You are just out of residency. Today you are scheduled to do a laparoscopic tubal ligation. The patient is a 28-yr-old diabetic with an insulin pump placed. She had a baby boy 2 wk earlier and now wishes to have her tubes tied. Otherwise, she is healthy, weighs 118 kg, and is 5′6″. You meet the patient for the first time in the preoperative area and discover to your dismay that the insulin pump is on. She has been fasting since the night before. You check the blood sugar and find it is 25 mg%. By now you have a working IV and you are infusing 50 ml of 50% dextrose. An epidural for her delivery had been a great success, and she wonders if she can have the same again. You explain to her that because the surgeon will be distending her peritoneal cavity with gas and tilting her head down it will be difficult for her to breath. She will also get a “referred pain” to her shoulder, which could be very bad and which an epidural would not prevent. The surgeon does not want to do a local with some sedation, and he leaves you with two options: either a general anesthetic or an epidural/spinal
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