General:
- The patient is a 67 year-old, 90 kg,
white male presenting for a right lobe resection
for treatment of a biopsy-proven carcinoma. His
past medical history is remarkable for coronary
artery disease treated seven years prior with
coronary artery bypass grafting of or vessels --
hypertension treated with metoprolol and
verapamil.
- He admits to a 50 pack-year history of
cigarette smoking; however, has not smoked for 10
years.
- Additionally, he reports a life long
history of chronic anxiety which is required
intermittent treatment with various anxiolytics.
Most recently, he has been treated with lorazepam
as needed.
- Three months prior, he had an exercise
stress test which was negative for myocardial
ischemia
- Pertinent laboratory tests include
hematocrit of 45%, arterial blood gas, pH 7.37,
PCO2
45, PO2
to 74, HCO3
23.
- Pulmonary function tests reveal a forced
vital capacity (FVC) at 70% of predictive value
any forced expiratory volume at one second (FEV1)
at 45% of predictive value.
- His electrocardiogram was remarkable for
a first degree A-V block any heart rate of 68
bpm.
Preoperative
interview:
- The preanesthetic visit
was completed the morning of surgery. During the
anesthesiologist's interview, the patient's
prevailing concern was postoperative pain
control.
- The benefits and risks of
the thoracic epidural for postoperative analgesia
were discussed.
- The patient elected to
proceed with the epidural.
- The patient had taken his
usual metoprolol and extended release verapamil
at home
Preoperative
preparations:
- The patient was
transported to the preoperative area. After a
large bore IV catheter was placed, the patient
was mildly sedated with midazolam. A second large
bore IV catheter was inserted as well as a left
radial artery catheter.
- The thoracic epidural
catheter was then placed in threaded 2 cm at the
seventh thoracic interspace.
- A test dose of 1.5%
lidocaine with 1:200,000 epinephrine was
administered with a resultant T4 to T11 block to
cold perception.
- BP and heart rate of
130/74 and 65 bpm respectively, were maintained
throughout.
- Following the test does, 3
mg of preservative-free morphine was placed in
the epidural space.
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