Gray Matter

Non-perioperative

Opioid-naive patient with uncontrolled pain on IV PCA after open hemicolectomy

A 58 y.o., 82 kg, 5'4" woman is on the surgical floor on postoperative day 1 after an open right hemicolectomy. The acute pain service is consulted first thing in the morning for poorly controlled pain.

HPIA planned laparoscopic right hemicolectomy for cecal adenocarcinoma was converted to open through an upper-to-lower midline incision because of dense adhesions. Preoperatively she declined an epidural should the case be converted. Four-hour general anesthetic: fentanyl 250 mcg and hydromorphone 1.5 mg; acetaminophen 1 g IV, dexamethasone 4 mg, ondansetron 4 mg; no NSAID. The surgeon infiltrated the incision with 20 mL of bupivacaine 0.25% at closure. EBL 350 mL; 2.5 L crystalloid. In PACU she received hydromorphone 1.2 mg IV and an IV PCA was started.

PMHHypertension. GERD. Depression, well controlled. Prior cesarean delivery. No alcohol or recreational drug use. Has never taken an opioid outside of the hospital.

MEDSHome: lisinopril 20 mg daily, sertraline 100 mg daily, omeprazole 20 mg daily. Current orders: hydromorphone PCA, 0.2 mg demand dose, 10-minute lockout, no basal infusion; acetaminophen 650 mg PO q6h prn; ondansetron 4 mg IV q6h prn; diphenhydramine 25 mg IV q6h prn itching, given twice overnight; lisinopril given this morning. Clear liquid diet.

PHYS EXAMAwake, tearful, holding a pillow against the incision. HR 108; BP 156/92; RR 22 and shallow; SpO2 93% on 2 L nasal cannula; T 37.9 C. Diminished breath sounds at both bases. Abdomen mildly distended, hypoactive bowel sounds, midline dressing dry.

LABSThis morning: Hgb 10.8 g/dL (preop 12.6); WBC 11.8 K/uL; platelets 238 K/uL; Na 137; K 4.4; creatinine 1.3 mg/dL (preop 0.8); glucose 168. Urine output 20 mL/h over the last 6 hours.

CURRENT STATEPain 7/10 at rest and 10/10 with coughing or turning. She has not been out of bed and will not use the incentive spirometer. Her husband has stayed at the bedside overnight.

Non-perioperative

High-dose oxycodone patient for open ventral hernia repair

A 58 y.o., 104 kg, 5'10" man is referred for a chronic pain consultation two weeks before an elective open ventral hernia repair with component separation.

HPIMidline incisional hernia after a laparotomy for perforated appendicitis at age 30, enlarging over 5 years; two ED visits in the past 3 months for painful incarceration, both reduced at the bedside. CT: 10 cm wide periumbilical fascial defect containing small bowel, no obstruction. The surgeon plans an open repair with bilateral posterior component separation (transversus abdominis release) and retromuscular mesh through a midline incision, xiphoid to below the umbilicus; expected stay 4 to 5 days. Chronic low back pain for 12 years from lumbar spondylosis with right L5 radiculopathy; spine surgery has not been offered. On opioids for 8 years, the current regimen unchanged for 2 years, all prescribed by one pain physician under an opioid agreement. Back pain 5/10 on his regimen; works part-time and walks a mile most days. After an open cholecystectomy four years ago his pain was uncontrolled for three days on a hydromorphone PCA; he went home on twice his usual oxycodone and took four months to return to his usual dose.

PMHObstructive sleep apnea (AHI 34) on CPAP, uses it most nights. Hypertension. Obesity, BMI 33. Depression and generalized anxiety, stable. Midline laparotomy for perforated appendicitis at age 30; open cholecystectomy four years ago. Drinks rarely; never smoked.

MEDSOxycodone ER 60 mg every 12 hours. Oxycodone IR 15 mg every 4 hours as needed, about four tablets a day. Gabapentin 600 mg three times daily. Duloxetine 60 mg daily. Alprazolam 0.5 mg at bedtime. Lisinopril 20 mg daily. Senna and polyethylene glycol daily.

PHYS EXAMHR 74; BP 136/84; RR 14; SpO2 95% on room air. Mallampati III, neck circumference 45 cm. Midline and right subcostal scars; reducible periumbilical hernia, nontender. Lumbar paraspinal tenderness; decreased sensation over the right dorsal foot; strength 5/5 throughout; gait normal.

LABSHgb 13.6 g/dL; platelets 248 K/uL; INR 1.0; creatinine 0.9 mg/dL; AST and ALT normal; albumin 3.9 g/dL. ECG: sinus rhythm, QTc 438 ms.

Long stem

Small bowel obstruction, volume depleted, for urgent exploratory laparotomy

A 66 y.o., 74 kg, 5'4" woman is brought to the operating room for urgent exploratory laparotomy for a small bowel obstruction.

HPIThree days of crampy abdominal pain, distension, and vomiting; no flatus or stool for two days. Unable to keep liquids down since yesterday. Came to the ED early this morning after taking her usual morning medicines at home. A nasogastric tube placed 8 hours ago has drained 1.6 L of bilious fluid. Admitted for a trial of nonoperative management, but over the last 2 hours her pain has become constant and she has new focal tenderness. She is lightheaded when she sits up.

PMHHypertension. Type 2 diabetes, HbA1c 7.4%. Open abdominal hysterectomy 18 years ago, after which she had severe nausea and vomiting and stayed an extra night. Walks two miles most days without symptoms. Never smoked. No other surgery.

MEDSLisinopril 40 mg and hydrochlorothiazide 25 mg each morning (taken today). Metformin 1000 mg twice daily. Insulin glargine 18 units at bedtime (taken last night). Atorvastatin. No known drug allergies.

PHYS EXAMHR 114; BP 102/60 supine; RR 22; SpO2 95% on room air; T 37.7°C. Dry mucous membranes. Abdomen distended and tympanitic, tender with guarding in the right lower quadrant; healed lower midline scar. Mallampati 2, full dentition, normal mouth opening and neck extension. Lungs clear.

CT ABDOMEN (IV contrast, 6 hours ago)Dilated, fluid-filled small bowel to 4 cm with a transition point in the lower abdomen; collapsed distal ileum and colon. Mesenteric haziness and a small amount of free fluid. No free air. Stomach distended with fluid.

LABSNa+ 133 mEq/L; K+ 3.0 mEq/L; Cl- 89 mEq/L; HCO3- 33 mEq/L; BUN 46 mg/dL; creatinine 1.7 mg/dL (0.9 three months ago); glucose 236 mg/dL; Mg2+ 1.5 mg/dL; lactate 2.6 mmol/L (1.8 six hours ago); WBC 14.8 K/uL; Hgb 15.1 g/dL; platelets 310 K/uL; INR 1.1.

OR ARRIVALOne 20 g IV in the left hand with her second liter of lactated Ringer's running; 1 L was given in the ED. Nasogastric tube to low wall suction. Foley catheter: 60 mL of urine over the last 4 hours. Standard monitors on.

Long stem

Adult polytrauma with TBI for emergent craniotomy

A 58 y.o., 82 kg, 5'8" man is brought to the operating room for emergent left frontotemporal craniotomy and evacuation of an acute subdural hematoma.

HPIUnrestrained driver ejected from a motor vehicle collision approximately 90 minutes ago. EMS found him unresponsive at the scene and intubated him in the field with succinylcholine and etomidate. Brought to MGH ED where ATLS resuscitation was initiated. Two large-bore peripheral IVs in place. One unit of PRBC began infusing in the ED. CT scans completed. Now arriving in OR.

PMHMyocardial infarction 3 years ago, treated with two drug-eluting stents to the LAD. No anginal symptoms since. Hypertension. Hyperlipidemia. No prior surgeries.

MEDSAspirin 81 mg daily, atorvastatin 40 mg daily, lisinopril 20 mg daily. Last meal 5 hours prior to MVC.

PHYS EXAMHR 115; BP 95/55; assist control ventilation, FiO2 1.0; T 36.0°C; SpO2 92%. GCS 7T (E2, M4, intubated off sedation). Pupils: left 5 mm sluggish, right 3 mm reactive. Cervical collar in place. Chest auscultation: decreased breath sounds on the right. Abdomen soft. Right thigh and pubic region tender. Foley catheter in place.

CT HEADLarge left frontotemporal acute subdural hematoma with 8 mm midline shift. Effacement of the left lateral ventricle. No contralateral hemorrhage. No skull fracture.

CT C-SPINEUnstable C5-C6 ligamentous injury without fracture.

CT CHESTRight pulmonary contusion; small right pneumothorax, no chest tube; three right-sided rib fractures (4th, 5th, 6th).

CT PELVISRight superior and inferior pubic ramus fracture without retroperitoneal hematoma.

LABSHgb 9.8 gm/dL; platelets 198 K/uL; INR 1.3; K+ 3.2 mEq/L; glucose 220 mg/dL; lactate 5.2 mmol/L; creatinine 1.1 mg/dL. ABG on FiO2 1.0: pH 7.30; PaO2 88; PaCO2 38.

OR ARRIVALPatient is intubated and sedated on propofol 30 mcg/kg/min. Two 16 g peripheral IVs functioning. Arterial line not yet placed. Type and crossmatch sent; 4 units PRBC available in the OR. Surgeon is scrubbed and ready to incise.

Long stem

Cervical myelopathy for posterior fusion with neuromonitoring

A 66 y.o., 78 kg, 5'3" woman is scheduled for posterior cervical decompression and instrumented fusion, C3 to C6, prone, with somatosensory and motor evoked potential monitoring.

HPIEighteen months of progressive hand clumsiness — she has stopped buttoning her own shirts — with six months of gait imbalance and two recent falls. No bowel or bladder symptoms. Symptoms progressed despite physical therapy; surgery was scheduled after new cord signal change appeared on MRI.

PMHRheumatoid arthritis for 22 years, seropositive, followed by rheumatology. Obstructive sleep apnea on nightly CPAP. Hypertension. No diabetes. No known cardiac disease; climbed a flight of stairs without chest symptoms until gait limited her.

MEDSMethotrexate 20 mg weekly with folic acid. Prednisone 7.5 mg daily for the past 6 years. Naproxen 500 mg twice daily for joint pain, last dose yesterday evening. Amlodipine 10 mg daily. Took prednisone and amlodipine this morning.

PHYS EXAMHR 76; BP 152/88; RR 14; SpO2 96% on room air; T 36.7°C. Symmetric MCP swelling and ulnar deviation of both hands with intrinsic wasting. Grip 4+/5 bilaterally. Biceps and brachioradialis reflexes brisk; Hoffmann positive bilaterally; sustained clonus at both ankles; wide-based, unsteady gait. Sensation mildly reduced in the fingertips.

AIRWAY EXAMMouth opening 3 cm. Mallampati III. Neck extension visibly limited and uncomfortable at the extremes; flexion also limited. Thyromental distance 5.5 cm. Voice normal; no stridor; teeth intact.

IMAGINGMRI cervical spine: multilevel spondylosis with severe canal stenosis C3-C6 and T2 hyperintensity within the cord at C4-5. Neutral lateral cervical radiograph: atlantodental interval 3 mm. Flexion-extension views not obtained.

LABSHgb 10.8 g/dL; MCV 84; platelets 348 K/uL; WBC 8.2 K/uL; INR 1.0; creatinine 0.9 mg/dL; K+ 4.2 mEq/L; glucose 102 mg/dL.

OR ARRIVALIONM technologist in the room; SSEP and transcranial MEP montage planned; Mayfield head clamp on the field. Two 18 g peripheral IVs; radial arterial line planned before induction. Her CPAP machine came with her belongings. Surgeon estimates 4 to 5 hours.

Long stem

Transsphenoidal pituitary resection in acromegaly with a spinal cord stimulator

A 54 y.o., 6'1", 124 kg man is scheduled for endoscopic endonasal transsphenoidal resection of a pituitary macroadenoma.

HPIFour years of enlarging hands and feet, coarsening facial features, and daily headaches. Over the past year his voice has become deeper and hoarse, and he has started bumping into door frames on both sides. IGF-1 is 3.2 times the upper limit of normal, and growth hormone did not suppress after an oral glucose load.

PMHSevere obstructive sleep apnea (AHI 52) on CPAP 14 cm H2O nightly, adherent. Hypertension. Type 2 diabetes, HbA1c 8.3%. Chronic low back and bilateral leg pain after an L4-S1 fusion 7 years ago; a spinal cord stimulator was implanted 2 years ago and he uses it continuously with partial relief. Anesthesia record from the fusion: "two-handed mask ventilation with oral airway; grade 2 view with videolaryngoscope."

MEDSOxycodone extended-release 20 mg BID and oxycodone 5 mg up to three times daily; gabapentin 600 mg TID; lisinopril 40 mg; amlodipine 10 mg; metformin 1000 mg BID; insulin glargine 30 units nightly.

PHYS EXAMHR 72; BP 162/96; RR 16; SpO2 93% on room air; T 36.8°C. Frontal bossing, prognathism, large tongue, broad hands. Bitemporal visual field loss on confrontation. Lungs clear. A palpable implanted device under a healed incision in the left upper buttock.

AIRWAY EXAMMallampati IV. Mouth opening 4 cm. Neck circumference 51 cm. Full neck range of motion. Voice hoarse; no stridor at rest.

IMAGINGMRI: 2.4 cm sellar mass with suprasellar extension elevating the optic chiasm. Thoracic spine radiograph: two percutaneous stimulator leads in the dorsal epidural space, tips at T8, tunneled to a generator in the left upper buttock.

ECHO / ECGEcho: concentric LVH; LVEF 55%; grade II diastolic dysfunction; no significant valve disease. ECG: sinus rhythm; LVH with repolarization changes.

LABSHgb 14.8 g/dL; platelets 236 K/uL; Na+ 140 mEq/L; K+ 4.3 mEq/L; creatinine 0.9 mg/dL; glucose 214 mg/dL; 8 AM cortisol 13 mcg/dL; free T4 normal.

OR ARRIVALTook oxycodone ER 20 mg and gabapentin 600 mg at 0600; lisinopril and metformin held; glargine reduced to 20 units last night. His stimulator is on; he left the controller at home. The surgeon plans an abdominal fat graft if a CSF leak is found. Radial arterial line and two 18 g IVs planned.

Long stem

Morbid obesity, OSA, prior failed neuraxial, repeat cesarean with placenta accreta

A 36 y.o. G3P2 at 39 weeks gestation, 152 kg, 5'4" (BMI 58), is scheduled for repeat cesarean delivery, her third. Obstetric ultrasound raises concern for placenta accreta over the prior cesarean scar.

HPIFirst cesarean under uncomplicated spinal at an outside hospital. Second cesarean at age 31: 90 minutes of attempted epidural placement, ultimately converted to general anesthesia after surgical incision under inadequate block; required two attempts at intubation. She recalls feeling pulling during the second cesarean but reports no nightmares or avoidance. On home CPAP at 14 cm H2O for severe OSA (AHI 65), uses it nightly. Has been doing prenatal pool exercise. BMI was 48 prior to pregnancy.

PMHClass III obesity. Severe OSA on CPAP. Gestational diabetes on insulin. Chronic hypertension on labetalol. Mild iron-deficiency anemia. GERD on PPI.

MEDSLabetalol 200 mg PO BID; insulin lispro sliding scale; omeprazole 40 mg PO daily; low-dose aspirin 81 mg; prenatal vitamins.

PHYS EXAMHR 88; BP 142/88; RR 18; SpO2 94% on room air; T 37.0°C. Neck circumference 47 cm. Mallampati IV, restricted neck extension, mouth opening 3 fingerbreadths, thyromental distance 4 cm. Redundant soft tissue over the lumbar back; bony landmarks not palpable on exam.

LABSHgb 10.5 g/dL; platelets 195 K/uL; INR 1.0; glucose 110 mg/dL; creatinine 0.7 mg/dL. Type and screen positive antibody (anti-E); four units crossmatched.

IMAGINGObstetric ultrasound suggestive of placenta accreta spectrum (lower segment, prior scar adherence). MRI confirms placenta percreta with bladder involvement. Cardiology TTE: LV hypertrophy, mild diastolic dysfunction, EF 65%, RVSP 38 mmHg.

FETALEstimated fetal weight 4200 g. FHR baseline 140 with appropriate variability.

OR ARRIVALBariatric OR table with ramp pillows in place. After multiple attempts a single 18 g IV in the right forearm. Right radial arterial line attempted twice unsuccessfully. Ultrasound brought into the room. NICU and gynecologic oncology team notified for the accreta. IR notified for possible postpartum embolization.

Long stem

Severe rheumatic mitral stenosis with new AF, planned cesarean

A 33 y.o. G2P1 at 36 weeks gestation, 58 kg, 5'3", is admitted for planned cesarean delivery tomorrow morning for known severe rheumatic mitral stenosis with progressive symptoms.

HPIProgressive exertional dyspnea since week 28, now NYHA class III to IV; orthopnea and paroxysmal nocturnal dyspnea for the past week. Two triage visits in 10 days for shortness of breath. Today walking from the parking lot left her breathless. No chest pain. Immigrated from Vietnam at age 19; first child delivered uneventfully at 24.

PMHChildhood rheumatic fever. Severe rheumatic mitral stenosis with mitral valve area 0.85 cm² and mean gradient 18 mmHg on echo this month. New-onset atrial fibrillation four weeks ago, rate-controlled. Mild gestational hypertension. No prior anesthetics other than uncomplicated spinal for first cesarean.

MEDSMetoprolol 50 mg PO BID; furosemide 20 mg PO daily; therapeutic-dose enoxaparin 1 mg/kg SC BID for AF (last dose 24 hours ago); prenatal vitamins.

PHYS EXAMHR 92 (atrial fibrillation, controlled); BP 118/72; RR 22; SpO2 95% on 2 L NC; T 36.8°C. Loud opening snap, low-pitched mid-diastolic murmur at the apex with presystolic accentuation lost in AF. Bibasilar crackles to the mid-zone. JVP elevated to the angle of the jaw. Mild pitting edema. Airway: Mallampati II, full mouth opening, full neck extension.

ECGAtrial fibrillation at 92 with diffuse repolarization changes; no ischemic features.

LABSHgb 10.2 g/dL; platelets 195 K/uL; INR 1.2; creatinine 0.7 mg/dL; BNP 1240 pg/mL; anti-Xa drawn this morning (~24 h after last dose) 0.5 IU/mL. Type and screen positive for anti-K antibody (notified blood bank, two crossmatched units on hold).

IMAGING / TTE todayMitral valve area 0.85 cm², mean gradient 18 mmHg; estimated RVSP 60 mmHg; RV mildly dilated with preserved function; LV ejection fraction 60%; biatrial enlargement; no thrombus seen. CXR with cephalization and small bilateral pleural effusions.

FETALFHR baseline 140 with appropriate variability and accelerations.

OR ARRIVALTwo 16 g peripheral IVs and a right radial arterial line in. Cardiology and cardiac surgery on standby. NICU team present. Epidural cart in the room. ECMO consult notified the day before.

Long stem

32-week parturient after MVC with hemorrhagic shock and fetal distress

A 27 y.o. G2P1 at 32 weeks gestation, 70 kg, 5'6", is brought to the trauma bay 30 minutes after a head-on motor vehicle collision. Trauma surgery plans emergent exploratory laparotomy for a positive FAST and hemodynamic instability; obstetrics is scrubbed for possible cesarean if fetal status worsens.

HPIRestrained driver, head-on collision at approximately 45 mph, airbag deployed, brief loss of consciousness, complains of left chest and diffuse abdominal pain. Bleeding from a forehead laceration. Last meal was a granola bar and coffee 2 hours ago.

PMHUnremarkable. One prior uncomplicated vaginal delivery three years ago. No prior anesthetics.

MEDSPrenatal vitamins, no other medications.

PHYS EXAMHR 128; BP 92/58; RR 26; SpO2 95% on 4 L NC; T 36.4°C. Cervical collar in place. Airway: Mallampati II, full mouth opening, full neck extension behind collar. Obvious left chest wall ecchymosis with crepitus; decreased breath sounds at the left base. Diffuse abdominal tenderness, gravid uterus tender to palpation. Pelvis stable. 5 cm forehead laceration packed.

ECGSinus tachycardia at 128, no ischemic features.

LABSHgb 11.5 g/dL (12.4 at 26 weeks; hemoglobin lags acute blood loss); platelets 180 K/uL; INR 1.1; fibrinogen 280 mg/dL; lactate 4.2; base deficit minus 7; creatinine 0.8; type and screen with anti-K antibody, two units crossmatched, MTP activated.

IMAGINGFAST positive for free fluid in the right upper quadrant and pelvis. CT not yet performed. Portable CXR: left rib fractures 4-7, small left pneumothorax, no widened mediastinum.

FETALEstimated fetal weight 1900 g. FHR baseline 165 with reduced variability and recurrent late decelerations over the past 20 minutes.

OR ARRIVALTwo large-bore peripheral IVs in upper extremities. No arterial line yet. C-collar maintained. Patient with 15° left tilt on the OR table. Trauma, OB, NICU teams present; cardiothoracic surgeon notified for chest tube and possible thoracotomy.

Long stem

Idiopathic pulmonary arterial hypertension in active labor at term

A 26 y.o. G1P0 at 36 weeks gestation, 62 kg, 5'5", presents in active labor at 6 cm cervical dilation. She has known idiopathic pulmonary arterial hypertension and was scheduled for elective cesarean at 37 weeks but went into spontaneous labor today, a few days before the planned date.

HPIIdiopathic PAH diagnosed at age 22 after presyncope and progressive dyspnea on exertion; right-heart catheterization at that time showed mean PA pressure 56 mmHg, PVR 9 Wood units. Initial improvement on dual oral therapy. Pregnancy proceeded despite counseling; she elected to continue.

PMHIdiopathic PAH (WHO Group 1, functional class II to III). Multidisciplinary plan with cardiology, OB, and anesthesia for delivery at 37 weeks by elective cesarean. No prior surgeries, no prior anesthetics.

MEDSSildenafil 20 mg PO TID; selexipag 1600 mcg PO BID; low-dose aspirin 81 mg daily; prophylactic enoxaparin 40 mg SC daily (last dose 14 hours ago); prenatal vitamins.

PHYS EXAMHR 102, sinus; BP 110/68; RR 22; SpO2 92% on room air; T 37.0°C. Loud P2, parasternal RV heave. JVP elevated to 8 cm. Trace edema. Airway: Mallampati II, full mouth opening, full neck extension.

ECGSinus tachycardia, RV hypertrophy, right-axis deviation, T-wave inversions V1-V3.

LABSHgb 12.4 g/dL; platelets 220 K/uL; INR 1.0; BNP 980 pg/mL; creatinine 0.7 mg/dL; type and screen negative.

TTE (recent)RVSP estimated at 78 mmHg; RV moderately dilated with preserved function; septal flattening; moderate tricuspid regurgitation; reduced RVOT VTI; LV ejection fraction 60%.

IMAGINGCXR with enlarged central pulmonary arteries, no acute infiltrate.

FETALEstimated fetal weight 3500 g. FHR baseline 145 with appropriate variability, no decelerations.

OR ARRIVALAdmitted to L&D 90 minutes ago. Cardiology and adult cardiac anesthesia notified. ECMO team aware. 18 g antecubital IV. No arterial line yet. OB asks whether anesthesia is comfortable with assisted vaginal delivery versus moving to cesarean now.

Non-perioperative

Hypoxemia in PACU after laparoscopic sleeve gastrectomy in a patient with severe OSA

A 58 y.o., 128 kg, 175 cm man (BMI 42) arrives in the PACU after elective laparoscopic sleeve gastrectomy under general anesthesia. He is booked for a regular surgical floor bed overnight.

HPIObesity since his twenties; BMI 42 despite a supervised weight-loss program. Completed multidisciplinary bariatric evaluation. Two-week low-calorie liquid diet before surgery.

PMHSevere obstructive sleep apnea (AHI 38 on a sleep study two years ago), on CPAP at 11 cm H2O nightly with good adherence. Hypertension. Type 2 diabetes (HbA1c 7.6%). No prior anesthetic problems.

MEDSLisinopril, metformin, atorvastatin. Metformin and lisinopril held this morning.

PRE-OP EXAMMallampati 3, neck circumference 47 cm, full dentition. Lungs clear. SpO2 97% on room air.

INTRA-OPERATIVE COURSEAprepitant 40 mg PO in pre-op holding. Ramped and preoxygenated. Propofol, fentanyl, rocuronium 50 mg; video laryngoscopy, grade 1 view, first pass. Sevoflurane maintenance. Rocuronium redosed 20 mg at 1 hour. Pneumoperitoneum to 15 mmHg in steep reverse Trendelenburg. Orogastric tube fully removed before stapling; calibration bougie passed by anesthesia, held in place during stapling, then withdrawn; leak test negative. Volume control, Vt 500 mL, PEEP 5. Fentanyl 250 mcg and hydromorphone 1.5 mg in total, the last hydromorphone dose (0.5 mg) during closure. Acetaminophen 1 g IV, dexamethasone 4 mg after induction, ondansetron 4 mg at closure; surgeon infiltrated the port sites with bupivacaine. Surgical time 100 minutes. At closure, TOF count 2 of 4 by visual assessment at the ulnar nerve; neostigmine 4 mg with glycopyrrolate 0.8 mg given. Extubated awake 10 minutes later after a sustained 5-second head lift.

PACU ARRIVALDrowsy but rousable to voice, snoring. Face mask at 6 L/min. HR 92, BP 148/86, RR 10, SpO2 93%, T 36.4 C. Pain 3/10 when roused.

LABSPre-op: Hgb 13.8 g/dL, creatinine 0.9 mg/dL, K 4.1 mEq/L, glucose 168 mg/dL.

Opioid-naive patient with uncontrolled pain on IV PCA after open hemicolectomy

Multiple rib fractures with flail chest and failing pulmonary mechanics

Thoracic epidural not working after open pancreaticoduodenectomy

Aortic valve replacement for bicuspid valve with chronic severe aortic regurgitation

Surgical aortic valve replacement for severe aortic stenosis

Urgent CABG for left main / three-vessel disease with failure to separate from bypass

Cardiogenic shock and mechanical circulatory support after a large anterior MI

Mitral valve repair for severe degenerative mitral regurgitation

Mitral valve replacement for severe rheumatic mitral stenosis

Post-CPB coagulopathy and massive transfusion after redo aortic root/ascending replacement under DHCA

Elective on-pump CABG for multivessel CAD

Open repair of acute Stanford Type A aortic dissection

Pacemaker-dependent ICD patient for noncardiac surgery with EMI

High-dose oxycodone patient for open ventral hernia repair

Lumbar radiculopathy on apixaban, referred for epidural steroid injection

Small bowel obstruction, volume depleted, for urgent exploratory laparotomy

Laparoscopic cholecystectomy in a morbidly obese patient with reflux and a suspected sleep disorder

Myasthenia gravis for abdominal hysterectomy

Adult polytrauma with TBI for emergent craniotomy

Cervical myelopathy for posterior fusion with neuromonitoring

Isolated severe TBI, epidural hematoma for emergent craniotomy

Posterior fossa tumor in the sitting position

Aneurysmal SAH for craniotomy and clipping

Transsphenoidal pituitary resection in acromegaly with a spinal cord stimulator

Awake craniotomy for eloquent-cortex glioma

Chronic subdural hematoma for burr-hole evacuation (foundational)

Elective supratentorial tumor craniotomy (foundational)

Morbid obesity, OSA, prior failed neuraxial, repeat cesarean with placenta accreta

Severe rheumatic mitral stenosis with new AF, planned cesarean

Postpartum hemorrhage after vaginal delivery with a labor epidural in place

32-week parturient after MVC with hemorrhagic shock and fetal distress

Idiopathic pulmonary arterial hypertension in active labor at term

RUQ pain and abnormal labs in the third trimester (HELLP with hepatic rupture)

Severe preeclampsia with thrombocytopenia and morbid obesity, emergent cesarean

Stat cesarean in laboring parturient with epidural, conversion to general

Opioid use disorder on buprenorphine in labor

Active asthma flare in labor at term

Sickle cell disease in active labor after recent vaso-occlusive crisis

Elective cardioversion of atrial fibrillation with LVEF 30%

Urgent ERCP under propofol sedation in a patient with severe OSA and obesity

Fistulogram under MAC in a dialysis patient with stable angina and limited revascularization options

Hip fracture on apixaban in an older woman with mild cognitive impairment

Elective total hip arthroplasty under spinal in an obese hypertensive man with suspected OSA

PACU agitated emergence, PONV, and hypotension after laparoscopic hysterectomy

Hypoxemia in PACU after laparoscopic sleeve gastrectomy in a patient with severe OSA

Inguinal hernia repair in the ex-premature infant with postoperative apnea risk

Tonsillectomy and adenoidectomy in an obese 4 y.o. with severe OSA

Toddler with a current URI for bilateral myringotomy and tubes

Total shoulder arthroplasty with severe COPD in the beach chair

Ankle ORIF with popliteal sciatic and saphenous blocks in a diabetic with neuropathy and OSA

Supraclavicular block for distal radius ORIF in an anxious outpatient with mild asthma

Total knee arthroplasty with anticoagulation and aortic stenosis

SICU postop perforated diverticulitis (Hartmann's), septic shock

Postoperative hypoxemic respiratory failure from hospital-onset aspiration pneumonia after hip hemiarthroplasty

Cervical mediastinoscopy and biopsy of a large anterior mediastinal mass

Right upper lobectomy with one-lung ventilation in severe COPD

Off-site navigational bronchoscopy and transbronchial biopsy in COPD

Right pneumonectomy with borderline pulmonary function and coronary disease

Tracheal resection and reconstruction for post-intubation stenosis

VATS wedge resection in an active smoker with a known difficult airway

Healthy young adult for urgent laparoscopic appendectomy

Unexpected difficult mask ventilation after induction in a bearded man for outpatient hernia repair

Symptomatic carotid stenosis with coronary disease for carotid endarterectomy

Open infrarenal AAA repair with aortic cross-clamp physiology in a high-risk vasculopath

Femoral-popliteal bypass in a diabetic with a recent coronary stent and CKD

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