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Anaesthesia and the ICU

Leaders:

Claude Tousignant, MD, FRCPC
Jon Hooper, MD, FRCPC

Case 1:

A 49 year old man with a large bowel obstruction is brought to the operating room for semi-urgent laparotomy. On arrival to the OR he has profuse vomiting of feculent material. During this episode he clearly aspirates. He quickly develops severe dyspnea and hypoxemia despite 100 % 02.

Discussion points to include:

• immediate airway management
• pathophysiology of aspiration
• immediate treatment of aspiration
• postoperative ventilation management
• current recommendations for ventilation of patients with ARDS
• volutrauma and barotrauma
• lung protective strategies
• various modes of ventilation, what is best?
• permissive hypercarbia
• prone positioning
• inhaled nitric oxide

Case 2:

A 56 year old woman is scheduled for urgent laparotomy. She is now currently seven days postop from a laparotomy for small bowel obstruction. At that time lysis of adhesions and a small bowel resection were performed.. She initially did well, but over the last few days has developed a fever and increasing shortness of breath. The initial diagnosis had been pneumonia and she was treated with broad spectrum antibiotics. Today, sbe became hypotensive and intestinal contents were seen leaking from her abdominal wound. The current diagnosis is intra-abdominal sepsis causing septic shock and ARDS. She is currently intubated and ventilated. Dopamine is running. The ICC has called you to see what you would like (therapeutically and diagnostically) preop.

Discussion points to include:

• pathophysiology of septic shock
• resuscitation and management
• appropriate investigations preop
• hemodynamic management
• oxygen delivery
• anesthetic management

Case 3:

You are called to the ER to assist in managing a 19 year man suffering from severe asthma. He developed a URI 8 days ago and has become increasingly dyspneic since. His respirologist thinks he needs to be intubated, and would then like to give him one of those anesthetic gases to help break his asthma.

Discussion points to include:

• initial assessment and management of severe asthma
• who needs intubation and who doesn't
• airway management
• ventilation management
• volutrauma and barotrauma
• what to do when you can't ventilate
• what drugs to give and how to deliver (while on a ventilator).