Case of the Month

Prepared by: Douglas B. Coursin, MD

Critical Care Anesthesiology Case Report

History: A 56-year-old female with longstanding severe rheumatoid arthritis presented with hypotension, hypothermia, confusion, and purulent drainage coming from a four-month-old wound at the base of her occiput where she'd undergone a fusion for atlanto–occipital subluxation. The patient was on chronic prednisone 5 mg a day alternating with 10 mg a day, Cytoxan q.d., and Vioxx q.d. She had a h/o multiple orthopedic procedures including bilateral hip and knee replacements, multiple cervical spinal fusions and other joint fusions.

Physical exam revealed a thin, chronically ill appearing female oriented intermittently to person, not time or place. Blood pressure was 80-85/60, pulse 126 and regular, respirations — 16, temperature 95° F (35°). Purulent drainage present at the base of her occiput and a loose screw was expressed through the wound. Neurological exam - symmetrical and nonfocal. Neck - limited range of motion, negative Kernig's sign. Lungs – bilateral coarse rales at the bases with decreased lung excursion. Cardiac – grade 1-2/6 soft systolic murmur along the left sternal border.

Labs: Anemic, hematocrit of 29, leukopenic, white count of 3000 with severe lymphopenia, and thrombocytopenic, platelet count of 106,000. Electrolytes – normal, creatinine elevated at 1.5, BUN elevated at 33, and albumin 2.5. INR elevated at 1.6, elevated fibrinogen of 400 and a negative D-dimer. CXR – bibasilar atelectasis. ECG – sinus tachycardia. AP and lateral of the cervical spine – loosening of multiple screws on the two plates from the occiput to C-2 and a soft tissue mass. Gram stain of the wound – scattered PMNs and multiple gram-positive cocci in clusters.

Assessment and Course:

What do you see as her problem list, issues, and priorities?
These were ours:

How would you initiate care and what monitoring would you initiate?
Here is what we did:

How would you proceed and induce and maintain anesthesia?
Here is how we proceeded:

Would you perform an LP with an INR of 1.6?
Here is what we did:

What would you do at the end of the case?
Here's what we did:

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