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This 33-year-old white female patient with Down syndrome (Figure 32-1) presented to the gastrointestinal (GI) service with a history of vomiting blood. You first encounter her when she is brought to the operating room at 22:00 hours with gross hematemesis and the general surgeon is going to attempt GI endoscopy to determine the site of bleeding and its cause, and attempts to stop it. Failing that, an open laparotomy is planned.
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As she is being transferred to the operating room (OR) table, her only IV is inadvertently pulled out. In the past, she has had repeated episodes of aspiration pneumonia felt to be related to grossly carious teeth and is scheduled for a full mouth dental extraction in 2 weeks.
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On examination, she is 5 ft 2 in (157.5 cm) tall and weighs 210 lb (96 kg) with a moderate developmental delay. Vital signs are: heart rate (HR) 122 beats per minute (bpm), blood pressure (BP) 100/80 mm Hg, and her oxygen saturation on blow by oxygen is 92% (she is combative and will not permit an oxygen mask to be applied). You suspect that she has aspirated some blood.
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She is not cooperative and will not permit an IV to be restarted. She does not answer questions. She lies on her side with her head flexed forward and will not extend her neck when requested nor will she permit you to do so. She will not open her mouth as per your request and it seems that blood is everywhere.
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According to the surgeon, her sister has cared for her for the past 20 years (parents are deceased). As far as her sister knows, she is perfectly healthy and has never had an anesthetic before. She is on no medication and has no allergies. Her past cardiac history is unremarkable according to the surgeon. She does not smoke.
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Blood work done earlier in the day shows hemoglobin of 10.2 g/dL (102 mmol/L) and is otherwise normal.
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She will require a general anesthetic with an endotracheal intubation. In addition, she is grossly uncooperative, is exhibiting some evidence of hypovolemia, has features indicative of a difficult airway, and has probably aspirated some blood.
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32.2.1 What Kind of Vital Organ System Reserve Does This Patient Have?
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Cardiovascular reserve: The elevated pulse rate and the narrowed pulse pressure suggest an element of hypovolemia. You are hoping that the surgeon is correct and that she has no congenital heart disease (eg, an endocardial cushion defect).
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CNS reserve: She is moderately developmentally delayed and anticipated to be combative on emergence. Her response to sedative hypnotic agents and ketamine ...