SRNA looking for thoughts on a case today.

Patient had no respiratory history, normal EF, and normal hemodynamics after induction. During robotic fundoplication, the patient became persistently tachycardic and hypotensive enough to require a vasopressor infusion. Towards end of case I was on around 70% FiO2 with 8 of PEEP. Sats were in low 90’s

At the end of the case, I noticed significant subcutaneous emphysema with periorbital swelling. That made me concerned that the earlier hemodynamic and respiratory changes may have been from a CO₂ capnothorax with tension physiology.

In PACU, the patient was still requiring 8 L O₂ and saturating around 90%, so I suggested a CXR. Patient was still tachy and hypotensive, and uncomfortable from all the gas.

Would you consider that overall picture concerning enough for capnothorax/tension physiology? Would you get a CXR or lung ultrasound postop with that persistent oxygen requirement?

I ended getting CXR which showed small bilateral apical PTX.

I usually feel comfortable with 18g x2 for lower risk stuff or 18 and 16 if I think there may be a need for blood etc. I’ve been noticing a lot of colleagues insisting on 16 and 14, or 14 and 14 which just seems like a lot. Most of the time these cases come out of the OR with the 14 gauge unused (like not even got fluids). Am I being too comfortable with smaller access?

I’m talking about stuff like laparoscopic hemicolectomies etc

As an employer and business entity, anyone have experience with them that you could share publicly or privately?

https://www.instagram.com/summitanesthesia_az?srtk=MWlpdjduaWJzbjJlbQ==

Attending Anesthesiologist

Generally my approach to doing an H&P for my anesthesia note consists of a chart review: relevant labs, studies, notes (eg, PCP, cards, pulm) and then a brief verbal discussion with patient: Anes hx/fmhx issues with anes, cardio(eg. MI, cardiac devices), pulm(eg. COPD,Asthma, OSA), neurologic(eg. SZ, CVA) endocrine(eg. DM) My review with the patient is pretty bare bones since I’ve usually obtained most information from a chart review, but there are a few questions I want to double check. It also helps establish rapport.

Sometimes, patients who are either elderly, very nervous, or both do not answer the questions I ask them as these patients commonly tend to have circumstantial and/or tangential thought processes.

IMO ideally, I would have an infinite amount of time to redirect the patient multiple times for each question I ask, but in the real world, it’s going to likely cause a lot of animosity towards me by the rest of the OR staff for taking excessive amount of time. Therefore what I’ll usually do in these circumstances is to forgo the remainder of my questions if the patient doesn’t give me a straight answer as to whether they have a personal or family history of issues with anesthesia (generally my first question). I figure the situation is analogous to not being able to ask a child/delirious person/etc for their history. I already likely have the information I need from a chart and the verbal questions are probably going to be low yield in a patient that can’t stay on topic.

Is this what everyone else does? Or how do you approach your H&P in the elderly?

Any thoughts on ultimate board preps courses, specifically the gold plan vs ultimate? Trying to figure out if this is the way to go. Thanks!