A 40-year-old male presents for a UPP secondary to severe obstructive sleep apnea. He is unable to tolerate CPAP. Additional past medical history includes hypertension, NIDDM and obesity. He weights 142 kg. How will you assess this patient for the proposed surgery?
Known OSA and risk of OHS. Quantify severe of OSA with Hx of symptoms (STOP BANG) and sleep study. Treatment history. Lytes for Bicarb (27).
HTN Hx & Mx. NIDDM Hx and possible complications. Prev Anesth Hx
Careful assessment of airway. At risk of DA and DV. Assess for possible Rt heart failure (peripheral edema, crackles, cyanosis).
Lx- CBC, Lytes, CXR, ?ABG, ? echo
The patient is noted to have severe OSA with hypersomnolence that interferes with daily activities and work. He has been assessed by cardiology because of SOBOE. An echocardiogram shows moderate right ventricular hypokinesis with an elevated mean PAP of 47mmHg. Airway examination reveals a Mal Class II, large tonsils, short thick neck and a TMD of 3. Room air SaO2 is 90%. A multidisciplinary note suggests the patient is optimized and a UPP is a reasonable approach to manage this mans refractory OSA/OHS. How will you provide anesthesia?
Conflict: anesthetic goals in keeping with Pul HTN and RV failure vs short, stimulating anesthetic. Potential for difficult airway and ventilation. Must take appropriate caution but not highly suspect. Should avoid large doses of negative inotropes. Avoid hypoxia, hypercapnia, acidosis. Artline. Narcotic sparing analgesic technique.
Requires postop monitoring in high dependency unit. High risk of worsening OSA postop with consequential heart failure.
You induced in the described manner. Laryngoscopy revealed a Grade III larynx and a 8 ETT is secured. The surgeon notes there is significant bleeding while working on the tonsils. While readjusting his retractor, you notice a sudden air leak with empty bellows. Blood sprays from the airway. The SaO2 immediately fall to 85%. What is happening and how will you manage this?
ETT dislodgement (circuit disconnect, cuff rupture). Declare emergency, crash chart, difficult airway cart, skilled help, rigid bronch, trach tray. Immediately try to re-secure the airway. Low tolerance to BMV to avoid hypoxia, hypercarbia. Must have airway plan that is not reliant on fiberoptic technology.