2023.1 Day 2 VIVA 1

You are currently doing an all-day endoscopy list in the procedure room. The surgeon would like to add an 80 year old male patient to the end of your afternoon list. He was admitted 2 days ago with a partial bowel obstruction from a possible right sided colon cancer and has undergone bowel preparation as best tolerated. He has a background of COPD and has a decreased eGFR.

What specific additional information do you want to obtain prior to proceeding with his case?

Clinical status of partial bowel obstruction

• Ongoing symptoms? Pain, distension, nausea, vomiting?

• Tolerance of bowel prep (fluid losses, electrolyte imbalances)?

• Volume status

  • BP, HR, orthostatic changes?

  • Recent fluid balance, urine output?

  • Any signs of sepsis (fever, tachycardia, raised WCC)?

COPD severity & respiratory function

• Baseline dyspnoea? Oxygen requirements?

• Recent exacerbations, hospitalisations?

• Pulmonary function tests (if available), baseline ABG?

• Renal function & risk of contrast-induced nephropathy

  • eGFR trends, creatinine, electrolyte abnormalities?

  • Medications affecting renal function (e.g., ACEi, NSAIDs)?

Aspiration risk

• Last oral intake?

• Gastric distension on exam (NG decompression needed pre-induction?)

Q: Would you proceed with this case in Scenarioville?

• Yes, if adequately optimised with appropriate staff, monitoring, and rescue plans.

• If septic, haemodynamically unstable, or needs ICU → discuss transfer to tertiary centre.

What are your key anaesthetic concerns for this patient?

• Aspiration risk – partial bowel obstruction → RSI needed.

• Hypovolaemia – bowel prep & obstruction → cautious induction.

• COPD – risk of perioperative hypoventilation, bronchospasm, CO₂ retention.

• Renal impairment – avoid nephrotoxic drugs, ensure adequate perfusion.

How would you optimise the patient before induction?

IV fluid resuscitation

• Balanced crystalloid (e.g., Hartmann’s or Plasmalyte) 500–1000 mL titrated.

• Endpoints: MAP >65 mmHg, HR normalising, improving urine output.

Electrolyte correction (esp. K+, Mg²+, Ca²+).

Preoxygenation for 3-5 mins (consider NIV if COPD with hypercapnia).

Electrolyte Correction: Potassium, bicarbonate, calcium, and magnesium as needed.

Respiratory Support: Optimise bronchodilators, consider CPAP.

NG tube decompression if significant gastric distension.

What is your induction plan?

• Aspiration Risk: High risk due to bowel obstruction.

• RSI Required: Preoxygenation, consideration of cricoid pressure (not universally applied), avoidance of bag-mask ventilation, suction availability.

Rapid sequence induction (RSI)

• Fentanyl 25-50 mcg IV (blunt pressor response, avoid excessive dosing).

• Ketamine 0.5-1 mg/kg IV (if haemodynamically unstable) OR

• Propofol 0.5-1 mg/kg IV (cautious dosing due to hypotension risk).

• Rocuronium 1.2 mg/kg IV (to secure airway rapidly).

• Immediate intubation with cricoid pressure (release if difficulty arises).

Fentanyl	25-50 mcg	Blunts response to laryngoscopy, haemodynamic stability.
Ketamine	0.5 mg/kg	Preserves MAP, avoids excessive hypotension.
Propofol	0.5–1 mg/kg	Lower dose to mitigate hypotension.
Etomidate	0.2–0.3 mg/kg	Alternative for cardiovascular stability.
Rocuronium	1.2 mg/kg	RSI muscle relaxation.

Q: How would you maintain anaesthesia?

• Low-dose volatile (Sevoflurane) OR TIVA (Propofol infusion) if haemodynamically stable.

• Analgesia: Fentanyl or remifentanil infusion (adjust for renal function).

• Ventilation strategy for COPD:

  • Avoid excessive tidal volumes (~6 mL/kg).

  • Permissive hypercapnia if needed to prevent barotrauma.

• Monitor BP closely, use noradrenaline if needed.

Despite your assessment this becomes a difficult airway. Ho do you approach this?

• Assess Difficult Airway Predictors: Mallampati score, neck mobility.

• Plan for Video Laryngoscopy: Better first-pass success in difficult airways.

• Alternative Approach: Awake fibreoptic intubation if airway concerns exist.

• Backup Plan: Supraglottic device, emergency surgical airway.

• Post-intubation Ventilation: Cautious PEEP, permissive hypercapnia if COPD exacerbation risk.

What intraoperative challenges do you anticipate?

• Haemodynamic Instability: Due to hypovolaemia and anaesthetic agents.

• Aspiration Risk: Maintain RSI precautions.

• Ventilation Difficulties: COPD exacerbation, potential need for bronchodilators.

• Electrolyte Management: Monitor potassium, calcium, magnesium, bicarbonate intraoperatively.

How would you monitor this patient intraoperatively?

• Standard Monitoring: ECG, NIBP, SpO₂, capnography.

• Invasive Monitoring (if needed): Arterial line for continuous BP monitoring.

• Neuromuscular Monitoring: Ensure adequate reversal of neuromuscular blockade.

• Blood Gas Analysis: Check for metabolic derangements, CO₂ retention.

The patient is agitated in PACU. What are your differential diagnoses?

• Hypercapnia: COPD with residual sedation, narcotic accumulation.

• Hypotension: Residual anaesthetic effects, unresolved hypovolaemia.

• Pain or Delirium: Poorly controlled pain, emergence delirium.

• Hypocalcaemia: Possible due to fluid shifts, electrolyte depletion.

• Uraemia: If renal dysfunction is present.

How would you systematically assess and manage this agitation?

1. Airway & Breathing: High-flow O₂, ABG for CO₂ levels, consider CXR.

2. Circulation: Check BP, fluid status, correct hypovolaemia.

3. Neurological Status: Exclude stroke, assess for opioid toxicity (naloxone if needed).

4. Pain Management: Titrate analgesia carefully.

5. Sedation Strategy: Consider dexmedetomidine for agitation control.

What are your criteria for safe discharge from PACU?

• Haemodynamic Stability: BP and HR within acceptable range.

• Adequate Oxygenation: SpO₂ >94% on room air or baseline level.

• Appropriate Consciousness Level: Responding to commands.

• Adequate Pain Control: Comfortably managed with minimal opioids.

• No Uncontrolled Agitation or Delirium

What is your postoperative disposition plan?

• Monitoring in HDU or High nurse:patient ratio if unstable postoperatively.

• Renal Function Follow-Up: Repeat UECs, address any acute kidney injury concerns.

• Respiratory Follow-Up: Monitor for COPD exacerbation, ensure bronchodilator therapy.

• Electrolyte Reassessment: Check calcium, potassium, bicarbonate postoperatively.