Case 40: Check Your Facts

Abstract

You are just out of residency and have joined your first anesthesia practice group. This evening you are on fourth call. There is nothing for you to do, so you are told to leave. Just then an emergency laparotomy is booked. The patient is a morbidly obese patient (BMI 34) with an acute abdomen. She is 4 days out following a gastric bypass procedure. You offer to help and the first call accepts your offer. The patient arrives within 5–10 min in the operating room. She complains of severe abdominal pain. Her respiratory rate is over 40 and shallow. Her heart rate is 130 sinus tachycardia, with a blood pressure of 100/60. She has a cold periphery and her oxygen saturation is 91% on room air. The patient is placed on the operating table with a ramp as previously described [1] to improve your view on laryngoscopy. Preoxygenation and a rapid sequence induction commence. You provide cricoid pressure. The anesthesia induction drugs are given by your colleague. It appears to you that your colleague is using fentanyl, etomidate, and rocuronium, in that order, for anesthetic induction. You see no fasciculation. Your colleague performs the laryngoscopy and tells you that he has a grade 1 view. The endotracheal tube is seen to pass between the cords and bilateral air entry is heard. An obstructive end-tidal CO₂ pattern is seen. For general anesthesia maintenance, isoflurane is added to the oxygen. At this point, your colleague is called urgently to another room where there is a code blue. You say you will stay and look after this case. He leaves in a hurry. You place the patient on the ventilator and the vital signs, including the respiratory parameters, are stable. However, the heart rate is still 130 sinus tachycardia. You start getting ready to place an internal jugular vein line, but the oxygen saturation is seen to fall to 88% from 98%. The airway pressure has risen from 40 to 56 cm H₂O. You start to ventilate the patient manually and notice that it is very difficult to do so. It is now 5–6 min since the anesthetic induction. The airway pressures continue to be high but the saturation is improving. You listen to the chest and confirm bilateral, equal air entry. You pass a suction catheter down the whole length of the endotracheal tube without any problem. Sucking on the catheter yields no secretion. Since the oxygen saturation is improving, you place the patient back on the ventilator. Unfortunately, the peak pressures are still high (58 cm H₂O), and the oxygenation saturation starts to fall again. The patient is not moving and the pupils are pinpoint. You are at a loss as to what to do next. You can feel the pressure mounting in the room, as everyone is looking at you and wondering what is the “new boy” going to do? So what will you do?