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.

How would you assess this patient pre-operatively

  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).

He admits to drinking 6 beers nightly. How does this change your plan?

Alcohol withdrawal risk: Consider AWS protocol post-op.

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

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

  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

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?

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

      • Residual NMB → sugammadex if rocuronium used.

      • Hypercaponea

      • Hypoglycaemia

  2. Key Investigations:

    • ABG (rule out hypercapnia from OSA).

    • Bedside glucose (hypoglycemia).

    • ECG

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

  1. Safety Criteria:

    • Modified Aldrete Score ≥9 (Notes ✏️)(activity, respiration, circulation, consciousness).

    • No hypoxia/hypercapnia (OSA risk).

  2. Scenarioville Considerations:

    • No HDU → ward nurses must be trained in OSA monitoring.

His wife asks why he’s confused. How would you respond?

Differential is broad:

  • Postoperative Delerium

  • Watershead infarction secondary to hypotension

  • CVA

  • Drug reaction

  • Hypercaponea

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