Lap Nephrectomy, Morbid Obesity and Aortic Stenosis

You asked to see a 69yo M who is booked for a laparoscopic right radical nephrectomy for suspected malignancy. He presented 2 weeks ago with increasing fatigue, shortness of breath on exertion and flank pain. He has OSA requiring CPAP and weighs 148kg. He was noted to have a systolic ejection murmur on examination. How would you assess this patient?

· Urgent, time sensitive procedure b/c of the cancer.

· Suspected Cancer

o 4M’s. Looking for mass effect, metastases, metabolic derangements (electrolyte abN), meds (chemo, rads).

o Nutritional deficiencies.

o Duration of disease, previous treatments, & current status.

o Review blood work looking at electrolytes abN and renal function.

o CT scans for any other compressive effects…specifically if the tumor invades into the IVC with extension into the heart.

o Review urology and oncology consult letters.

· OSA

o Duration of disease, previous/current treatments (specifically CPAP), and current status.

o AW exam, potentially difficult AW.

o Review previous sleep studies for severity.

o Previous echos for any evidence of pulmonary HTN if untreated.

o ECG for any evidence of AFib.

o Review respirology consult letters (if available).

· SEM

o Duration of disease, previous treatments, current status.

o Symptomatic?

o Increased risk for IE, want to ask pt re: previous episodes.

o Review cardiology consult letters.

· Post-op disposition

o Given his co-morbidities he may need to be admitted to a monitored care area or even ICU depending on the intra-op events.


· Post-op pain.

o Potential for this to be converted to an open procedure, discuss post-op pain control with patient.


The patient was unaware of his murmur. An echocardiogram performed prior to surgery revealed an AVA of 0.8cm2 , LVEF of 35%, severely dilated LA, moderate MR, a moderately dilated RV with an RVSP of 52, and an ascending aorta aneurysm of 5.5cm. He is asymptomatic from his AS. A pre-op cardiac cath revealed a 70% distal LAD lesion

On examination he has a BMI of 48.3, airway exam reveals a MP-3, normal mouth opening and thyromental distance, he has slightly decreased neck extension.


Blood work reveals a hemoglobin of 130, platelets of 200, Cr 122, normal electrolytes, normal coags, A1C 8. Cardiac surgery was consulted and they felt that he should have his nephrectomy prior to dealing with his cardiac issues.


How will you provide anesthesia for this procedure?


· Set up the OR and check th anesthetic machine in the usual fashion.

· Standard emergency drugs. In addition to that I would also have an infusion of phenylephrine (or norepi) set up and ready to use.

· Usual airway adjuncts present (+/- glidescope).

· 2 large bore IVs

· Pre-induction arterial line.

· +/- cordis or central access (fluids and or pressors)

· Pre-cordial pads on the pt (I didn’t put them on but probably should have). Given his dilated LA is high risk for going into AFib.

· Should mention his hemodynamic goals for this case – conflict of maintaining a high afterload for his AS but at the same time don’t want the BP too high b/c of his aneurysm. Also laparoscopic sx & pt’s pulmonary HTN.


The patient is induced and airway secured in the manner you describe. The case is progressing uneventfully in the lateral position when the ventilator alarms and you notice the bellows collapse. You look over to the pt and see the ETT has become dislodged, and the cuff is out of the patients mouth. How will you manage this situation?


· Emergency situation, alert the room and get the surgeon to stop & deflate the abdomen.

· Call for help.

· Have to remember that pt is in the lateral position so decide if you want to manage patient in the lateral position or go back into the supine position.

· Main priority is to oxygenate the patient, then have to provide and anesthetic.

· BMV the patient with an oral AW.

· Need to reintubate so they can choose to do DL, glidescope or FOB.


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