Several hours into the case the surgeon complains that he is operating on a moving target. How would you manage this situation?
This situation presents a unique challenge for the anes-thesiologist. It is important to assess the patient for all causes of agitation. The presence of hypoxia, hypercarbia, myocardial ischemia, hypotension, and hypertension must be assessed first and treated accordingly. Methylmethacrylate cement toxicity should be considered in this setting as well, since it can cause any of the above findings. Only after the above differential is ruled out should dissipation of the spinal block be considered.
If inadequate anesthesia is the cause of the agitation, one must first determine the remaining operative time so that an appropriate action can be taken. If the surgeon is already closing, administration of midazolam, fentanyl, propofol and/or ketamine while assuring a patent airway may be all that is needed. If there is still a significant amount of opera-tive time left, then conversion to a general anesthetic may be necessary and the airway should be secured. Ideally, this can be done without disrupting the surgery. It would be advisable to call for help at this time. A reasonable option at this time would be the placement of a laryngeal mask airway (LMA). In most cases, the LMA can be placed safely even in the lateral decubitus position. The LMA will allow for the use of volatile agents and opioids.
If an LMA is deemed not safe, such as in the morbidly obese patient, an endotracheal intubation will be necessary. Since the patient is in the left lateral decubitus position, it will be necessary to position the operating room table so that the patient is somewhat supine. This is accomplished by turning the bed laterally in the direction opposite to that in which the patient is facing. For example, if the patient is in the right lateral decubitus position, the table should be moved toward the left. Although this position is not ideal, it can result in the patient as close to the supine position as possible without disrupting the surgical field. If this maneu-ver does not provide reasonable intubating conditions, then the surgery should be stopped and the patient posi-tioned supine for intubation. Although a hip infection can be devastating, airway management should always take precedence. Another possible approach to securing the airway would be to perform a fiberoptic intubation in the lateral decubitus position.