Case Study – Anesthetic Drugs

by Pravin Shukle, MD

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    00:01 Let's do a question. Heating up the OR. A 42-year-old woman is undergoing a D&C for fibroids.

    00:08 She is under general anesthesia with propofol and halothene. Her heart rate climbs to 145 beats per minute, and her temperature at 8:04 a.m. was 37,5, at 8:08 was 39,6, and at 8:09 was 40,1 degrees.

    00:28 Now, if you're still using Fahrenheit, that's 104 degrees, and you can write that down on your stone tablet.

    00:34 The gynecologist tells you that the patient is starting to twitch. What is the appropriate action for this patient? Do you A, request an urgent blood test and assess this patient for rhabdomyolysis? B, do you request an urgent urine test to assess for myoglobulinuria? C, do you administer more propofol urgently because she is under-sedated? Or D, do you administer dantrolene urgently? Okay. If you answer D, you can become a doctor.

    01:09 If you answered anything else, you should hang up your stethescope now and become a truck driver because really, you need to recognize malignant hyperthermia. This is critical for your training.

    01:19 This is going to be critical for your exams. Malignant hyperthermia, dantrolene, within 1 minute or the patient dies.

    01:26 So, remember this stuff. It's going to be on your exams, you may even have more than one question on your exam.

    01:31 So remember, if you see halothene and a high temperature, think malignant hyperthermia first, and look for the dantrolene in the answer.

    01:41 A 32-year-old female is brought into the ER unconscious with evidence of physical abuse.

    01:47 She is suspected to have had a head injury. She has increased intracranial pressure when you look on the fundoscopic exam.

    01:54 The ER have referred her for an urgent craniotomy because they have diagnosed intracranial bleed.

    02:03 You are called in to sedate the patient. What drug would you choose? Would you choose thiopental, midazolam, propofol, ketamine or nitrous oxide? Okay, you chose thiopental. In this clinical scenario, reduction of intracranial pressure is the most important issue.

    02:26 Choosing a drug that may increase intracranial pressure is contraindicated.

    02:30 Ketamine may increase ICP through cardiac stimulation. Nitrous oxide causes cranial vascular dilatation, which also may cause increased ICP. Thiopental is well known to reduce intracranial pressure and is the drug of choice here.

    02:48 Now, midazolam and propofol may reduce intracranial pressure but this is a less predictable phenomenon.

    02:56 So, the answer here is thiopental. I put thiopental, midazolam and the propofol all in the same question on purpose because I want you to recognize that thiopental is the drug of choice and it works a little bit better.

    03:10 That's it for the questions. I hope you enjoyed this course and good luck on your exams.

    About the Lecture

    The lecture Case Study – Anesthetic Drugs by Pravin Shukle, MD is from the course CNS - Pharmacology.

    Included Quiz Questions

    1. Dantrolene should be administered as soon as malignant hyperthermia is suspected.
    2. Propofol is an anesthetic drug that is commonly associated with malignant hyperthermia.
    3. Myoglobinuria is one of the earliest clinical markers of malignant hyperthermia.
    4. Malignant hyperthermia has a subacute onset and usually starts within 2 weeks after the surgery.
    5. Reverse the effect of dantrolene as soon as possible.

    Author of lecture Case Study – Anesthetic Drugs

     Pravin Shukle, MD

    Pravin Shukle, MD

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    Bring the cases
    By Filipe C. on 21. May 2020 for Case Study – Anesthetic Drugs

    In Portugal, almost all exams are clinical cases, and it's awesome one we can find problems like this lecture and detail explanation on the answers. Great lecture

    Great teacher!
    By Waqqar A. on 17. December 2017 for Case Study – Anesthetic Drugs

    Very good lecture, a great teacher and a good sense of humor !