52 yr old obese woman BMI 32 kgm

52 yr old obese woman BMI 32 kg/m 2 Type 2 DM on Insulin Pump 15 yrs HTN on Losartan 40 mg and Amlodipine 10 mg 1 0 yrs Shoulder Arthroscopy Dr. Mary Thomas

What are the relevant history you will ask this patient in your pre anesthetic clinic? Questions pertaining to her comorbidities helping you to assess fitness for surgery

Obesity OSA, COPD, CPAP, sleeping in supine possible? GERD, metabolic syndrome Amphetamine drugs-apetite suppressant Activity, stair climbing, dyspnoea DM, HTN End organ disease-IHD, Renal disease, peripheral neuopathy, Stroke Arthroscopy Rh arthritis, injury, osteoarthritis

Clinical examinations you will do specifically for this patient bearing in mind the patients comorbidities

Obesity Airway tests-neck circumference Right ventricular failure, iv access DM Limb paraesthesia and weakness Site where insulin pump is attached BP , orthostatic hypotension, autonomic neuropathy Arthroscopy Rheumatoid arthritis - palm print, prayer sign/atanto occipital joint mobility

Relevant Investigations you will send and why?

Obesity Hb-polycythemia 6 MWT pulm function , ABG LFT, lipid profile DM Endocrine work up RBS +Hb. A 1 C Electrolytes RFT HTN Cardio workup ECG arrythmia, prolonged Qt ECHO- LVDD, PHT , RVH Obesity cardiomyopathy CPET

What are the ways you can optimize this patient for surgery?

Diet and exercise Breathing exercise , Inspiratory muscle training Home oxygen, CPAP

Premedication orders?

Will you give anxiolytics DVT prophylaxis Choice of antiemetic and antacid Insulin orders. Antihypertensives withhold or continue Repeat inv. Informed high risk consent for what problems? GA/Regional

Will you give anxiolytics? Benzodiazepines decrease ACTh release so decrease blood glucose DVT prophylaxis ? LMWH Choice of antiemetic 5 HT 3 blocker CTZ -increased incidence in peripheral nerve block, DM , ? Insulin orders. document insulin pump- Glucose containing. Fluid 2 hrs before surgery if hypoglycemic. Blood glu <70 should consume 1 g fast acting carbohydrate. one gm glucose raises by 5 gm/dl

Antihypertensives withhold or continue It is reasonable to hold ACE inhibitors and ARBs for a period of 24 hours prior to surgery or administer the evening dose on the day before surgery (and not on the morning of surgery) withholding these agents on the morning of noncardiac surgery was associated with a decreased incidence of intraoperative hypotension compared with administration Repeat inv. Informed high risk consent for all perioperative problems GA/Regional choice

When will you postpone the surgery?

Bp>180/110 Sugar>400

What will you do on receiving the patient in OT in the holding area?

Mark cricothyroid membrane with Ultrasound for emergency FONA Insulin pump- Document presence of pump in chart and location. look for inflammation and leak. Check Blood glucose in preop area. If BG<70 give iv 2 dex 12. -25 ml iv and recheck. If hyperglycemia ask patient to give bolus acc to usual regime before sedating him If >300 disconnect and start IV insulin. if not using give back to family Check BP -IV sedation /Antihypertensives/Anxiolytics

What is your plan of anesthesia? How will you prepare the OT?

Extra equipment will you keep ready-difficult airway awake intubation/semi recumbant Advantages of GA/block GA ETT/SGA or sedation Problem of positioning-BCP/LD Extra large BP cuff /Arterial canulation stockings/Compression stockings Monitoring cerebral perfusion MAP>60 at. EAM r. SO 2 Sevoflurane increases blood sugar, des good for obesity early recovery

What are the Blocks you can give for shoulder arthroscopy? Mention advantages and disadvantages of each block Checking of successful block

ISB-SSISB or With Catheter- A modified Winnie technique in the interscalene region. Other approaches such as the Meier modification may facilitate catheter placement interscalene block should only be performed before the induction of general anaesthesia, as it is associated with potentially serious complications Other major complications include subarachnoid/epidural injection, stellate ganglion block, and pneumothorax The phrenic nerve, with associated ipsilateral hemidiaphragmatic paresis, is nearly always blocked. A combination of COPD with a high BMI is particularly problematic, although most patients will tolerate a unilateral block if maintained in the deck chair or seated positions

Shudder block supraspinatus + axillary nerve Truncal block at C 7 spares the phrenic which is blocked in ISB ES B at T 2

Checking of successful block? The three components of the block should be tested: (i) motor by asking the patient to abduct and flex the arm from the shoulder ; (ii) cutaneous sensation to cold over the relevant dermatomes; (iii) joint sensation by demonstrating the loss of pain (when present) during passive movement. Cutaneous anaesthesia alone is not a reliable indicator of block success. After the insertion of the block and the demonstration of its efficacy, general anaesthesia is induced if required

How will you calculate drug dose for GA and LA Obesity

NM agents –Ideal body weight +20% Scoline –total body weight Propofol- total body weight LA infiltration –IBW Etomidate good for diabetics

How will you manage the diabetic status? What is your Target Blood sugar levels? Ta. BP? How will you manage ?

Decisions regarding timing of preoperative ACE inhibitor or ARB dosing Target BP Method of Prevention of increased stress response Management of hypotension Monitoring IBP/NIBP Intraop ST segment variation/arrythmia

Continue pump? IV continuous insulin? Dose? IV fluid of choice How will you adjust the dose of insulin Potassium correction When will you declare unfit for elective surgery

Management Of diabetes? Continue pump? ? Use in type 2 diabetics Remove and put in thigh away from quatery Stop if disposables not available and not used to operating it. convert to IV insulin Do not use if Xray CT MRI required

IV fluid of choice- normal saline dextrose How will you adjust the dose of insulin? 1 -3 hrs surgery -If normoglycemic self treat with bolus of one hour and disconnect. If <110 no bolus If bg>300 Start. 5 U/hr if basal rate <1 Start 2/3 of basal rate if more than 1 U/hr Continue maintain 140 -180 If patient recovers stable continue regime till awake and able to use pump. Start pump ½ hr before discontinuing iv insulin Potassium correction

Management Of problems due to obesity?

Positioning Airway Full stomach precaution

Problems of surgical procedure?

Port Insertion LA Sub cutaneous emphysema Airway edema Type of procedure subacromial greater risk HBEs with interscalene brachial blocks and cerebral hypoperfusion events, cervical neuropraxia (lesser occipital nerve, greater auricular nerve, hypoglossal nerve), air embolism and pneumothorax have been reported with BCP

Precautions at end of surgery

Suddenly there is bradycardia and hypotension. why? What will you do? Extravasation of irrigation fluid in shoulder

What precautions will you take at the end of surgery?

Leak test before extubation Neck circumference Ultrasound chest Extubate awake CPAP post op

What are the methods of Postoperative pain relief? What will you avoid?

conventional oral and parenteral analgesia; Non-steroidal anti-inflammatory drugs are relatively contraindicated in the first 24 h after surgery due to the increased risk of bleeding associated with this group of drugs. A strong opioid should be prescribed for the postoperative period, patient-controlled analgesia using morphine is entirely appropriate interscalene analgesia with catheter intra-articular analgesia with or without continuous infusion; suprascapular nerve block combined with axillary nerve block local anaesthetic wound infiltration.