. There have been some interesting challenges settling into the new job but I am largely enjoying my time perfecting basic airway manoeuvers, laryngoscopy and playing with some brilliant airway toys (McGrath video laryngoscopes, the AirTraq, intubating LMAs etc). I thought I’d share with you a case (from Anaesthetic week 2) that presenting some multifaceted challenges & several points of reflection …
A 59 year old male undergoes an elective radical prostatectomy. He is previously well, however takes some ‘herbal Chinese medicines’ that he stopped 2 weeks prior to surgery. His surgery appears to go without a hitch, except for the 1200mL of blood in the surgical suction container at the end of the case. He has received 2 liters of Hartmann’s & 500mL Volvuven during his OT time. He is extubated and taken to recovery at the end of the case where he reports feeling quite comfortable.
I am called back to recovery about 20-25 minutes later to address his hypotension. Continue reading
A 3 week old infant is bought into your ED late at night. She is febrile and looks incredibly unwell. Her parents report a 36 hour history of increasing vomiting and poor oral intake. She has not had a wet nappy for 12 hours or so and the parents now report a fever of 39.5*C.
She was born at 39 weeks gestation following an unremarkable pregnancy and delivery. They were only in hospital for 2 days as everything was going so well…..
When you approach this child in resus, you immediately identify that she is in a whole world of trouble. She is flat and listless, tachypnoeic at 70/min (with moderate work of breathing) and tachycardic at 204 bpm. Her capillary return is 5-6 seconds and her skin is mottled. Her abdomen is quite obviously distended.
Amongst the flurry of activity at the bedside the following x-ray is taken….
What’s going on here ?
What are your differentials ??
What are you going to do next ???
It’s night shift & you’ve received handover of an entire department. You plug on and start chipping away at the waiting-list that doesn’t seem ever get any shorter….
At 3am your nursing staff alert you to an 11 year old female who just isn’t getting any better. She was admitted under Paediatrics on the evening shift with 24 hours of vomiting (no diarrhoea) & had failed her trial of fluid. Whilst she is waiting for a paediatric ward bed she has continued to vomit a further 8-10 times and is complaining of severe epigastric pain. She had used up all her available antiemetics and analgesics on her medication chart…
She looks miserable, crying in pain and clutching at her abdomen. She is slightly tachycardic (otherwise normal observations). Her abdomen is non-distended but exquisitely tender with percussion tenderness and rebound. She has reduced bowels sounds. There is a scar in her RIF indicating a previous open appendicectomy ( ~18 months earlier).
You review her bloods (WCC 16, otherwise unremarkable) and her urinalysis is normal.
Despite further boluses of morphine, she continues to vomit and complain of severe pain….so, you order an abdominal xray.
What’s going on here ?
What are you going to do now ??