UBP 1.8 (Long Form): Renal – Chronic Renal Failure

Question 1

Intra-operative Management:

What monitoring would you require for this surgery?

• (A 64-year-old, 118 kg man is scheduled for an exploratory laparotomy for a suspected ruptured diverticulum. He reports increased abdominal pain over the last two days associated with fever and chills.*
• PMHx: His past medical history includes HTN for the past 10 years, chronic renal failure with hemodialysis, and anemia. He receives dialysis three times a week and his last session was 48 hours ago.*
• Meds: Clonidine, Metoprolol, Erythropoietin, and Heparin with dialysis*
• Allergies: Contrast dye*
• PE: VS: BP = 152/90 mmHg, P = 96, RR = 20, T = 38.1 ºC*
• Airway: Mallampati II, thyromental distance > 6 cm, dentition intact, full range of cervical motion*
• Lungs: Decreased breath sounds in lower lung fields bilaterally*
• Cardiovascular: Tachycardia*
• Abdominal: Abdomen tight with generalized tenderness*
• Extremities: Functioning AV fistula in the right arm*
• Labs: WBC 23, Hgb 9.2 g/dL, Na 134 mEq/L, K 5.6 mEq/L, Cr 3.8 mEq/L, Glucose 148 mg/dL.)*

Answer 1

In addition to the ASA standard monitors, I would place 5-lead EKG to monitor for ischemia.

Also, due to the risk of atriovenous fistula (AVF) occlusion, I would avoid placing the blood pressure cuff or peripheral IVs in the same arm as an AVF.

I do not believe invasive monitors would be necessary in this case, unless the history and physical revealed severe cardiopulmonary dysfunction.

Question 2

Intra-operative Management:

What is your plan for induction?

• (A 64-year-old, 118 kg man is scheduled for an exploratory laparotomy for a suspected ruptured diverticulum. He reports increased abdominal pain over the last two days associated with fever and chills.*
• PMHx: His past medical history includes HTN for the past 10 years, chronic renal failure with hemodialysis, and anemia. He receives dialysis three times a week and his last session was 48 hours ago.*
• Meds: Clonidine, Metoprolol, Erythropoietin, and Heparin with dialysis*
• Allergies: Contrast dye*
• PE: VS: BP = 152/90 mmHg, P = 96, RR = 20, T = 38.1 ºC*
• Airway: Mallampati II, thyromental distance > 6 cm, dentition intact, full range of cervical motion*
• Lungs: Decreased breath sounds in lower lung fields bilaterally*
• Cardiovascular: Tachycardia*
• Abdominal: Abdomen tight with generalized tenderness*
• Extremities: Functioning AV fistula in the right arm*
• Labs: WBC 23, Hgb 9.2 g/dL, Na 134 mEq/L, K 5.6 mEq/L, Cr 3.8 mEq/L, Glucose 148 mg/dL.)*

Answer 2

My primary goals with induction are – to secure the airway, avoid significant hypotension, hypoxia, and aspiration.

Therefore, I would:

1. use a nasogastric tube to empty the stomach as much as possible;
2. provide aspiration prophylaxis (avoiding metoclopramide due to bowel rupture);
3. administer an antiemetic to help reduce the risk of vomiting with subsequent aspiration;
4. place the patient in reverse trendelenburg to improve respiratory mechanics, reduce passive regurgitation, and facilitate rapid intubation; and
5. pre-oxygenate with 100% oxygen using a tight mask seal. Then, assuming a reassuring airway, I would
6. perform a rapid sequence induction with cricoid pressure, using rocuronium to avoid the 0.5 mEq/L increase in potassium that often occurs following succinylcholine administration.

Xtra Q – Would you use succinylcholine?

Question 3

Intra-operative Management:

Are there any anesthetic drugs you would avoid in someone with CRF?

• (A 64-year-old, 118 kg man is scheduled for an exploratory laparotomy for a suspected ruptured diverticulum. He reports increased abdominal pain over the last two days associated with fever and chills.*
• PMHx: His past medical history includes HTN for the past 10 years, chronic renal failure with hemodialysis, and anemia. He receives dialysis three times a week and his last session was 48 hours ago.*
• Meds: Clonidine, Metoprolol, Erythropoietin, and Heparin with dialysis*
• Allergies: Contrast dye*
• PE: VS: BP = 152/90 mmHg, P = 96, RR = 20, T = 38.1 ºC*
• Airway: Mallampati II, thyromental distance > 6 cm, dentition intact, full range of cervical motion*
• Lungs: Decreased breath sounds in lower lung fields bilaterally*
• Cardiovascular: Tachycardia*
• Abdominal: Abdomen tight with generalized tenderness*
• Extremities: Functioning AV fistula in the right arm*
• Labs: WBC 23, Hgb 9.2 g/dL, Na 134 mEq/L, K 5.6 mEq/L, Cr 3.8 mEq/L, Glucose 148 mg/dL.)*

Answer 3

If possible, I would avoid drugs that were dependent on renal elimination or had active metabolites that could accumulate in patients with renal failure.

Some of these drugs include –

pancuronium, atropine, glycopyrrolate, ketamine, morphine, diazepam, and meperidine.

Also, the dosage of drugs that are highly protein bound, such as –

thiopental and the benzodiazepines,

should be reduced in patients with CRF, as they may exert an exaggerated drug effect in the presence of decreased protein binding.

Drugs with active metabolites that can accumulate – e.g. morphine & demerol.

Question 4

Intra-operative Management:

A few minutes after intubation, the SpO2 decreases to 91%, despite a Fio2 of 100%.

What are the possible causes of his hypoxia?

• (A 64-year-old, 118 kg man is scheduled for an exploratory laparotomy for a suspected ruptured diverticulum. He reports increased abdominal pain over the last two days associated with fever and chills.*
• PMHx: His past medical history includes HTN for the past 10 years, chronic renal failure with hemodialysis, and anemia. He receives dialysis three times a week and his last session was 48 hours ago.*
• Meds: Clonidine, Metoprolol, Erythropoietin, and Heparin with dialysis*
• Allergies: Contrast dye*
• PE: VS: BP = 152/90 mmHg, P = 96, RR = 20, T = 38.1 ºC*
• Airway: Mallampati II, thyromental distance > 6 cm, dentition intact, full range of cervical motion*
• Lungs: Decreased breath sounds in lower lung fields bilaterally*
• Cardiovascular: Tachycardia*
• Abdominal: Abdomen tight with generalized tenderness*
• Extremities: Functioning AV fistula in the right arm*
• Labs: WBC 23, Hgb 9.2 g/dL, Na 134 mEq/L, K 5.6 mEq/L, Cr 3.8 mEq/L, Glucose 148 mg/dL.)*

Answer 4

The most likely causes of hypoxia shortly after intubation would include –

• inadequate ventilation,
• advancement of the ETT into the right mainstem bronchus, and
• bronchospasm (the latter may occur secondary to light anesthesia and/or aspiration).

Other less likely causes would include –

• changes in pulmonary compliance with the supine position,
• atelectasis,
• obstruction of the ETT, or
• delivery of a hypoxic gas mixture.

–

In this situation, I would begin by – examining the oropharynx for gastric material, making sure to suction and clear the airway (oropharynx and ETT) before applying positive pressure ventilation, which could further disseminate gastric material in the lungs.

Next, I would hand ventilate with 100% oxygen, confirm appropriate ETCO2 and inspired O2 concentrations, and auscultate both lung fields.

Depending on what I found, I might pull back on the ETT, administer a bronchodilator, deepen my anesthetic, increase the tidal volume, apply PEEP, or place the patient in the reverse trendelenburg position.

Question 5

Intra-operative Management:

A few minutes after intubation, the SpO2 decreases to 91%, despite a Fio2 of 100%.

Can the capnograph help in diagnosing the problem?

• (A 64-year-old, 118 kg man is scheduled for an exploratory laparotomy for a suspected ruptured diverticulum. He reports increased abdominal pain over the last two days associated with fever and chills.*
• PMHx: His past medical history includes HTN for the past 10 years, chronic renal failure with hemodialysis, and anemia. He receives dialysis three times a week and his last session was 48 hours ago.*
• Meds: Clonidine, Metoprolol, Erythropoietin, and Heparin with dialysis*
• Allergies: Contrast dye*
• PE: VS: BP = 152/90 mmHg, P = 96, RR = 20, T = 38.1 ºC*
• Airway: Mallampati II, thyromental distance > 6 cm, dentition intact, full range of cervical motion*
• Lungs: Decreased breath sounds in lower lung fields bilaterally*
• Cardiovascular: Tachycardia*
• Abdominal: Abdomen tight with generalized tenderness*
• Extremities: Functioning AV fistula in the right arm*
• Labs: WBC 23, Hgb 9.2 g/dL, Na 134 mEq/L, K 5.6 mEq/L, Cr 3.8 mEq/L, Glucose 148 mg/dL.)*

Answer 5

*Per Online UBP – Be familiar with Capnograph waveforms*

The end tidal CO2 waveform can be useful in identifying some causes of hypoxia, such as – esophageal intubation, obstructive lung disease, inadequate muscle relaxant, and incompetent ventilatory valves.

Question 6

Intra-operative Management:

The surgeon decides the patient needs a hemicolectomy.

Assuming there has been minimal blood loss, how would you manage fluid administration in this patient?

• (A 64-year-old, 118 kg man is scheduled for an exploratory laparotomy for a suspected ruptured diverticulum. He reports increased abdominal pain over the last two days associated with fever and chills.*
• PMHx: His past medical history includes HTN for the past 10 years, chronic renal failure with hemodialysis, and anemia. He receives dialysis three times a week and his last session was 48 hours ago.*
• Meds: Clonidine, Metoprolol, Erythropoietin, and Heparin with dialysis*
• Allergies: Contrast dye*
• PE: VS: BP = 152/90 mmHg, P = 96, RR = 20, T = 38.1 ºC*
• Airway: Mallampati II, thyromental distance > 6 cm, dentition intact, full range of cervical motion*
• Lungs: Decreased breath sounds in lower lung fields bilaterally*
• Cardiovascular: Tachycardia*
• Abdominal: Abdomen tight with generalized tenderness*
• Extremities: Functioning AV fistula in the right arm*
• Labs: WBC 23, Hgb 9.2 g/dL, Na 134 mEq/L, K 5.6 mEq/L, Cr 3.8 mEq/L, Glucose 148 mg/dL.)*

Answer 6

In order to avoid fluid overload, I would replace insensible losses and third space losses with an isotonic crystalloid (i.e. normal saline), limiting replacement to 1-2 mL/kg/hr.

With the same goal in mind, I would replace blood losses using a colloid solution or packed red blood cells, rather than a 3:1 ratio of crystalloid.

Given this patient’s hyperkalemia and probable glucose intolerance, I would avoid the administration of lactated ringers (contains 4 mEq/L of potassium) and glucose containing solutions.

*Per Online UBP – address why this question is being asked: -volume overload possibility and -LR vs. NS (K+)

Question 7

Intra-operative Management:

What are 3rd space losses and why do they occur?

• (A 64-year-old, 118 kg man is scheduled for an exploratory laparotomy for a suspected ruptured diverticulum. He reports increased abdominal pain over the last two days associated with fever and chills.*
• PMHx: His past medical history includes HTN for the past 10 years, chronic renal failure with hemodialysis, and anemia. He receives dialysis three times a week and his last session was 48 hours ago.*
• Meds: Clonidine, Metoprolol, Erythropoietin, and Heparin with dialysis*
• Allergies: Contrast dye*
• PE: VS: BP = 152/90 mmHg, P = 96, RR = 20, T = 38.1 ºC*
• Airway: Mallampati II, thyromental distance > 6 cm, dentition intact, full range of cervical motion*
• Lungs: Decreased breath sounds in lower lung fields bilaterally*
• Cardiovascular: Tachycardia*
• Abdominal: Abdomen tight with generalized tenderness*
• Extremities: Functioning AV fistula in the right arm*
• Labs: WBC 23, Hgb 9.2 g/dL, Na 134 mEq/L, K 5.6 mEq/L, Cr 3.8 mEq/L, Glucose 148 mg/dL.)*

Answer 7

Third spacing occurs when – fluids in the intravascular compartment are lost into the interstitial space due to traumatized, inflamed, or infected tissue (or from surgery itself).

This shifting of fluid occurs at the expense of the intracellular and intravascular compartments, requiring replacement.

Estimates of these losses are often based on the extent and type of surgery.

(The more extensive and significant the surgery, the more 3rd space loss there is.)

Question 8

Intra-operative Management:

The patient’s blood pressure gradually declines to 82/60 mmHg, despite fluid replacement.

What would you do?

• (A 64-year-old, 118 kg man is scheduled for an exploratory laparotomy for a suspected ruptured diverticulum. He reports increased abdominal pain over the last two days associated with fever and chills.*
• PMHx: His past medical history includes HTN for the past 10 years, chronic renal failure with hemodialysis, and anemia. He receives dialysis three times a week and his last session was 48 hours ago.*
• Meds: Clonidine, Metoprolol, Erythropoietin, and Heparin with dialysis*
• Allergies: Contrast dye*
• PE: VS: BP = 152/90 mmHg, P = 96, RR = 20, T = 38.1 ºC*
• Airway: Mallampati II, thyromental distance > 6 cm, dentition intact, full range of cervical motion*
• Lungs: Decreased breath sounds in lower lung fields bilaterally*
• Cardiovascular: Tachycardia*
• Abdominal: Abdomen tight with generalized tenderness*
• Extremities: Functioning AV fistula in the right arm*
• Labs: WBC 23, Hgb 9.2 g/dL, Na 134 mEq/L, K 5.6 mEq/L, Cr 3.8 mEq/L, Glucose 148 mg/dL.)*

Answer 8

I would –

• recheck the blood pressure,
• ensure adequate ventilation and oxygenation,
• check the EKG for signs of ischemia or arrhythmia (i.e. peaked T-waves and widening of the QRS associated with hyperkalemia),
• check the surgical field for excessive bleeding,
• place the patient in the trendelenburg position,
• give a fluid bolus, and
• consider administration of a vasoconstrictor.

Question 9

Post-operative Management:

How will you extubate this patient?

• (A 64-year-old, 118 kg man is scheduled for an exploratory laparotomy for a suspected ruptured diverticulum. He reports increased abdominal pain over the last two days associated with fever and chills.*
• PMHx: His past medical history includes HTN for the past 10 years, chronic renal failure with hemodialysis, and anemia. He receives dialysis three times a week and his last session was 48 hours ago.*
• Meds: Clonidine, Metoprolol, Erythropoietin, and Heparin with dialysis*
• Allergies: Contrast dye*
• PE: VS: BP = 152/90 mmHg, P = 96, RR = 20, T = 38.1 ºC*
• Airway: Mallampati II, thyromental distance > 6 cm, dentition intact, full range of cervical motion*
• Lungs: Decreased breath sounds in lower lung fields bilaterally*
• Cardiovascular: Tachycardia*
• Abdominal: Abdomen tight with generalized tenderness*
• Extremities: Functioning AV fistula in the right arm*
• Labs: WBC 23, Hgb 9.2 g/dL, Na 134 mEq/L, K 5.6 mEq/L, Cr 3.8 mEq/L, Glucose 148 mg/dL.)*

Answer 9

Given his increased risk of aspiration, and assuming extubation criteria were met, I would:

1. ensure complete reversal of muscle relaxants (*Don’t forget to mention this), adequate oxygenation, normocarbia, stable hemodynamics, and sufficient tidal volumes with spontaneous ventilation;
2. utilize the nasogastric tube to empty his stomach; and
3. extubate him as soon as he was awake, alert, and exhibiting intact airway reflexes.

Question 10

Post-operative Management:

During emergence, the patient vomits clear non-particulate matter prior to removal of the ETT. What would you do?

• (A 64-year-old, 118 kg man is scheduled for an exploratory laparotomy for a suspected ruptured diverticulum. He reports increased abdominal pain over the last two days associated with fever and chills.*
• PMHx: His past medical history includes HTN for the past 10 years, chronic renal failure with hemodialysis, and anemia. He receives dialysis three times a week and his last session was 48 hours ago.*
• Meds: Clonidine, Metoprolol, Erythropoietin, and Heparin with dialysis*
• Allergies: Contrast dye*
• PE: VS: BP = 152/90 mmHg, P = 96, RR = 20, T = 38.1 ºC*
• Airway: Mallampati II, thyromental distance > 6 cm, dentition intact, full range of cervical motion*
• Lungs: Decreased breath sounds in lower lung fields bilaterally*
• Cardiovascular: Tachycardia*
• Abdominal: Abdomen tight with generalized tenderness*
• Extremities: Functioning AV fistula in the right arm*
• Labs: WBC 23, Hgb 9.2 g/dL, Na 134 mEq/L, K 5.6 mEq/L, Cr 3.8 mEq/L, Glucose 148 mg/dL.)*

Answer 10

I would:

1. turn the patients head to the side;
2. place him in a slight trendelenburg position to facilitate the movement of gastric material away from the airway;
3. apply cricoid pressure;
4. thoroughly suction the oropharynx to remove as much gastric content as possible;
5. suction the ETT to remove any aspirated material and collect a sample for culture and sensitivity testing;
6. utilize the nasogastric tube to determine the pH of gastric content and empty the stomach as much as possible;
7. treat any bronchospasm with B2-agonists; and
8. monitor the patient for any signs of hypoxia (an early sign of aspiration).

Question 11

Post-operative Management:

You decide to go ahead and extubate the patient and take him to the PACU. Fifteen minutes after you leave, the nurse calls and reports that his oxygen saturation is lingering at 88-91% on 15 L of O2 per facemask. She would like to give him a breathing treatment. What would you tell her?

• (A 64-year-old, 118 kg man is scheduled for an exploratory laparotomy for a suspected ruptured diverticulum. He reports increased abdominal pain over the last two days associated with fever and chills.*
• PMHx: His past medical history includes HTN for the past 10 years, chronic renal failure with hemodialysis, and anemia. He receives dialysis three times a week and his last session was 48 hours ago.*
• Meds: Clonidine, Metoprolol, Erythropoietin, and Heparin with dialysis*
• Allergies: Contrast dye*
• PE: VS: BP = 152/90 mmHg, P = 96, RR = 20, T = 38.1 ºC*
• Airway: Mallampati II, thyromental distance > 6 cm, dentition intact, full range of cervical motion*
• Lungs: Decreased breath sounds in lower lung fields bilaterally*
• Cardiovascular: Tachycardia*
• Abdominal: Abdomen tight with generalized tenderness*
• Extremities: Functioning AV fistula in the right arm*
• Labs: WBC 23, Hgb 9.2 g/dL, Na 134 mEq/L, K 5.6 mEq/L, Cr 3.8 mEq/L, Glucose 148 mg/dL.)*

Answer 11

I would carefully evaluate the patient prior to agreeing to this treatment, because, –

although the hypoxia may be due to –

• bronchospasm (possibly secondary to aspiration), it could also be secondary to –
• sedation,
• upper airway obstruction (this obese patient may have undiagnosed obstructive sleep apnea),
• inadequate ventilation (secondary to respiratory depression and/or decreased lung compliance),
• atelectasis (secondary to inadequate ventilation or aspiration),
• aspiration (can lead to atelectasis, bronchospasm, pulmonary edema, and intrapulmonary shunting),
• pulmonary edema (secondary to fluid overload and/or aspiration), or
• pulmonary embolism (increased risk secondary to his obesity).

A breathing treatment would not be the optimum treatment option for most of these conditions.

Question 12

Post-operative Management:

While assessing the patient, you find his respiratory rate is 18 and his O2 saturation is 90% on 15L O2 via a non-rebreathing mask. Upon auscultation, the lungs are clear and breath sounds are absent at the left lung base. What would you do?

• (A 64-year-old, 118 kg man is scheduled for an exploratory laparotomy for a suspected ruptured diverticulum. He reports increased abdominal pain over the last two days associated with fever and chills.*
• PMHx: His past medical history includes HTN for the past 10 years, chronic renal failure with hemodialysis, and anemia. He receives dialysis three times a week and his last session was 48 hours ago.*
• Meds: Clonidine, Metoprolol, Erythropoietin, and Heparin with dialysis*
• Allergies: Contrast dye*
• PE: VS: BP = 152/90 mmHg, P = 96, RR = 20, T = 38.1 ºC*
• Airway: Mallampati II, thyromental distance > 6 cm, dentition intact, full range of cervical motion*
• Lungs: Decreased breath sounds in lower lung fields bilaterally*
• Cardiovascular: Tachycardia*
• Abdominal: Abdomen tight with generalized tenderness*
• Extremities: Functioning AV fistula in the right arm*
• Labs: WBC 23, Hgb 9.2 g/dL, Na 134 mEq/L, K 5.6 mEq/L, Cr 3.8 mEq/L, Glucose 148 mg/dL.)*

Answer 12

I would –

• continue to provide the 15 liters of oxygen,
• assess his level of sedation,
• place him in the head up position, and
• order incentive spirometry, a chest x-ray, and an ABG.

If these actions did not identify or resolve the problem, I would consider consulting a pulmonologist.

Question 13

Post-operative Management:

The patient confides that his wife has recently overcome an addiction to prescription pain medications and is concerned about his own risk of dependence after surgery. What would you tell him?

• (A 64-year-old, 118 kg man is scheduled for an exploratory laparotomy for a suspected ruptured diverticulum. He reports increased abdominal pain over the last two days associated with fever and chills.*
• PMHx: His past medical history includes HTN for the past 10 years, chronic renal failure with hemodialysis, and anemia. He receives dialysis three times a week and his last session was 48 hours ago.*
• Meds: Clonidine, Metoprolol, Erythropoietin, and Heparin with dialysis*
• Allergies: Contrast dye*
• PE: VS: BP = 152/90 mmHg, P = 96, RR = 20, T = 38.1 ºC*
• Airway: Mallampati II, thyromental distance > 6 cm, dentition intact, full range of cervical motion*
• Lungs: Decreased breath sounds in lower lung fields bilaterally*
• Cardiovascular: Tachycardia*
• Abdominal: Abdomen tight with generalized tenderness*
• Extremities: Functioning AV fistula in the right arm*
• Labs: WBC 23, Hgb 9.2 g/dL, Na 134 mEq/L, K 5.6 mEq/L, Cr 3.8 mEq/L, Glucose 148 mg/dL.)*

Answer 13

I would explain to the patient that appropriate post-operative use of narcotics is not usually associated with addiction.

However, given his obvious concern, I would discuss other options of postoperative pain control such as – ketorolac, ultram, and/or regional anesthesia.

Question 14

Post-operative Management:

Would you place an epidural in this patient for post-op pain control?

• (A 64-year-old, 118 kg man is scheduled for an exploratory laparotomy for a suspected ruptured diverticulum. He reports increased abdominal pain over the last two days associated with fever and chills.*
• PMHx: His past medical history includes HTN for the past 10 years, chronic renal failure with hemodialysis, and anemia. He receives dialysis three times a week and his last session was 48 hours ago.*
• Meds: Clonidine, Metoprolol, Erythropoietin, and Heparin with dialysis*
• Allergies: Contrast dye*
• PE: VS: BP = 152/90 mmHg, P = 96, RR = 20, T = 38.1 ºC*
• Airway: Mallampati II, thyromental distance > 6 cm, dentition intact, full range of cervical motion*
• Lungs: Decreased breath sounds in lower lung fields bilaterally*
• Cardiovascular: Tachycardia*
• Abdominal: Abdomen tight with generalized tenderness*
• Extremities: Functioning AV fistula in the right arm*
• Labs: WBC 23, Hgb 9.2 g/dL, Na 134 mEq/L, K 5.6 mEq/L, Cr 3.8 mEq/L, Glucose 148 mg/dL.)*

Answer 14

Since thoracic epidurals are associated with superior postoperative analgesia and reduced pulmonary complications,

I would consider placement as long as the patient consented to the procedure, appropriate antibiotics had been initiated (the patient’s fever may be due to bacteremia, placing him at risk for epidural abscess and meningitis with dural puncture and vascular disruption), and there were no contraindications.

Given his CRF and dependence on hemodialysis, however, I would ensure the absence of a coagulopathy and coordinate epidural catheter removal to occur at least one hour before heparinization for hemodialysis or 2-4 hours after heparinization.

Question 15

Post-operative Management:

What are the ASRA guidelines for epidural placement in someone receiving unfractionated heparin?

• (A 64-year-old, 118 kg man is scheduled for an exploratory laparotomy for a suspected ruptured diverticulum. He reports increased abdominal pain over the last two days associated with fever and chills.*
• PMHx: His past medical history includes HTN for the past 10 years, chronic renal failure with hemodialysis, and anemia. He receives dialysis three times a week and his last session was 48 hours ago.*
• Meds: Clonidine, Metoprolol, Erythropoietin, and Heparin with dialysis*
• Allergies: Contrast dye*
• PE: VS: BP = 152/90 mmHg, P = 96, RR = 20, T = 38.1 ºC*
• Airway: Mallampati II, thyromental distance > 6 cm, dentition intact, full range of cervical motion*
• Lungs: Decreased breath sounds in lower lung fields bilaterally*
• Cardiovascular: Tachycardia*
• Abdominal: Abdomen tight with generalized tenderness*
• Extremities: Functioning AV fistula in the right arm*
• Labs: WBC 23, Hgb 9.2 g/dL, Na 134 mEq/L, K 5.6 mEq/L, Cr 3.8 mEq/L, Glucose 148 mg/dL.)*

Answer 15

There is NO contraindication to performing neuraxial techniques on patients receiving SQ unfractionated heparin.

For patients receiving systemic (IV) heparinization, however, needle insertion or catheter removal should occur at least 2-4 hours following discontinuation of systemic heparin.

In addition, laboratory confirmation of normal coagulation should precede either procedure.

On the other hand, heparin dosing can be started or continued one hour following needle insertion or catheter removal.