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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