laparotomy severe aortic stenosis what do you do for the induction so this is a case of an elderly
patient that requires um uh an anesthetically safe uh sorry a cardiovascularly safe um uh induction
um uh this particular cardiovascular goals that i need to achieve in terms of preload afterload and
contractility to best achieve these goals i'd be um providing them with a large dose of fentanyl
judicious doses of propofol and then my relaxant of choice depending on also this is an emergency
case so um in this case um uh salsa methodium as well yeah that sounds good so what you
rightly what i believe you did really well there is to just state your goals up front so sometimes
when you have you know i guess an approach that has many many different opinions it's it's far
easier just to say what your goals are and then just go through it so i guess the point of this
priorities talk is when you start with your goals or priorities then the specifics matter a lot less
every different aenesis will have a different way of doing every different induction right
and aortic stenosis for me will be different induction for me than for you the things you said
there very correctly was i probably you know i've made this very detailed and you may not need to go
into that detail so just to appreciate that i'm just trying to i guess be thorough with my goals
but this is such a common induction for people that it would be you know to say something like
you know my goal induction is to you know maintain a full preload and a high high afterload maintain
chronic perfusion that's probably probably pretty reasonable but specifically i do look
at my preload full maintain sinus rhythm low normal heart rate and normal contractility and
high afterload and then to do this i would use a high dose of fentanyl small dose midas or profile
and sucks methodium with metaraminol running and an outline but really those are the key
factors you know you to imagine imagine mentioning everything about your setup the fact that you'd
have full monitoring and an assistant and even at the start you said these um you said the words
of saying uh i would do i mean maybe something along the lines of this is a high-risk condition
i'll do a cardiovascularly safe induction and that's fair to say if you especially if you
move on quickly to say what that means which you know which you did so someone who says i want to
do something that's hemodynamically stable shows nothing of their knowledge of what the
human diet goals are and how they approach it and to just say the word humanically stable is
doesn't seem very much like it will attract any marks so it's good that you moved on
to talk about your priorities and then finally the medications that you give i just want to specify
as well that you may something might be so common and so regular that you may not even need to do
this you'd say look this is a this is a high-risk induction i'd use you know an art line aramin
running prep foal lots of fentanyl and continue what was what was um a big deal in the past
becomes very normal and well known and talked about and more of a cliche as time goes on
so i just want you to appreciate that as well let's talk about this so not thinking about
the induction we're just thinking about the general interop plan a six year old male for
a carotid endotherectomy what is your introvert plan so again i want you to pick out the goals
that are specific to this case aside from every other general anesthetic or major surgery my goals
would be to maintain total confusion um especially during clamping whilst avoiding avoiding
hypertension because of risk of bleeding and also to maintain inability for surgical conditions
yeah sounds good i like that you mentioned a few so instead of mentioning specifically humanoid
stability the fact that you've mentioned cerebral perfusion probably is the most relevant part of
hemodynamic stability the the fact that this case has clamping is very specific to this case and
you know everything i do around this case is to manage the periphery period around clamping you
know raising the blood pressure at clamp and then decreasing it back to normal after clamp but i
also do the particular things in this case i think we all do to achieve rapid emergence you might you
know use a local anesthetic technique with very minimal other opioids and you know you might run
remy you essentially want a rapid emergence so the surgeon can assess neurological function
i also think if this question was then extended to the perioperative period we know that these
cases have a higher risk of mi and stroke so i might want to just say that those are my
priorities so depending on the situation in your question i try to think about what would make what
would make this scenario so different to every other scenario because again that's a point of
difference that's what that's what's examinable uh you're called to see a russian aaa that just
arrived