I recently started a new position at a facility that performs a fair number of DIEP flaps after breast cancer surgery.  The surgeries are very adamant that the anesthesia provider avoid all vasopressors and give at minimum 4 to 5 liters of fluid regardless, and also use additional repaid fluid infusion to treat and prevent hypotension.  This approach is actually written down as instructions to the anesthesia providers on how to approach their patients.  In my previous practice we did flap repairs but never received direct instructions from the surgeons involved with an alg ..read more

 a 59 year old male presented with a complex VHR via robot laparoscopy.  He had a prior history of drug abuse, hepatitis C and a long smoking history resulting in mild undiagnosed and untreated COPD.   The patient was given a GETA anesthetic with sevoflurane, rocuronium, dilaudid, and low dose ketamine. During the anesthetic, his minute ventilation was unusually large for this 71 kg male.  His peak airway pressures were also elevated despite no trendelenburg positioning requested from the surgeon.  The procedure began at approximately 7:45am and closure was completed ..read more

 59 year old female for D&C and hysteroscopy with a history of pituitary adenoma, empty sella syndrome, Adrenal insufficiency, HTN, OSA, and BMI of 31. The patient was taking cabergoline to inhibit the secretion of prolactin via agonism of dopamine receptors. The patient also had a history of PONV and was very concerned with this prior to surgery. The patient had been followed for several years for her pituitary adenoma and had had no recent changes in her medical status.  I verified that her labs were within normal limits and proceeded with a general anesthetic with LMA. The p ..read more

 The other day I arrived to our main hospital to relieve one of my partners who was working with several CRNAs.  One of the CRNAs had just arrived in the cath lab where we had been asked to anesthetize a patient for a cardiac catheterization procedure.  We induced general anesthesia with an ETT.  Shortly thereafter I was called to the room for an alarm of high pressure in the anesthesia machine. I quickly determined that there was high pressure in the 3 Liter scavenging system bag and this was a result of not having the vacuum line connected to a central vacuum.  I tho ..read more

Sunday afternoon the friendly GI doc boarded a case for an urgent ERCP in a 31 year old female with choledokolithiasis.  She had elevated liver enzymes and he was concerned that she might develop ascending cholingitis.  The patient had hypothyroidism and was morbidly obese with a weight of apporoximately 320 lbs and was 5'3". We proceeded to the OR after 2 mg versed, 100 mcg fentanyl and 4 mg decadron were given as a premed.  In the OR after monitors were applied, pre oxygenation in the reverse T - burg position with HOB up at 30 degrees was accomplished.  Induction with 15 ..read more

As the Anesthesia Chair at a small community hospital I have been involved in helping to make decisions about how to ramp up elective cases as Government Abbot's decision to cancel elective cases comes to an end.  We are scheduled to begin regular cases on May 1st as we certified that we would comply with all of the requirements in order to do so. I work for a large anesthesia group that has communicated recommendations on how we should protect ourselves as we ramp up.  Some of the recommendations have caused me to think about the rationale behind them a little more in depth to see ..read more

A 26 year old female diagnosed with HIV for several years was urgently brought to the OR for a c/s for NRFHT.  The patient was being treated by quadruple anti viral therapy for her HIV. She was also on bactrim presumably as a prophylactic against PCP +/- toxoplasmosis.  After successful spinal anesthesia, the patient was laid down and oxygen applied.  I discarded of all sharps, and then went to dispose of the remaining packaging.  As I did so, my index finger received a superficial puncture from a needle that had not been visible in the remaining packaging.  I discove ..read more

This morning while watching the news showing the DOW plunging by another 2000 + points in the midst of a panicked public related to the spread of the novel corona virus, I was called up to L&D to place an epidural.  The patient was a G3P2 31 year old patient who was otherwise healthy with the exception of a reported prior history of Idiopathic Intracranial Hypertension.  She reported that she had been told that she could have an epidural by an anesthesiologist, but not a spinal.  Upon further questioning, I was able to determine that the patient had been treated by doxycycline for a routin ..read more

A  76 Year old male was admitted to the hospital after a syncopal episode during a BM at home.  The patient was found to be constipated and admitted for further testing. The patient deteriorated in a day and a half and required intubation due to ventalitaory failure. Pressors were required in low dose shortly thereafter, with accompanying renal failure.  The GI physician was called in on Sunday morning to attempt colonic decompression via a colonoscopy and I was called into the hospital to provide anesthesia.  I explained to the GI doctor, that giving additional sedation to the patient might c ..read more

On a Saturday call I was called in to take care of a 72 year old gentleman who had undergone a six hour paraesophageal hernia repair and extensive lysis of adhesions 10 days prior.  He was now suffering from abdominal pain with radiological studies that showed extensive colon dilation with stool and lack of movement from the stomach to the duodenum leading to a diagnosis of gastric outlet obstruction.  The patient had an NG tube in place which was on suction.  The patient was alert and orientated able to answer questions with no signs of obtundation or lethargy.  Lab values were significant f ..read more