UBP 2.3 (Long Form): Orthopedics – Shoulder Surgery/Beach Chair

Question 1

Intra-operative Management:

What monitoring will you require for this case?

• (A 46-year-old, 97 kg, 5’2” female is scheduled for surgery at an ambulatory surgery center to repair her left rotator cuff.*
• Past Medical History: Significant for hypertension and hypothyroidism for which she takes a thyroid supplement. She has been smoking for 29 years and gets short of breath with normal activity. She also states that she has gastroesophageal reflux disease with abdominal bloating.*
• Past Surgical History: Right-sided mastectomy 4 years ago. She states that several lymph nodes were removed.*
• Anesthetic History: The patient says that during her mastectomy the anesthesiologist “had some trouble getting the tube in”. She also reports that her voice began to change several months after her last surgery. Finally, she adds that her ENT wants to perform a tonsillectomy as soon as her shoulder is repaired.*
• Physical Exam: Vital Signs: P = 108; BP = 168/98; R = 12; T = 36ºC.*
• Airway: Mallampati Class IV airway. She has good thyromental distance and neck range of motion.*
• Cardiovascular: Regular rate and rhythm; Lack of expected heart rate increase with inspiration, exhibits significant postural hypotension*
• Lungs: clear to auscultation bilaterally*
• Medications: NPH insulin, regular insulin, omeprazole, synthroid*
• Lab: BS = 135 mg/dL, Hgb A1C = 9.2%*
• CXR: hyper-expanded lungs)*

Answer 1

I would require standard ASA monitoring with special attention to placement of the blood pressure cuff.

Given her right-sided mastectomy and the site of surgery, it may be necessary to place the blood pressure cuff on one of her legs.

Regardless of cuff location, with the patient in the beach chair position it is important to account for the hydrostatic pressure difference between the point of measurement and the Circle of Willis to ensure adequate cerebral perfusion.

Given these concerns, I would also see if the patient would agree to arterial line placement after she was asleep.

This would be especially helpful if the surgeon required periods of deliberate hypotension during the procedure.

What if the patient refuses arterial line? – see online UBP prep.

Question 2

Intra-operative Management:

The patient agrees to general anesthesia in combination with an interscalene block for post-operative pain control. How will you induce her?

• (A 46-year-old, 97 kg, 5’2” female is scheduled for surgery at an ambulatory surgery center to repair her left rotator cuff.*
• Past Medical History: Significant for hypertension and hypothyroidism for which she takes a thyroid supplement. She has been smoking for 29 years and gets short of breath with normal activity. She also states that she has gastroesophageal reflux disease with abdominal bloating.*
• Past Surgical History: Right-sided mastectomy 4 years ago. She states that several lymph nodes were removed.*
• Anesthetic History: The patient says that during her mastectomy the anesthesiologist “had some trouble getting the tube in”. She also reports that her voice began to change several months after her last surgery. Finally, she adds that her ENT wants to perform a tonsillectomy as soon as her shoulder is repaired.*
• Physical Exam: Vital Signs: P = 108; BP = 168/98; R = 12; T = 36ºC.*
• Airway: Mallampati Class IV airway. She has good thyromental distance and neck range of motion.*
• Cardiovascular: Regular rate and rhythm; Lack of expected heart rate increase with inspiration, exhibits significant postural hypotension*
• Lungs: clear to auscultation bilaterally*
• Medications: NPH insulin, regular insulin, omeprazole, synthroid*
• Lab: BS = 135 mg/dL, Hgb A1C = 9.2%*
• CXR: hyper-expanded lungs)*

Answer 2

Given this patient’s history of difficult intubation and increased risk of aspiration (GERD, diabetic neuropathy, obesity, and history of difficult airway management), I would:

1. ensure the presence of difficult airway equipment;
2. administer an antisialagogue to reduce airway secretions and facilitate awake fiber optic intubation;
3. provide metoclopramide, an H2-blocker, and a nonparticulate antacid for aspiration prophylaxis;
4. place the patient in the reverse-trendelenburg position to improve respiratory mechanics, reduce the risk of airway obstruction, improve intubating conditions, and reduce the risk of passive regurgitation;
5. provide adequate analgesia of the airway (i.e. blocks, nebulized local anesthetic, lidocaine soaked pledgets, etc.);
6. proceed with an awake fiberoptic intubation; and, following ETT placement,
7. induce her with fentanyl, versed, and propofol.

• Clinical Note:*
• Antisialagogues are NOT recommended for aspiration prophylaxis because they have NOT been shown to reduce acidity or gastric volume, and may reduce lower esophageal sphincter tone.

Question 3

Intra-operative Management:

You intubate and induce the patient and, as you expected, the surgeon requests that she be placed in the beach chair position.

What are the physiologic effects of this position on the anesthetized patient?

• (A 46-year-old, 97 kg, 5’2” female is scheduled for surgery at an ambulatory surgery center to repair her left rotator cuff.*
• Past Medical History: Significant for hypertension and hypothyroidism for which she takes a thyroid supplement. She has been smoking for 29 years and gets short of breath with normal activity. She also states that she has gastroesophageal reflux disease with abdominal bloating.*
• Past Surgical History: Right-sided mastectomy 4 years ago. She states that several lymph nodes were removed.*
• Anesthetic History: The patient says that during her mastectomy the anesthesiologist “had some trouble getting the tube in”. She also reports that her voice began to change several months after her last surgery. Finally, she adds that her ENT wants to perform a tonsillectomy as soon as her shoulder is repaired.*
• Physical Exam: Vital Signs: P = 108; BP = 168/98; R = 12; T = 36ºC.*
• Airway: Mallampati Class IV airway. She has good thyromental distance and neck range of motion.*
• Cardiovascular: Regular rate and rhythm; Lack of expected heart rate increase with inspiration, exhibits significant postural hypotension*
• Lungs: clear to auscultation bilaterally*
• Medications: NPH insulin, regular insulin, omeprazole, synthroid*
• Lab: BS = 135 mg/dL, Hgb A1C = 9.2%*
• CXR: hyper-expanded lungs)*

Answer 3

In the awake patient, the beach chair position results in decreased –

• cerebral perfusion pressure (approximately 15% decrease in the nonanesthetized patient),
• stroke volume, and
• cardiac output.

These effects are at least partially compensated for by an increase in systemic vascular resistance (up to 50-80%).

However, under general anesthesia, this compensatory increase in systemic vascular resistance is inhibited, further compromising cardiac output and cerebral perfusion pressure and, therefore, placing the patient at increased risk of cerebral ischemia.

Moreover, this patient exhibits signs of diabetic autonomic neuropathy which could further impair her ability to compensate for the reduction in cerebral perfusion that is likely to occur when she is placed in the beach chair position (secondary to impaired peripheral vasoconstriction and baroreceptor function).

Question 4

Intra-operative Management:

The patient’s oxygen saturation begins to fall. You hear diminished breath sounds on the left. What will you do?

• (A 46-year-old, 97 kg, 5’2” female is scheduled for surgery at an ambulatory surgery center to repair her left rotator cuff.*
• Past Medical History: Significant for hypertension and hypothyroidism for which she takes a thyroid supplement. She has been smoking for 29 years and gets short of breath with normal activity. She also states that she has gastroesophageal reflux disease with abdominal bloating.*
• Past Surgical History: Right-sided mastectomy 4 years ago. She states that several lymph nodes were removed.*
• Anesthetic History: The patient says that during her mastectomy the anesthesiologist “had some trouble getting the tube in”. She also reports that her voice began to change several months after her last surgery. Finally, she adds that her ENT wants to perform a tonsillectomy as soon as her shoulder is repaired.*
• Physical Exam: Vital Signs: P = 108; BP = 168/98; R = 12; T = 36ºC.*
• Airway: Mallampati Class IV airway. She has good thyromental distance and neck range of motion.*
• Cardiovascular: Regular rate and rhythm; Lack of expected heart rate increase with inspiration, exhibits significant postural hypotension*
• Lungs: clear to auscultation bilaterally*
• Medications: NPH insulin, regular insulin, omeprazole, synthroid*
• Lab: BS = 135 mg/dL, Hgb A1C = 9.2%*
• CXR: hyper-expanded lungs)*

Answer 4

I would provide 100% oxygen, hand ventilate and attempt to quickly verify proper ETT placement by direct visualization with a fiberoptic scope through the ETT.

If the placement was correct, I would consider the possibility that her hypoxia is due to left-sided phrenic nerve paralysis (left interscalene block) or left-sided pneumothorax (smoker, COPD, recent left interscalene block).

Given the potentially serious consequences of a tension pneumothorax, I would order a bedside ultrasound (higher sensitivity than a chest radiograph) or chest radiograph and look for signs and symptoms consistent with this diagnosis, such as tracheal deviation and/or hyper-resonance to percussion over the left thorax.

If, after examining her, I believed her hypoxia was the result of a pneumothorax, I would attempt to establish spontaneous respiration, recognizing that positive pressure ventilation could potentially convert a simple pneumothorax into a tension pneumothorax.
If the patient’s oxygen saturation continued to fall, or if she exhibited signs of cardiovascular instability, I would consider performing a needle thoracostomy using a 14-gauge needle inserted into the second intercostal space at the midclavicular line.

Definitive treatment, however, would include placement of a chest tube in the fourth or fifth intercostal space just anterior to the midaxillary line.

Question 5

Intra-operative Management:

You relieve the tension pneumothorax by performing the needle thoracostomy and the surgeon places a chest tube. Subsequently, the patient’s oxygen saturation returns to normal, and the case continues.

Her blood pressure is 154/87 mmHg and the surgeon asks you to lower the systolic blood pressure to less than 100 mmHg.

What do you say? What are the risks of deliberate hypotension?

• (A 46-year-old, 97 kg, 5’2” female is scheduled for surgery at an ambulatory surgery center to repair her left rotator cuff.*
• Past Medical History: Significant for hypertension and hypothyroidism for which she takes a thyroid supplement. She has been smoking for 29 years and gets short of breath with normal activity. She also states that she has gastroesophageal reflux disease with abdominal bloating.*
• Past Surgical History: Right-sided mastectomy 4 years ago. She states that several lymph nodes were removed.*
• Anesthetic History: The patient says that during her mastectomy the anesthesiologist “had some trouble getting the tube in”. She also reports that her voice began to change several months after her last surgery. Finally, she adds that her ENT wants to perform a tonsillectomy as soon as her shoulder is repaired.*
• Physical Exam: Vital Signs: P = 108; BP = 168/98; R = 12; T = 36ºC.*
• Airway: Mallampati Class IV airway. She has good thyromental distance and neck range of motion.*
• Cardiovascular: Regular rate and rhythm; Lack of expected heart rate increase with inspiration, exhibits significant postural hypotension*
• Lungs: clear to auscultation bilaterally*
• Medications: NPH insulin, regular insulin, omeprazole, synthroid*
• Lab: BS = 135 mg/dL, Hgb A1C = 9.2%*
• CXR: hyper-expanded lungs)*

Answer 5

Recognizing that she is suffering from autonomic neuropathy and chronic hypertension, and considering the physiologic effects of anesthesia and the beach chair position on cerebral perfusion,

I would only agree to lower the patient’s mean arterial blood pressure to 80 mmHg after adjusting for the hydrostatic pressure gradient between the point of measurement and the Circle of Willis.

My concern is that the rightward shifting of her cerebral autoregulation curve (secondary to chronic hypertension), the physiologic effects of the beach chair position on cerebral perfusion pressures, and the impaired compensatory response to hypotension that occurs with both general anesthesia and autonomic neuropathy, will place this patient at significant risk of cerebral ischemia in the setting of excessive deliberate hypotension.

Therefore, in addition to maintaining a mean arterial blood pressure of at least 80 mmHg, I would place an arterial line (if not already done) and zero the transducer at the level of the Circle of Willis.

Question 6

Intra-operative Management:

You agree to lower the systolic blood pressure to 120 mmHg. Does it matter that the blood pressure cuff is on the leg?

How could you appropriately monitor cerebral perfusion pressure?

• (A 46-year-old, 97 kg, 5’2” female is scheduled for surgery at an ambulatory surgery center to repair her left rotator cuff.*
• Past Medical History: Significant for hypertension and hypothyroidism for which she takes a thyroid supplement. She has been smoking for 29 years and gets short of breath with normal activity. She also states that she has gastroesophageal reflux disease with abdominal bloating.*
• Past Surgical History: Right-sided mastectomy 4 years ago. She states that several lymph nodes were removed.*
• Anesthetic History: The patient says that during her mastectomy the anesthesiologist “had some trouble getting the tube in”. She also reports that her voice began to change several months after her last surgery. Finally, she adds that her ENT wants to perform a tonsillectomy as soon as her shoulder is repaired.*
• Physical Exam: Vital Signs: P = 108; BP = 168/98; R = 12; T = 36ºC.*
• Airway: Mallampati Class IV airway. She has good thyromental distance and neck range of motion.*
• Cardiovascular: Regular rate and rhythm; Lack of expected heart rate increase with inspiration, exhibits significant postural hypotension*
• Lungs: clear to auscultation bilaterally*
• Medications: NPH insulin, regular insulin, omeprazole, synthroid*
• Lab: BS = 135 mg/dL, Hgb A1C = 9.2%*
• CXR: hyper-expanded lungs)*

Answer 6

It does matter that the cuff is on the leg because this likely creates a greater difference in the measured pressure as compared to the actual pressure at the Circle of Willis.

Adjustments can be made to account for this difference, the hydrostatic pressure gradient, by subtracting 0.77 mm Hg from the measured pressure for every centimeter gradient and ensuring that this calculated number is sufficient to provide adequate cerebral perfusion.

Alternatively, I could place an arterial line and position the transducer at the level of her Circle of Willis to provide more accurate measurement of blood pressure at this level (assuming the patient had consented to placement after induction).

Question 7

Intra-operative Management:

What cerebral perfusion pressure is appropriate?

• (A 46-year-old, 97 kg, 5’2” female is scheduled for surgery at an ambulatory surgery center to repair her left rotator cuff.*
• Past Medical History: Significant for hypertension and hypothyroidism for which she takes a thyroid supplement. She has been smoking for 29 years and gets short of breath with normal activity. She also states that she has gastroesophageal reflux disease with abdominal bloating.*
• Past Surgical History: Right-sided mastectomy 4 years ago. She states that several lymph nodes were removed.*
• Anesthetic History: The patient says that during her mastectomy the anesthesiologist “had some trouble getting the tube in”. She also reports that her voice began to change several months after her last surgery. Finally, she adds that her ENT wants to perform a tonsillectomy as soon as her shoulder is repaired.*
• Physical Exam: Vital Signs: P = 108; BP = 168/98; R = 12; T = 36ºC.*
• Airway: Mallampati Class IV airway. She has good thyromental distance and neck range of motion.*
• Cardiovascular: Regular rate and rhythm; Lack of expected heart rate increase with inspiration, exhibits significant postural hypotension*
• Lungs: clear to auscultation bilaterally*
• Medications: NPH insulin, regular insulin, omeprazole, synthroid*
• Lab: BS = 135 mg/dL, Hgb A1C = 9.2%*
• CXR: hyper-expanded lungs)*

Answer 7

The recommended cerebral perfusion pressures is often cited as a mean arterial pressure of 70-80 mmHg.

This is because it is felt that cerebral autoregulation maintains constant blood flow between 60-150 mmHg of pressure.

With this patient’s chronic hypertension and the potential for a rightward shift of this curve, it would be appropriate to maintain at least a mean arterial pressure of 80 mmHg adjusted for the hydrostatic pressure gradient.

Question 8

Intra-operative Management:

The ETT is accidentally pulled when the drapes are removed. To make matters worse, she begins to vomit, with a signifcant amount of gastric material entering the oropharynx. What would you do?

• (A 46-year-old, 97 kg, 5’2” female is scheduled for surgery at an ambulatory surgery center to repair her left rotator cuff.*
• Past Medical History: Significant for hypertension and hypothyroidism for which she takes a thyroid supplement. She has been smoking for 29 years and gets short of breath with normal activity. She also states that she has gastroesophageal reflux disease with abdominal bloating.*
• Past Surgical History: Right-sided mastectomy 4 years ago. She states that several lymph nodes were removed.*
• Anesthetic History: The patient says that during her mastectomy the anesthesiologist “had some trouble getting the tube in”. She also reports that her voice began to change several months after her last surgery. Finally, she adds that her ENT wants to perform a tonsillectomy as soon as her shoulder is repaired.*
• Physical Exam: Vital Signs: P = 108; BP = 168/98; R = 12; T = 36ºC.*
• Airway: Mallampati Class IV airway. She has good thyromental distance and neck range of motion.*
• Cardiovascular: Regular rate and rhythm; Lack of expected heart rate increase with inspiration, exhibits significant postural hypotension*
• Lungs: clear to auscultation bilaterally*
• Medications: NPH insulin, regular insulin, omeprazole, synthroid*
• Lab: BS = 135 mg/dL, Hgb A1C = 9.2%*
• CXR: hyper-expanded lungs)*

Answer 8

In this situation, I would immediately:

1. begin placing the patient in the head-down position (to facilitate drainage of gastric contents out of the lungs), while at the same time,
2. directing someone to apply cricoid pressure and
3. suctioning out the oropharynx. I would then:
4. re-intubate her to prevent additional aspiration;
5. suction through the ETT in an attempt to remove aspirated material;
6. provide 100% oxyen;
7. support ventilation; and
8. apply PEEP as necessary (suctioning of the oropharynx and through the ETT should be performed prior to positive pressure ventilation in order to prevent the distal dissemination of aspirated material);
9. insert an orogastric tube to empty the stomach and determine the pH of gastric content;
10. collect a sample of tracheal aspirate for culture and sensitivity testing;
11. order a baseline chest x-ray and arterial blood gas;
12. treat any bronchospasm with B2-agonists; and
13. monitor the patient for 24-48 hours for the development of aspiration pneumonitis.

I would NOT administer steroids or prophylactic antibiotics, given the lack of evidence that these measures are effective.

Bronchoscopy may be helpful in the removing of particulate aspirate.

Question 9

Intra-operative Management:

Would you apply cricoid pressure to help keep the vomit from entering the oropharynx?

• (A 46-year-old, 97 kg, 5’2” female is scheduled for surgery at an ambulatory surgery center to repair her left rotator cuff.*
• Past Medical History: Significant for hypertension and hypothyroidism for which she takes a thyroid supplement. She has been smoking for 29 years and gets short of breath with normal activity. She also states that she has gastroesophageal reflux disease with abdominal bloating.*
• Past Surgical History: Right-sided mastectomy 4 years ago. She states that several lymph nodes were removed.*
• Anesthetic History: The patient says that during her mastectomy the anesthesiologist “had some trouble getting the tube in”. She also reports that her voice began to change several months after her last surgery. Finally, she adds that her ENT wants to perform a tonsillectomy as soon as her shoulder is repaired.*
• Physical Exam: Vital Signs: P = 108; BP = 168/98; R = 12; T = 36ºC.*
• Airway: Mallampati Class IV airway. She has good thyromental distance and neck range of motion.*
• Cardiovascular: Regular rate and rhythm; Lack of expected heart rate increase with inspiration, exhibits significant postural hypotension*
• Lungs: clear to auscultation bilaterally*
• Medications: NPH insulin, regular insulin, omeprazole, synthroid*
• Lab: BS = 135 mg/dL, Hgb A1C = 9.2%*
• CXR: hyper-expanded lungs)*

Answer 9

If she were actively vomiting, I would avoid the application of cricoid pressure due to the risk of esophageal rupture.

However, if she were not actively vomiting, I would apply 30 N of cricoid pressure in an attempt to compress the esophagus against the cervical vertebral bodies, thereby hindering the passive regurgitation of gastric contents.

If at any point she began to actively vomit, I would discontinue any cricoid pressure.

Similarly, if I believed that the cricoid pressure was interfering with my attempts to rapidly secure her airway with an ETT, then I would reduce or eliminate the pressure.

Question 10

Post-operative Management:

The patient is extubated and transported to post-operative recovery.

Some time later, you are called because her oxygen saturation is in the 80s. What will you do?

• (A 46-year-old, 97 kg, 5’2” female is scheduled for surgery at an ambulatory surgery center to repair her left rotator cuff.*
• Past Medical History: Significant for hypertension and hypothyroidism for which she takes a thyroid supplement. She has been smoking for 29 years and gets short of breath with normal activity. She also states that she has gastroesophageal reflux disease with abdominal bloating.*
• Past Surgical History: Right-sided mastectomy 4 years ago. She states that several lymph nodes were removed.*
• Anesthetic History: The patient says that during her mastectomy the anesthesiologist “had some trouble getting the tube in”. She also reports that her voice began to change several months after her last surgery. Finally, she adds that her ENT wants to perform a tonsillectomy as soon as her shoulder is repaired.*
• Physical Exam: Vital Signs: P = 108; BP = 168/98; R = 12; T = 36ºC.*
• Airway: Mallampati Class IV airway. She has good thyromental distance and neck range of motion.*
• Cardiovascular: Regular rate and rhythm; Lack of expected heart rate increase with inspiration, exhibits significant postural hypotension*
• Lungs: clear to auscultation bilaterally*
• Medications: NPH insulin, regular insulin, omeprazole, synthroid*
• Lab: BS = 135 mg/dL, Hgb A1C = 9.2%*
• CXR: hyper-expanded lungs)*

Answer 10

Given this patient’s obesity, suspected obstructive sleep apnea, recent tension pneumothorax, and likely aspiration during emergence, I would:

1. place her in the head-up position to potentially relieve any obstruction and improve respiratory mechanics;
2. administer 100% oxygen;
3. auscultate the lungs bilaterally;
4. ensure a properly functioning chest tube, adequate ventilation, and a normal cardiac rhythm;
5. administer reversal agents as indicated for oversedation (patients with autonomic neuropathy and/or obstructive sleep apnea are more susceptible to the respiratory depressant effects of central nervous system depressants) and/or residual neuromuscular blockade;
6. order serial chest x-rays and ABGs to identify any aspiration pneumonitis; and, after identifying the underlying cause of her hypoxia,
7. provide definitive treatment.

Question 11

Post-operative Management:

What is the pathophysiology of aspiration pneumonitis?

• (A 46-year-old, 97 kg, 5’2” female is scheduled for surgery at an ambulatory surgery center to repair her left rotator cuff.*
• Past Medical History: Significant for hypertension and hypothyroidism for which she takes a thyroid supplement. She has been smoking for 29 years and gets short of breath with normal activity. She also states that she has gastroesophageal reflux disease with abdominal bloating.*
• Past Surgical History: Right-sided mastectomy 4 years ago. She states that several lymph nodes were removed.*
• Anesthetic History: The patient says that during her mastectomy the anesthesiologist “had some trouble getting the tube in”. She also reports that her voice began to change several months after her last surgery. Finally, she adds that her ENT wants to perform a tonsillectomy as soon as her shoulder is repaired.*
• Physical Exam: Vital Signs: P = 108; BP = 168/98; R = 12; T = 36ºC.*
• Airway: Mallampati Class IV airway. She has good thyromental distance and neck range of motion.*
• Cardiovascular: Regular rate and rhythm; Lack of expected heart rate increase with inspiration, exhibits significant postural hypotension*
• Lungs: clear to auscultation bilaterally*
• Medications: NPH insulin, regular insulin, omeprazole, synthroid*
• Lab: BS = 135 mg/dL, Hgb A1C = 9.2%*
• CXR: hyper-expanded lungs)*

Answer 11

Aspiration can lead to pneumonitis, pneumonia, and acute respiratory distress syndrome (ARDS).

The aspiration of significant gastric contents results in damage to surfactant-producing cells and the pulmonary capillary endothelium, with subsequent atelectasis, exudative pulmonary edema, bronchospasm, laryngospasm, intrapulmonary shunting, reduced pulmonary compliance, hypoxemia, tachypnea, tachycardia, increased pulmonary vascular resistance (secondary to hypoxic pulmonary vasoconstriction), and increased work of breathing.

An intense inflammatory response may then develop (aspiration pneumonitis), potentially leading to acute respiratory distress syndrome (ARDS) and fibrosing alveolitis.

Moreover, the inflammatory response associated with aspiration pneumonitis may predispose the patient to develop pneumonia following the transmission of bacteria into the lungs with the aspiration of colonized oropharyngeal or gastric content.

Finally, obstruction of the lower airways by particulate matter can lead to persistent atelectasis and subsequent abscess formation.

Question 12

Post-operative Management:

The patient says her eye hurts. On exam it appears red and watery. What will you do?

• (A 46-year-old, 97 kg, 5’2” female is scheduled for surgery at an ambulatory surgery center to repair her left rotator cuff.*
• Past Medical History: Significant for hypertension and hypothyroidism for which she takes a thyroid supplement. She has been smoking for 29 years and gets short of breath with normal activity. She also states that she has gastroesophageal reflux disease with abdominal bloating.*
• Past Surgical History: Right-sided mastectomy 4 years ago. She states that several lymph nodes were removed.*
• Anesthetic History: The patient says that during her mastectomy the anesthesiologist “had some trouble getting the tube in”. She also reports that her voice began to change several months after her last surgery. Finally, she adds that her ENT wants to perform a tonsillectomy as soon as her shoulder is repaired.*
• Physical Exam: Vital Signs: P = 108; BP = 168/98; R = 12; T = 36ºC.*
• Airway: Mallampati Class IV airway. She has good thyromental distance and neck range of motion.*
• Cardiovascular: Regular rate and rhythm; Lack of expected heart rate increase with inspiration, exhibits significant postural hypotension*
• Lungs: clear to auscultation bilaterally*
• Medications: NPH insulin, regular insulin, omeprazole, synthroid*
• Lab: BS = 135 mg/dL, Hgb A1C = 9.2%*
• CXR: hyper-expanded lungs)*

Answer 12

First, I would evaluate the patient and ask about symptoms typically associated with corneal abrasion (recognizing that this is the most common perioperative complication involving the eye) foreign-body sensation and photophobia.

I would also ask her to blink a few times recognizing that this would likely exacerbate the symptoms of a corneal abrasion (helping to confirm the diagnosis).

If after evaluating her, I believed this was a corneal abrasion, I would consult an ophthalmologist, possibly apply antibiotic ointment, and patch the eye shut (“bandage contact lenses” are often utilized instead of an eye patch since they allow adequate oxygen to the cornea and greatly reduce patient discomfort).

Review management and treatment of corneal abrasion.

Question 13

Post-operative Management:

What can be done to prevent corneal abrasion?

• (A 46-year-old, 97 kg, 5’2” female is scheduled for surgery at an ambulatory surgery center to repair her left rotator cuff.*
• Past Medical History: Significant for hypertension and hypothyroidism for which she takes a thyroid supplement. She has been smoking for 29 years and gets short of breath with normal activity. She also states that she has gastroesophageal reflux disease with abdominal bloating.*
• Past Surgical History: Right-sided mastectomy 4 years ago. She states that several lymph nodes were removed.*
• Anesthetic History: The patient says that during her mastectomy the anesthesiologist “had some trouble getting the tube in”. She also reports that her voice began to change several months after her last surgery. Finally, she adds that her ENT wants to perform a tonsillectomy as soon as her shoulder is repaired.*
• Physical Exam: Vital Signs: P = 108; BP = 168/98; R = 12; T = 36ºC.*
• Airway: Mallampati Class IV airway. She has good thyromental distance and neck range of motion.*
• Cardiovascular: Regular rate and rhythm; Lack of expected heart rate increase with inspiration, exhibits significant postural hypotension*
• Lungs: clear to auscultation bilaterally*
• Medications: NPH insulin, regular insulin, omeprazole, synthroid*
• Lab: BS = 135 mg/dL, Hgb A1C = 9.2%*
• CXR: hyper-expanded lungs)*

Answer 13

Preventative measures include taping the eyes after induction but prior to intubation; avoiding direct contact with the eyes when applying the oxygen mask, drapes, lines, etc.; and applying petroleum based ointments to the conjunctival sac.

However, some practitioners avoid petroleum-based ointments because they are flammable, can cause allergic reactions, and may cause the patient to excessively rub their eyes resulting in a patient-induced corneal abrasion.