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    Default Bad Choice?

    I had a recent case with a 73 year-old woman.....she had 2 stents to the LAD a year ago, echo showed normal wall motion with EF=60% with no valve issues, no pulmonary issues, DM with oral control, 5' 1" and 80kg. Case is right THR with anterior approach....this surgeon is pretty slick and cases are usually done in an hour. Patient prefers GA. I figure we will just place an LMA. The case goes well initially load up 250mcg of fentanyl in that first hour as she is spontaneously breathing with PSV pro and RR 15-20. VT is 350-420 which is def on the lower end but all I could get and keep pressure at around 18-19. Well, the surgeon had issues and 1 hour turned to 3.. During this time I worked in 2mg Dilaudid. During the case ETCO2 reading 45-50ish.

    The case concludes and her VT won't increase more than 100ml with rate of 20 or so with no support...think maybe I need some Narcan as she is not arousing....I dilute to 40mcg/ml x 3 doses. There is no change except a dramatic increase in B/P requiring Hydralazine. So, I see we are getting no where and start to think atelectasis or simple hypoventilation. Still in the OR call for CXR and ABG and of course...PCO2 is 80. I intubate her and go to the unit for a few hours she was extubated about 4 hours after surgery.

    With the info I have given, did I give too much narcotic, should I have made a decision during the case to intubate her, should I have tubed from the start? What I saw from a purely clinical standpoint was fairly normal progression during the case. I have in the past noticed a significant gradient from ventilator ETCO2 to actual ABG findings. I also think many of our patient have higher PACO2 when we go to PACU but never know it. Anyway, honest thoughts or comments are welcome.


    *****CXR did show some LLL scarring? and a bit of atelectasis.
    Last edited by pavementpounder; 06-25-2014 at 09:24 AM. Reason: Spelling
    Tom

    We gain strength, and courage, and confidence by each experience in which we really stop to look fear in the face... we must do that which we think we cannot
    -Eleanor Roosevelt

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