2023.1 Day 1 VIVA 8
Peri-operative Medicine
An 82 year old female has presented with a severely angulated distal radius fracture with median nerve paraesthesia, after slipping on a step outside the local pub this afternoon. The general surgeon indicates that urgent reduction of the fracture is required within 2 hours.
Past Medical History:
Rheumatoid Arthritis
Asthma
Hypertension
Pre- Operative ECG: Atrial Fibrillation at rate 70-80
Medications:
Prednisolone 5 mg daily
Candesartan 4 mg daily
Omeprazole 20 mg mane
Methotrexate – 20 mg weekly (for arthritis) Abatacept injection- 125 mg weekly (for arthritis)
Folic acid – daily
Ciclesonide 160mcg – 1 puff daily
Salbutamol PRN
How can this patient be further assessed prior to their procedure?
Major Issues are:
Severe Rheumatoid Arthritis (RA)
Airway concerns: Cervical spine instability, TMJ involvement, limited mouth opening.
Steroid dependency → risk of adrenal insufficiency.
Atrial Fibrillation (AF)
Rate-controlled at 70-80 bpm, but potential for perioperative destabilisation.
Is it new or longstanding? Identify triggers (pain, sepsis, hypoxia, electrolyte imbalance).
Asthma
Current severity? Recent exacerbations?
Steroid-dependent → higher risk of bronchospasm perioperatively.
Hypertension
Well-controlled? Check BP trends, medication compliance, volume status.
Mechanism of fall & fasting status
Did syncope contribute to the fall? Assess for underlying medical cause (e.g., arrhythmia, TIA).
Aspiration risk → recent meal/alcohol intake?
How would you assess this patient further prior to anaesthesia?
History:
RA symptoms: Severity, mobility, morning stiffness.
Asthma: Frequency of salbutamol use, any nocturnal symptoms.
AF history: When diagnosed? Rate vs rhythm control?
Examination:
Airway: Mouth opening, neck mobility (cervical spine stability).
Cardiovascular: BP, HR stability, signs of volume depletion.
Respiratory: Wheeze, oxygen saturation, peak expiratory flow (if possible).
Investigations:
ECG: AF rate, ischaemic changes.
Bloods: FBC, UECs, magnesium, calcium (electrolyte causes of AF).
CXR if concerns about aspiration or respiratory status.
How would you optimise the patient before proceeding with anaesthesia?
Pain relief: IV paracetamol + fentanyl (cautious dosing due to age/comorbidities).
Fluid resuscitation: If hypovolaemic, cautious IV fluid bolus (250-500 mL crystalloid).
Asthma: Ensure bronchodilator therapy (salbutamol MDI or nebuliser if needed).
AF: Correct electrolyte disturbances before considering rate control.
Steroid supplementation: Consider stress-dose hydrocortisone (50-100 mg IV) if concern for adrenal insufficiency.
What anaesthetic options would you consider for this procedure?
Regional anaesthesia (preferred if feasible):
Bier’s block (IV regional anaesthesia) – BUT caution if patient is intoxicated/uncooperative.
Ultrasound-guided brachial plexus block (axillary or supraclavicular approach).
General Anaesthesia (GA) considerations:
Aspiration risk: If recently eaten → RSI with modified doses.
Difficult airway risk: Plan for video laryngoscopy, awake fibreoptic if high risk.
Induction: Lower doses of propofol (e.g., 1 mg/kg) + fentanyl (25-50 mcg) + suxamethonium or rocuronium.
Maintenance: Sevoflurane or TIVA (if haemodynamically unstable).
Q: Would you proceed in the Emergency Department or take the patient to theatre?
In theatre if:
GA is required due to uncooperative patient.
Significant aspiration risk or need for advanced airway management.
Concerns about RA airway involvement requiring fibreoptic intubation.
In ED if:
Regional technique can be used successfully in a cooperative patient.
In PACU, the patient develops a HR of 124 bpm. What are your differentials?
Pain (most common cause).
Hypovolaemia (inadequate fluid resuscitation).
AF with rapid ventricular response (triggered by stress, pain, or hypoxia).
Hypoxia (bronchospasm, atelectasis).
Sepsis (if wound infection or aspiration occurred).
Electrolyte disturbance (hypokalaemia, hypomagnesaemia).
How would you assess and manage this tachycardia?
Immediate assessment:
Check full vitals (BP, SpO₂, temperature).
ECG: AF with RVR? Ischaemic changes? New arrhythmia?
Assess pain & administer adequate analgesia.
Consider fluid resuscitation (250–500 mL crystalloid bolus) if hypovolaemic.
If persistent AF with RVR (>120 bpm):
Correct electrolyte imbalances (replace K⁺/Mg²⁺).
Beta-blockers (if BP stable):
Metoprolol 2.5–5 mg IV slow push (titrate cautiously).
Diltiazem (if preferred over beta-blockers for AF control).
If haemodynamically unstable → urgent cardiology input +/- synchronised cardioversion.
Q: When would you consider safe discharge from PACU?
HR controlled (<100 bpm) and stable.
Pain well managed.
No worsening respiratory or neurological signs.
Plan for postoperative anticoagulation & AF follow-up if needed.
Bonus Question
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