Fig. 22.1
Algorithm of the Department of Anesthesiology of the University Hospital Dresden for perioperative glucocorticoid substitution in patients with Cushing’s syndrome or long-term corticosteroid therapy
The anesthesiologist who performed Ms. Pine’s preoperative evaluation, as well as Dr. Sofia, neglected to order perioperative glucocorticoids, and the patient developed an Addisonian crisis. An Addisonian crisis is caused by a rapid loss of adrenal gland function, as may occur with infarction or progression of chronic loss or through inadequate adrenal function in stressful situations – as in trauma or infection, with preexisting adrenal insufficiency. The symptoms of an Addisonian crisis are nonspecific.
Symptoms of an Addisonian crisis:
Weakness
Nausea and vomiting
Hypotension
Decreased vigilance
Dehydration
Fever
Hypoglycemia
In secondary causes, such as with Ms. Pine, electrolyte disorders are usually not present.
Due to the decreased blood pressure regulation, severe shock can occur. The therapy consists of:
Glucocorticoids
Glucose infusion
Fluids
>> Following orders from attending anesthesiologist Dr. Eldridge, Ms. Pine received 100 mg hydrocortisone IV, 40 ml dextrose 40 %, and an electrolyte infusion. She improved immediately and bombarded all the care takers around her with questions. Dr. Eldridge left the answers up to the PACU doc. He himself set off to find Dr. Sofia to discuss the case.
22.2 Case Analysis/Debriefing
22.2.1 Can Tourniquet Pain Appear in Other Forms of Anesthesia? Can It Be Prevented?
Tourniquet pain can occur with all types of anesthesia [11]. In a retrospective analysis of 699 orthopedic patients, cardiovascular changes were experienced by 67 % of patients during general anesthesia, 18.6 % of patients with intravenous anesthesia, 2.7 % of patients with spinal anesthesia, and 2.5 % of patients with upper limb plexus anesthesia. The occurrence of tourniquet pain correlates with age of the patient, duration of the ischemia, type of procedure, and leg procedures [15].
Tourniquet pain cannot be entirely prevented. An important factor is a complete as possible sensory block. Applying EMLA to the skin before the tourniquet sometimes helps. Many additives for IV regional anesthesia have been tested in small studies with partial success and include clonidine, morphine, melatonin, magnesium, and gabapentin.
However, therapy is often not successful. Opioids often do not achieve the desired effect. Ketamine or a nonsteroidal analgesic can be administered. It is important to limit the duration of the tourniquet because of the pain. Tourniquets are relatively contraindicated in sickle cell anemia patients due to the erythrocyte malformation.
22.2.2 Which Medical Errors Do You See in the Presented Case?
22.2.2.2 Blood Glucose
In addition to not considering a glucose check preoperatively, (see Sect. 22.1.2) the resident physicians neglected to order a postoperative glucose check.
22.2.2.3 Steroid and Implantation of Foreign Material
Due to her long-term steroid therapy, Ms. Pine was at an increased risk for postoperative (wound) infections. The implantation of a knee replacement must be viewed critically.
22.2.2.4 Therapy of the Systemic Hypertension
Administration of antihypertensive medications shortly before the tourniquet was opened was incorrect. The ensuing blood pressure decrease was amplified and endangered the patient.
22.2.2.5 Alarm Pause
An undesired monitor alarm should be cancelled for a short interval, not completely turned off or reset (see Case 9, Sect. 9.1.6).
22.2.3 Which Systems Failures Can You Find in the Presented Case?
22.2.3.1 Operating Room Scheduling
Patients with diabetes should be highlighted on the OR schedule and ideally obtain an early slot. A preset arrangement is needed between the anesthesia and surgical teams.
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