A case study is a written analysis of an actual clinical phenomenon or problem. This assignment involves a discussion of the related topic and should include citing research and background information supporting the issue. The analysis should also include possible solutions or how the issue was resolved. The purpose of the clinical case study is to complement didactic information and present actual patient encounters. Please follow the following guidelines. 1. Maximum of 10 pages, double – spaced, including references/ bibliography. 2. Bibliography should include current literature (within the past 5 years) as well as textbooks on anesthesia practice and should follow APA format. Master of Science Program in Anesthesiology SRNA: Date: JUNE 22, 2016 Pre-op Diagnosis: LT ureteral stone Planned Surgical Procedure: Cystoscopy: ureteroscopy, laser litherotripsy and stent placement to left side Patient Demographics Age: 62 HT: 160cm WT: 95kg BMI: 37 Gender: F NPO since: MN 9hrs Allergies: Tramadol Airway Assessment Mallampati Class: 2; soft palate, faces, portion of uvula Neck Movement: (FULL ROM) Mouth Opening: >3 Finger-breadth Dentition: 2 lower loose teeth Thyromental Distance: >3 Finger-breadth ASA Class: 2; able to see pillars and soft palate, only part of uvula METS: <4 slow walking (2mph) Review of Systems RESP: B/L breath sounds clear on auscultation CV: SR on cardiac monitor, no mummers heard. S1/ S2 CNS: AAOX4 HEP/RENAL: Kindey stone ENDOCRINE: (—) GI: (—) OTHER: Rt breast cancer HISTORY: Medical/Surgical: Rt breast Lumpectomy Anesthetic: GETA Social: patient denies Family: No family history with problems with anesthesia Medications / Dosage / Classification Anesthetic Implications 1. Hyzaar 100/12.5; Antihypertensive; angiotensin II receptor antagonists combined with a thiazide diuretic 2. Baby aspirin; antipyretics; nonopioid analgesics; salicylates 3. omeprazole; antiulcer agents; proton pump inhibitors 4. Pyridium; nonopioid analgesics; urinary tract analgesics 1. losartan 100 mg; given alone or with other agents in the management of hypertension. Treatment of diabetic nephropathy in patients with type 2 diabetes. Prevention of stroke in patients with hypertension and left ventricular hypertrophy. hydrochlorothiazide 12.5 mg; Increases excretion of sodium and water by inhibiting sodium reabsorption in the distal tubule. Promotes excretion of chloride, potassium, hydrogen, magnesium, phosphate, calcium and bicarbonate. May produce arteriolar dilation. 2. Produce analgesia and reduce inflammation and fever by inhibiting the production of prostaglandins. Decreases platelet aggregation. Reduction of inflammation. Reduction of fever. Decreased incidence of transient ischemic attacks and MI. 3. Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumen. 4. Acts locally on the urinary tract mucosa to produce analgesic .

1. A case study is a written analysis of an actual clinical
phenomenon or problem. This assignment involves a discussion
of the related topic and should include citing research and
background information supporting the issue. The analysis
should also include possible solutions or how the issue was
resolved.
The purpose of the clinical case study is to complement didactic
information and present actual patient encounters. Please follow
the following guidelines. 1. Maximum of 10 pages, double –
spaced, including references/ bibliography. 2. Bibliography
should include current literature (within the past 5 years) as
well as textbooks on anesthesia practice and should follow APA
format.
Master of Science Program in Anesthesiology
SRNA: Date: JUNE 22, 2016
Pre-op Diagnosis: LT ureteral stone
Planned Surgical Procedure: Cystoscopy: ureteroscopy, laser
litherotripsy and stent placement to left side
Patient Demographics
Age: 62
HT: 160cm
WT: 95kg
BMI: 37
Gender: F

2. NPO since: MN 9hrs
Allergies: Tramadol
Airway Assessment
Mallampati Class: 2; soft palate, faces, portion of uvula
Neck Movement: (FULL ROM)
Mouth Opening: >3 Finger-breadth
Dentition: 2 lower loose teeth
Thyromental Distance: >3 Finger-breadth
ASA Class: 2; able to see pillars and soft palate, only part of
uvula
METS: <4 slow walking (2mph)
Review of Systems
RESP: B/L breath sounds clear on auscultation
CV: SR on cardiac monitor, no mummers heard. S1/ S2
CNS: AAOX4
HEP/RENAL: Kindey stone
ENDOCRINE: (—)
GI: (—)
OTHER: Rt breast cancer
HISTORY:
Medical/Surgical: Rt breast Lumpectomy
Anesthetic: GETA
Social: patient denies
Family: No family history with problems with anesthesia
Medications / Dosage / Classification
Anesthetic Implications
1. Hyzaar 100/12.5; Antihypertensive; angiotensin II receptor
antagonists combined with a thiazide diuretic
2. Baby aspirin; antipyretics; nonopioid analgesics; salicylates
3. omeprazole; antiulcer agents; proton pump inhibitors
4. Pyridium; nonopioid analgesics; urinary tract analgesics
1. losartan 100 mg; given alone or with other agents in the
management of hypertension. Treatment of diabetic nephropathy

3. in patients with type 2 diabetes. Prevention of stroke in patients
with hypertension and left ventricular hypertrophy.
hydrochlorothiazide 12.5 mg; Increases excretion of sodium and
water by inhibiting sodium reabsorption in the distal tubule.
Promotes excretion of chloride, potassium, hydrogen,
magnesium, phosphate, calcium and bicarbonate. May produce
arteriolar dilation.
2. Produce analgesia and reduce inflammation and fever by
inhibiting the production of prostaglandins. Decreases platelet
aggregation.
Reduction of inflammation. Reduction of fever. Decreased
incidence of transient ischemic attacks and MI.
3. Binds to an enzyme on gastric parietal cells in the presence
of acidic gastric pH, preventing the final transport of hydrogen
ions into the gastric lumen.
4. Acts locally on the urinary tract mucosa to produce analgesic
or local anesthetic effects. Has no antimicrobial activity.
Diminished urinary tract discomfort.
Anesthetic Implications
Surgical Procedure Description: The surgeon passes a small
lighted tube (ureteroscope), through the urethra and bladder and
into the ureter to the point where the stone is located. If the
stone is small, it may be snared with a basket device and
removed whole from the ureter. If the stone is large and/or if
the diameter of the ureter is narrow, the stone will need to be
fragmented, which is usually accomplished with a laser. Once
the stone is broken into tiny pieces, these pieces are usually
removed from the ureter. In most cases, to ensure that the
kidney drains urine well after surgery, a ureteral stent is left in
place. Ureteroscopy can also be performed for stones located
within the kidney. Similar to ureteral stones, kidney stones can
be fragmented and removed with baskets. Occasionally, a
kidney stone will fragment with a laser into very small pieces
(grains of sand), too small to be basketed. The urologist will
usually leave a stent and allow these pieces to clear by
themselves over time. Lastly, if the ureter is too small to

4. advance the ureteroscope, the urologist will usually leave a
stent, allowing the ureter to “dilate” around the stent, and
reschedule the procedure for 2-3 weeks later. Ureteroscopy is
usually performed as an outpatient procedure. Some patients,
however, may require an overnight hospital stay if the
procedure proves lengthy or difficult.
Anesthetic Plan
Rationale
1. Technique: General ETT with muscle relaxer
This procedure is done using a laser which requires no
movement, If the patient cough the unexpected movement could
cause dire consequences.
2. Alternative Plan: Spinal, blocking up to T9-T10
This procedure can be done with spinal anesthesia but its not
preferred because the medication could wear off before the
surgery and case the patient to move.
Monitoring and Special Equipment: Spontaneous ventilation,
Negative inspiratory force > 20 cmH2O, Vital capacity > 15
ml/kg, Regular respiratory pattern, Paralytics reversed, Equal
grip strength, head lift > 5 sec, Awake and responsive with
stable VS
Meeting extubation criteria provides protection of airway,
prevention of obstruction/bronchospasm/laryngospasm.
Surgical Positioning: Lithotomy
Anesthetic Implications:
Patient is supine with arms extended laterally <90 degrees. Each
lower extremity is flexed at the hip (about 90 degrees) and
knees bent parallel to the floor. Extremities should be elevated
and lowered slowly and together. Seen most often in GYN and
Urology cases. Hip flexion >90 degrees can increase stretch of
the inguinal ligaments.
Complications: Can impair ventilation due to upward pressure;
more prominent in obese pt’s. Nerve injuries! Most common
problem with lithotomy Injuries: Sciatic, common peroneal,
femoral, saphenous and obturator. Common peroneal nerve

5. damage occurs from compression of lateral aspect of fibula head
(improper padding against stirrups) Avoids stretching of one
side of the nerve > 4 hrs in lithotomy increases risk of injury.
Ischemia, edema to skin and muscles.
Pharmacologic Intervention
Rationale
Pre-Operative Medication:
1. Midazolam 2mg IV
2. Benadryl 12.5mg IV
3. Zofran 4mg IV
1. Benzodiazepine. Enhances inhibitory effects of GABA.
Produces sedation & anterograde amnesia.
2. Antihistamine. H1 receptor antagonist. Antiemetic and
produces sedation.
3. Selective 5-HT3 receptor antagonist in GI tract &
chemoreceptor trigger zone. A preventative
& rescue treatment for N/V
Induction:
1. Fentanyl
2. Lidocaine
3. Propofol
4. sux
1. Opioid agonist. Blunts the SNS response while intubation
plus provide analgesia. Binds to intracellular Na channel and
stops depolarization.
2. Blunts the SNS response & used to decrease burning feeling
cause by propofol.
3. Enhances inhibitory effects of GABA. Produces sedation. Has
antiemetic & antipuretic affects.
4. We used succinylcholine (depolarizing muscle blocker) to
produce skeletal muscle paralysis after induction, this allowed
us to intubate the patient. We didn’t use roc because this is an
obese pt and we need something that will work fast because her
FRC might decrease

6. Maintenance and Other Pharmacologic Intervention:
Sevo
Volatile anesthetic used for maintenance of anesthesia. It can
cause Compound A which leads to renal failure, to stop this
from happening before removing the tube we ran 2L/min to
minimize production of Compound A.
Emergence:
Regular spontaneous respiratory pattern, Paralytics reversed,
Equal grip strength, head lift > 5 sec, Awake and responsive
with stable VS, TV >4ml/kg
Meeting extubation criteria provides protection of airway,
prevention of obstructions such as laryngospasm.
Fluid Management
FLUIDS
1ST HOUR
2ND HOUR
3RD HOUR
Deficit: 1080 mL
540mL
270mL
270mL
Maintenance: 135mL/hr
135mL
135mL
135mL
3RD Space: 3mL/hr
285mL
285mL
285mL
TOTAL
960ml
690ml
690ml
EBV: 6175
65ml/kg X 95kg
ABL: 6175 (37-30)

7. ————————————— = 1,168ml
37
Actual Blood Loss: 50ml
Anesthetic Implications / Problems / Concerns
Potential or Actual Problem
Proposed or Actual Intervention
1. Chemotherapy
2. Radiation
3. Possible movement during procedure/laser
4. HTN
5. Kidney stone
1. Indications for Laboratory Testing: H&H. Before surgery the
CRNA need to evaluate when was the last dose of
Chemotherapy given because chemotherapy cause massive cell
lysis; which can cause hyperphosphatemia and hyperkalemia.
Labs need to be drawn and the CRNA need to pay close
attention to K and phos. Hyperphosphatemia is thought to lower
plasma calcium by precipitation and deposition of calcium
phosphate in bone and soft tissues. Hyperkalemia need to be
assessed because succinylcholine administration can further
exaggerate K level, plus elevated K can cause
bradydysrhythmias
2. Indications for Laboratory Testing: H&H.
3. Patient’s eyes was protected with appropriate colored glasses
and/or wet gauze. We used the lowest concentration of oxygen
possible; plus, we did not using nitrous oxide (N2O), because it
supports combustion. This procedure was done using a laser
which requires no movement, not even coughing.
4. Optimize hydration status with replacement of fluid deficit.
Identify potentially reversible causes of hypertension: pain,
anxiety, hypothermia, bladder distention, lack of anesthesia.
Maintain patient within 20% of baseline blood pressure. Poorly
controlled hypertensive patient will need higher pressures to
maintain adequate cerebral perfusion (autoregulation curve
shifts to the right). Treatment of hypertension with adrenergic

8. antagonists.
5. The kidney stone cause the patient to be in pain 10/10 on
pain scale preoperatively which required her to receive pain
meds by the PACU RN so she was came to us in a mild euphoric
state.
Clinical
Faculty:______________________________________________
_________ Date:_______________
Feedback:____________________________________________
_____________________________________________________
_____________________________________________________
____________________________.
Laboratory Findings
EKG: NSR
CXR: (—)
Other: EF 60%
Hgb 12 Ptt 26
Hct 37 Pt 13
WBC 7 INR 1.1

9. Platelet 225 BUN 20
K 4.6 Creatinine 1.1
Na 142 Glucose 105