Case 39: Central Venous Access and the Obese Patient

Abstract

You are scheduled to anesthetize a 54-year-old 160 kg, 183 cm tall (BMI = 47.8 kg/m², ASA 3) man with vasospasm for cerebral angiography. He had been admitted to the ICU 3 days earlier, following an emergency craniotomy for a subarachnoid hemorrhage. When you meet him in the radiology suite, he responds sluggishly to verbal commands but reacts to pain. His heart rate is regular at 66 beats per minute and the blood pressure is 160/90. The neurosurgeon is happy with that pressure. An endotracheal tube had been removed 12 h previously. He is breathing spontaneously on an oxygen mask, providing 2 liters of oxygen per min. His vital signs are within normal limits. His only IV access is a triple lumen right subclavian venous catheter (16 cm long) (Arrowgard Blue Plus Multi-lumen CVC, Arrow International, Inc. Reading, PA 19605). This had been inserted at the time of the original operation. Through the proximal lumen of this catheter IV, propofol 100 mcg/kg/min is being infused for sedation. Via the medial lumen, neo-synephrine 200 mcg/kg/min is given for pressure support. Maintenance fluid is given through the distal port. You review the previous anesthesia team’s note in their anesthesia record. They report no problem with airway management. Despite that, you make sure you have a fiber-optic cart, bougie, etc. available. You check the anesthetic machine and make sure your anesthesia equipment and all your anesthesia drugs are ready. You call for a colleague to come and give cricoid pressure. He arrives and you look set to start the anesthetic.