Anesthesia Case #3: Introduction
  • 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.
Case Author: Clark Albert, M.D. Chairman, Department of Anesthesiology, used with permission; edited by Michael Gordon, Ph.D. Associate Professor of Pharmacology and Surgery, University of Kansas Medical Center.