CASE DISCUSSION 1: SYNTHESIS

SUBSEC B4
FACILITATOR: Dr. Cabansag
ROADMAP
1. Case Review
2. Learning Issues
Cell excitability
Osmosis
Autonomic nervous system
Skeletal muscle physiology
Mechanism of action of bupivacaine, phenylephrine and
midazolam
3. General Problems and Hypothesis
4. Clinical Issues



2
CASE
A 25 year old hospital worker sustained a deep lacerated wound
on his upper left leg. He was schedule for debridement and
possible wound closure. Upon arrival at the operating room suite, his
baseline vital signs were as follows: BP 120/80, HR 76/min, RR 12
cycles/min, Temp 36.4 C
Spinal anesthesia was induced with ease using bupivacaine. Five
minutes later, his vital sign signs wee as follows: BP 80/60, HR 90/min,
RR 12 cycles/min. Rapid infusion of isotonic fluid (PNSS) was given
followed by maintenance at 120 mL/hr. Phenylephrine was given
intravenously and BP rose to 110/70.

3
CASE
With both lower extremities immobile, the surgeon proceeded to
debride the wound. Due to presence of some bleeders, the
surgeon opted to use electrical cautery. With application of the
cautery on the surgical site, twitching of skeletal muscles were
noted. However, the patient remained comfortable with no
perception of pain.
30 minutes into surgery, the patient requested that he be put to
sleep. Midazolam 3 mg was given intravenously. The patient went
to sleep. The rest of the hospital stay was unremarkable. Patient
was discharge improved after two days.


4
SIGNS AND SYMPTOMS
SIGNS SYMPTOMS
Deep lacerated wound
Before Anesthesia:
Blood Pressure: 120/80
Heart Rate: 76/min
Respiratory Rate: 12 cycles/min
Temperature: 36.4 C
After Anesthesia:
Blood Pressure: 80/60
Heart Rate: 90/min
Respiratory Rate: 12 cycles/min
After administration of
Phenylephrine:
Blood Pressure: 110/70
Immobile lower extremities
Twitching of skeletal muscles

Pain from wound
No perception of pain

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LEARNING ISSUES
1. Cell Excitability
2. Autonomic Nervous System
3. Skeletal Muscle Physiology
4. Mechanism of action of drugs
6
Cell Excitability

7
Autonomic Nervous System

8
Skeletal Muscle Physiology

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BUPIVACAINE
Amide type local anesthetic
Voltage gated Na
+
channel blocker
Vasodilator
Insert picture
10
Bupivacaine Mechanism of Action

11
PHENYLEPHRINE
Alpha 1 agonist
Vasoconstrictor
Insert picture
12
Phenylephrine Mechanism of Action

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MIDAZOLAM
Acts on GABA A receptors
GABA major inhibitory neurotransmitter in the brain
GABA A: increases the frequency of opening Cl
-
channel
thereby making the cells less excitable
Induces sleep
14
Midazolam Mechanism of Action

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Generated Problems
1. Why does BP drop after inducing anesthesia?
2. Why Why did the BP increase after giving phenylephrine?
Why was PNSS given?
3. Why is there twitching of the skeletal muscle during cautery?
Why did the patient felt no pain?
4. Why did the patient go to sleep after giving midazolam?
5. Why was there a rapid infusion of PNSS?
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Generated Problems
6. Why did the doctor use spinal anesthesia and not local?
7. Why did the HR increased from 76 BPM to 90 BPM?
8. Why did the surgeon opt to use electrical cautery?
9. Why were normal vital signs detected even in the presence
of a deep lacerated wound?
10. Why was there a maintenance of 120 mL/hour of PNSS?

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HYPOTHESIS
1. BP decreased was due the anesthetic, it relaxes the muscle and
there would be vasodilation.
2. The rise in BP was due to the vasoconstriction caused by the 21
adrenergic agonist (phenylephrine).
3. Twitching of the skeletal muscle is maybe due to the electrical
stimulation brought about by electrical cautery. No perception of
pain was due to anesthesia (midazolam).
4. -
5. 5-


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HYPOTHESIS
6. Spinal anesthesia was used because spinal anesthesia covers a
wider/ broader area of the body.
7. Inhibited Na
+
causes Ca
++
to stay in ergo resulting to an increase in
HR.
8. Surgeon opted use electrical cautery because it is fast acting.
9. Since there is blood loss from the deep lacerated, the body tries to
cope up with the blood loss = increase vital signs
10. No perception of pain due to spinal anesthesia
11. Administration of Midazolam patient was put to sleep
19
Hypothesis
1. Why does BP drop after inducing anesthesia?
Hypothesis: BP decreased was due to the anesthetic, it relaxes
the muscle and there would be vasodilation.


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Hypothesis
2. Why Why did the BP increase after giving phenylephrine?
Why was PNSS given?
Hypothesis: The rise in BP was due to the vasoconstriction
caused by the 21 adrenergic agonist (phenylephrine).


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Hypothesis
3. Why is there twitching of the skeletal muscle during cautery?
Why did the patient felt no pain?
Hypothesis: Twitching of the skeletal muscle is maybe due to the
electrical stimulation brought about by electrical cautery. No
perception of pain was due to anesthesia (midazolam).

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Hypothesis
4. Why did the patient go to sleep after giving midazolam?
Hypothesis:
23
Hypothesis
5. Why was there a rapid infusion of PNSS?
Hypothesis:
24
Hypothesis
6. Why did the doctor use spinal anesthesia and not local?
Hypothesis: Spinal anesthesia was used because spinal
anesthesia covers a wider/ broader area of the body.

25
Hypothesis
7. Why did the HR increased from 76 BPM to 90 BPM?
Hypothesis: Inhibited Na
+
causes Ca
++
to stay in ergo resulting
to an increase in HR.

26
Hypothesis
8. Why did the surgeon opt to use electrical cautery?
Hypothesis: Surgeon opted use electrical cautery because it is
fast acting.

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Hypothesis
9. Why were normal vital signs detected even in the presence
of a deep lacerated wound?
Hypothesis: Since there is blood loss from the deep lacerated,
the body tries to cope up with the blood loss = increase vital
signs.

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Hypothesis
10. Why was there a maintenance of 120 mL/hour of PNSS?
Hypothesis:
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Clinical Issues
1. Why BP dropped and HR rose?
2. Why BP rose after the anesthesiologist gave PNSS &
phenylephrine?
3. Why was there twitching of the skeletal muscle after the
application of electrical cautery?
4. Why was there no perception of pain during surgery?
5. Why did the patient slept after giving midazolam?

30
Clinical Issues:
1. Why BP dropped and HR rose?

31
Clinical Issues:
2. Why BP rose after the anesthesiologist gave PNSS &
phenylephrine?

32
Clinical Issues:
3. Why was there twitching of the skeletal muscle after the
application of electrical cautery?
33
Clinical Issues:
4. Why was there no perception of pain during surgery?

34
Clinical Issues:
5. Why did the patient slept after giving midazolam?

35