2. Case 1
57 year old female with history of HTN and OA is
POD#0 s/p THR. CSE placed in OR. Spinal is
wearing off on the floor and you are asked to see
the patient.
Would you bolus the patient?
With what? How much? What are the toxic doses?
What is the onset time of various LA? What is the
MOA? Site of action?
What are your concerns regarding administration of
epidural medications?
What are your concerns regarding administration of
meds via the catheter?
What are s/sx of LA toxicity? Neural/Cardiac. Which
appears first?
3. Case 2
• 67 year male history of HTN, DM, smoker is
POD#2 s/p R-VATS. Patient is on 7W stepdown.
• What is the standard starting PCEA (patient controlled
epidural analgesia) infusion at this institution? What is the
hourly dose of local anesthetic? Of opioid?
• Patient has been stable on an infusion of 6/2/20 since his
surgery and has excellent pain control and HD stability
• The thoracic PA calls you and demands you stop
the epidural infusion immediately as patient’s
blood pressure is 80/40. What do you do?
4. Case 3
29 year old 214kg 4’11” female is POD#1 s/p Bowel
resection. She is complaining of abdominal pain in
the PACU.
How much medication should she get? PCA? Dose?
What is Pickwickian Syndrome (OHS)?
How do opioids cause respiratory depression?
She is found obtunded and non-responsive on 8W.
Oxygen is flowing via NRB mask at 10L/min and
her sat is 98%. Is this really an emergency?
What would you do?
If patient this patient’s pCO2 is 80. What is her pH
(assume starting 7.37)? What is her K+ (starting
5.3)?
5. Case 4
74 year old female is POD#3 s/p TKR. The
ortho PA calls you to remove her epidural
catheter.
What do you want to know before removing the catheter?
Patient received coumadin 5mg po last night. Do you want to
check coagulation studies?
Patient has been on heparin 5000U SC Q12 hours for 4 days.
Do you want to check any labs? Why?
Would you wait to remove the catheter if the patient was on
heparin 5000U SC Q8h and just received a dose?
How long? What about for therapeutic LMWH? Prophylactic
LMWH? Aspirin? Ibuprofen? Clopidogrel?
Next day you notice patient also has a femoral catheter. Her
INR is 1.8. Can you remove it?
6. Case 5
What are you thinking?
34 year old POD#1 s/p T12-L5 PLIF. Pain
was well controlled POD#1, but now you
are called as patient has severe pain.
What if this was POD#4?
What would you do?
7. Case 6
67 year old male POD#1 s/p TKR under spinal
anesthesia/MAC. Femoral catheter in place. Nurse
calls you to let you know that patient’s foot is
numb, but he still has pain in posterior aspect of
his knee.
Describe the innervation of the lower
extremity.
Innervation of the knee?
