2023.1 Day 1 VIVA 3
You are currently in pre-admission clinic. Your next patient is a 36-year-old female who is booked for an elective laparoscopic cholecystectomy in 1 weeks’ time. She has a Body Mass Index of 38.
Please outline your assessment of this patient. 📃(Notes)
Key concerns in this patient with a BMI of 38 undergoing elective laparoscopic cholecystectomy are:
Airway: Potentially difficult intubation (short neck, large tongue, high Mallampati score).
Respiratory: Risk of obstructive sleep apnoea (OSA), reduced lung volumes, atelectasis.
Cardiovascular: Increased risk of hypertension, ischaemic heart disease, pulmonary hypertension.
Metabolic syndrome: Diabetes, insulin resistance, fatty liver disease.
Anaesthetic history: Previous difficult airway, PONV, chronic opioid use.
Venous thromboembolism (VTE): Higher risk → DVT prophylaxis needed.
How would you assess for obstructive sleep apnoea (OSA) preoperatively? 📃(Notes)
STOP-BANG questionnaire (Snoring, Tiredness, Observed apnoeas, Pressure (BP), BMI >35, Age >50, Neck >40cm, Gender male).
Ask about CPAP use & adherence.
Signs of severe OSA: Daytime somnolence, morning headaches, nocturnal choking episodes.
Given this patient has a history of post-op nausea and vomiting (PONV), how would you address this? 🎓(Notes)
Risk factors: Female, non-smoker, opioid use, previous PONV.
Should have one preventative for each risk factor.
Prevention strategies:
Multimodal antiemesis: Ondansetron, dexamethasone, droperidol.
Total intravenous anaesthesia (TIVA) with propofol if possible.
Minimise opioids (regional blocks, multimodal analgesia).
Would you proceed with this case in a rural hospital? (📃Notes, 📃Notes)
Yes, if resources are adequate.
Key considerations:
Airway support: Equipment for difficult intubation & emergency airway management.
Post-op monitoring: High-risk patients (OSA, opioid use) may need HDU/ICU overnight.
Surgeon & facility capabilities: Is backup available for complications?
How would you modify your anaesthetic induction for this patient?
Pre-oxygenation with CPAP or 2-handed BMV (ramped position).
Airway adjuncts ready (video laryngoscope, bougie, supraglottic airway, FONA kit).
Induction drugs:
Propofol (careful dose adjustment) to avoid hypotension.
Fentanyl/remifentanil for propofol-sparing effect.
Rocuronium (1.2 mg/kg) for rapid sequence induction (RSI).
Cricoid pressure cautiously applied – release if difficulty arises.
STRIVE Hi induction could be considered in this patient.
What intraoperative considerations are important for this patient?
Ventilation: (📃Notes)
Pressure-controlled ventilation (PCV) to optimise lung recruitment.
Alternatively volume guarentee modes are useful in the laparotomy setting though peak pressures are likely to be limiting in this patinet.
PEEP (8-10 cmHâ‚‚O) & recruitment manoeuvres to prevent atelectasis.
Minimise opioid use:
Paracetamol, NSAIDs (if no contraindication), ketamine, lignocaine infusion.
VTE prophylaxis:
Mechanical (TEDs/SCDs) & pharmacological (LMWH if indicated).
Temperature control:
Active warming to prevent hypothermia.
How would you approach extubation in this patient?
Assess readiness:
Fully awake, strong cough reflex, head lift for >5 sec.
Extubation technique:
Reverse neuromuscular blockade (sugammadex if rocuronium used).
Suction airway aggressively to prevent obstruction.
Consider CPAP or NIV post-extubation if known OSA.
Minimise sedation to reduce airway collapse risk.
Discharge Planning
What are your key concerns in the post-anaesthetic care unit (PACU)? (📃Notes)
Airway obstruction: Due to residual sedation, airway collapse from obesity.
Hypoxia: Higher risk due to reduced FRC, atelectasis.
PONV: High risk, ensure antiemetic cover continues.
Pain control: Balance between adequate analgesia & opioid minimisation.
What are your discharge criteria for this patient as per ANZCA PG15(POM)?
Stable vitals, adequate pain control, no airway compromise.
Able to mobilise safely.
Minimal nausea & vomiting.
No ongoing bleeding or surgical complications.
Would you discharge this patient home the same day or admit overnight?
Admit for overnight monitoring if:
Severe OSA requiring CPAP.
High opioid requirements.
Persistent hypoxia or airway compromise.
Lack of social support at home.
Bonus Question
If the patient develops severe respiratory depression in PACU, how would you manage it? (📃Notes)
Assess & support airway:
Jaw thrust, supplemental Oâ‚‚, consider CPAP/NIV.
Check for opioid overdose:
If respiratory rate <8 or apnoea → naloxone titration.
If persistent respiratory failure → escalate to HDU if available
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