Systemic sclerosis for finger debridement under block48-year-old woman, 58 kg, for elective debridement of ulcers on two fingers

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A 48-year-old with diffuse systemic sclerosis, lung fibrosis and pulmonary hypertension, for elective finger debridement. Patient
   • I go through her systems: skin, gut, lungs, heart and kidneys. Disease
   • Her 2.5 cm mouth, stiff jaw and limited neck make any intubation difficult. Airway
   • Her lung fibrosis and pulmonary hypertension carry most of her risk; her right ventricle is fragile. Disease
   • Reflux with a weak lower oesophageal sphincter makes her an aspiration risk.
   • Thick skin and Raynaud's will make her venous and arterial access hard.

2. Prepare

   How will you assess her?

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   • Echo for her pulmonary pressure and right ventricular function. Disease
   • Lung function and gas exchange; a low diffusion capacity shortens her oxygen reserve.
   • Creatinine and BP for renal crisis: hypertension, retinopathy and falling renal function.
   • Mouth opening, jaw and neck movement measured, and the airway plan agreed now. Airway
   • Omeprazole continues; her mycophenolate is reviewed for side effects. Disease
   • Ultrasound ready for her cannula, since her skin hides the veins.

3. Plan

   What anaesthetic will you give her?

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   • Ultrasound-guided infraclavicular block for her fingers; it rarely blocks her phrenic nerve and spares her airway. Disease
   • The block also dilates her finger vessels and covers her pain afterwards. Surgery
   • It may last longer than usual, because poor perfusion slows local anaesthetic clearance. Disease
   • Warm theatre, warmed fluids and active warming, since cold constricts her vessels.
   • Light sedation only; hypoxia or hypercarbia would push up her pulmonary pressure.
   • If general anaesthesia is needed, awake fibreoptic intubation, the standard for her predicted difficult airway. Airway
   • No dexamethasone for nausea; high-dose steroid can trigger renal crisis. Disease

4. Crisis

   At incision she has sharp pain in two fingers; the block is incomplete. What do you do?

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   • I pause the surgeon rather than chase the gap with deep sedation. Crisis
   • A rescue block of the missed nerve, keeping her total local anaesthetic within the maximum.
   • If general anaesthesia is unavoidable, acid prophylaxis and long preoxygenation first.
   • Then awake fibreoptic intubation; never an asleep rapid sequence through her fixed small mouth. Airway
   • Lung-protective ventilation: small breaths, modest PEEP, and no hypercarbia to load her right ventricle. Crisis

5. Crisis

   After intubation, SpO2 is 85%, BP 78/50, HR 120, and echo shows a dilated right ventricle. What do you do?

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   • Acute right heart failure: low pressure and RV ischaemia feed each other. Crisis
   • 100% oxygen; correct hypercarbia and acidosis, and keep PEEP modest.
   • Raise her systemic pressure now: vasopressin 0.01–0.05 units/min, or noradrenaline 0.1–1 mcg/kg/min.
   • Inhaled nitric oxide 10–40 ppm to unload her right ventricle.
   • Milrinone 0.3–0.7 mcg/kg/min if contractility stays poor, under pressor cover.
   • No fluid boluses into her dilated ventricle; ICU afterwards with invasive monitoring. After surgery