# GA VIVA 1

68-year-old male for elective laparoscopic cholecystectomy in Scenarioville Rural Hospital.

\
**PMH:** Hypertension, OSA (non-compliant with CPAP), BMI 35.\
**Medications:** Ramipril, atorvastatin.

<details>

<summary>How would you assess this patient pre-operatively</summary>

1. **Focused History:**
   * **OSA severity:** Epworth score, nocturnal hypoxia episodes.
   * **Cardiorespiratory:** Exercise tolerance (METs >4?), angina symptoms.
   * **Airway:** Mallampati, neck mobility, snoring.
2. **Investigations:**
   * **Essential:** ECG (LVH? arrhythmias), FBC, UEC.
   * **If concerns:** Echocardiogram (if HF symptoms) – but unavailable in Scenarioville.
3. **Risk Mitigation:**
   * **OSA:** Plan for CPAP post-op; avoid opioids where possible.
   * **Hypertension:** Hold ramipril day of surgery (risk of hypotension under GA).

</details>

<details>

<summary>He admits to drinking 6 beers nightly. How does this change your plan?</summary>

**Alcohol withdrawal risk:** Consider AWS protocol post-op.

**Liver dysfunction:** Check LFTs, coag studies (limited blood bank in Scenarioville).

</details>

<details>

<summary>During pneumoperitoneum, his HR drops to 30 and BP to 70/40. What’s your management?</summary>

1. **Immediate Actions:**
   * **Stop insufflation**, decrease abdominal pressure.
   * **Atropine 600mcg IV** (repeat ×1 if no response).
   * **Adrenaline 10mcg boluses** if refractory.
2. **Differential:**
   * **Vagal surge** from peritoneal stretch + CO₂-induced acidosis.
   * Shock
     * Hypovolaemic - surgical complication
     * Primary cardiac - Risk factors include OSA, hypertension
       * AMI
       * Right heart failure
     * Vasodialtory - Induction agent dosing
     * Obstructive - Pneumothorax from high peak pressures
3. **Scenarioville Constraints:**
   * No cardiac catheterization lab → treat empirically for ischemia (aspirin, heparin if ECG changes).
   * Early consideration of transfer as patient will likely require further investigation and cardiac monitoring post-op

</details>

<details>

<summary>Patient stabilised and was extubated deep in theatre.  45mins post-op, he’s still poorly rousable. Observations: BP 100/60, HR 50, SpO₂ 96%, RR 8. What’s your differential?</summary>

First recognise the potential for airway compromise and perform siumltaneous assessment and resucitation.

1. **Systematic Approach:**
   * **ABCDE:** Ensure airway patent, ventilate if needed.
   * **Treat Reversible causes:**
     * Opioids → naloxone 40mcg IV.
     * Benzodiazepines →  Flumazanil 0.1 – 0.2 mg IV to 2mg maximum&#x20;
     * Residual NMB → sugammadex if rocuronium used.
     * Hypercaponea
     * Hypoglycaemia&#x20;
2. **Key Investigations:**
   * ABG (rule out hypercapnia from OSA).
   * Bedside glucose (hypoglycemia).
   * ECG

</details>

<details>

<summary>He’s now awake but mildly confused. Is he safe for discharge to the ward?</summary>

1. **Safety Criteria:**
   * **Modified Aldrete Score ≥9** ([Notes](https://app.gitbook.com/o/PpX6WjgGD8F5TRLuEBLA/s/o2GxZoxlUY4OpV2DDHxX/~/changes/142/markdown/study-notes/pacu-discharge-criteria/~/page/visibility#modified-aldrete-score-max-10-points) :pencil2:)(activity, respiration, circulation, consciousness).
   * **No hypoxia/hypercapnia** (OSA risk).
2. **Scenarioville Considerations:**
   * No HDU → ward nurses must be trained in OSA monitoring.

</details>

<details>

<summary>His wife asks why he’s confused. How would you respond?</summary>

Differential is broad:

* Postoperative Delerium
* Watershead infarction secondary to hypotension
* CVA
* Drug reaction
* Hypercaponea

</details>


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