Case 6: Just a Simple Monitored Anesthesia Care (MAC) Case
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It is at the end of a long day in the OR. You are scheduled to do an emergency BROVIAC® catheter placement under MAC. The scheduler promises you that this is your last case of the day. The patient is an 83-year-old female, who has been in the hospital for 3 days for a work-up of her severe aortic stenosis for a possible aortic valve replacement. During the work-up, she has developed acute renal failure, and hence the BROVIAC® catheter placement. The patient is admitted to the OR from the ICU and her consent is signed by her son. Neither he nor any other relative is available prior to surgery. You meet the patient outside your operating room and the surgeon is anxious to get going. You say that you would like to speak to the patient and examine her. The patient is partially orientated for time and place. She says she understands that she needs the BROVIAC® catheter for a “problem with her kidneys.” She is a small lady, weighing 59 kg and 5’6” tall. She has edema of her legs and sacrum. Her vital signs are HR 110 regular with a BP of 130/90. Room air oxygen saturation is 91%. The patient is receiving 10 l/min oxygen via a face mask. Chest auscultation reveals decreased air entry at both bases with crepitations and rales all over her chest. She has shallow breathing at a rate of 34. Her neck veins are distended. You diagnose congestive cardiac failure, and the surgeon concurs with your assessment but wishes to proceed. You elect not to give her any sedation or narcotics except for more furosemide 40 mg IV. The patient is placed on the operating table, and you reassure her and place noninvasive monitors. An oxygen mask is placed with a strap on her head and 8 l of oxygen is provided. The surgeon injects 20 ml of lidocaine 1% into the surgical site. The junior intern has several attempts at finding the left subclavian vein. Suddenly there is a major drop in the end-tidal CO2 from 38 mm Hg to 15 mm Hg, and oxygen saturation falls to 83%. You diagnose a pneumothorax and provide mask ventilation with 100% oxygen. The patient’s saturation goes up to 94%, the highest it has been since you took over her care. You are about to intubate the patient’s trachea when the circulating nurse shouts: “The patient is a DNR/DNI (do not resuscitate/do not intubate).” You elect not to intubate the patient but to treat her pneumothorax with an emergency chest drain. With the help of the nurse, you assemble the drain in less than a minute . With a functioning chest drain and more furosemide, the patient almost returns to her baseline over a period of 10–20 min. The surgeon aborts the catheter placement, and the patient is taken back to the ICU. Unfortunately, she dies within 2 h of arriving in the ICU without any heroic attempts to save her life as per her DNR/DNI.