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Final clinical long case 65

Created: 28/8/2020
 
A 78-year old presents for free-flap repair of an infraorbital defect post-radiotherapy for squamous cell carcinoma.

History
Type 2 diabetes, diet controlled.
Severe ischaemic heart disease.

Medications
Frusemide
Ramipril
Simvastatin

Examination

Heart sounds normal
Chest clear

Investigations

Full blood count: normochromic normocytic anaemia
Urea and electrolytes: Creatinine 140 µmol/L; Urea 12 mmol/L with normal electrolytes
Liver function tests: normal
Glucose (fasting): 10 mg/dL
ECG: left bundle branch block; heart rate 75 bmp
Angiography: 80%+ stenosis of the right, left anterior descending and circumflex coronary arteries; ejection fraction 40%; akinesia of the anterior wall.

Questions

1. Summarise the case.
2. Discuss the results of the investigations.
3. How would you assess cardiac risk?
4. How would you optimise the patient?
5. Why would you want a cardiology opinion?
6. The patient is due to undergo a coronary artery bypass graft (CABG), and the cardiologist says that it is safe to go ahead with this (elective) procedure beforehand. Hypothetically, how would you anaesthetise the patient?
- Describe the principles of anaesthesia for free-flap surgery.
- Describe the intravenous lines, cardiac output monitoring, intraoperative cardiac and renal protection needed in this case.
- How would you preoxygenate a patient with an infraorbital defect?
- Which drugs would you use?
- Discuss analgesia for multiple site surgery.
- Discuss postoperative care for this patient.

ArticleDate:20200828
SiteSection: Article
 
   
    
                                            
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