What is the appropriate anesthesia plan for a 60-year-old male with a complex medical history including CLL, probable RCC, hypertension, BPH, dyslipidemia, and obesity, who is undergoing surgery?

Anesthesia Plan for 60-Year-Old Male with Multiple Comorbidities

For this 60-year-old male with multiple comorbidities including morbid obesity (BMI 42.8), suspected OSA, CLL, probable RCC, hypertension, BPH, and dyslipidemia, general anesthesia with endotracheal intubation is the technique of choice to ensure optimal airway management and ventilation throughout the procedure. 1

Preoperative Considerations

Airway Assessment

• Mallampati II and upper lip bite test class I suggest a potentially manageable airway
• However, BMI 42.8 and suspected OSA significantly increase risk of difficult ventilation and rapid desaturation
• Ensure difficult airway equipment is immediately accessible 2

Cardiovascular Assessment

• ECG showing sinus rhythm with left ventricle deviation and borderline prolonged PR interval requires attention
• Continue antihypertensive medications (perindopril, amlodipine) on the day of surgery
• Consider invasive arterial monitoring due to cardiovascular risk factors 2

Respiratory Assessment

• High risk for OSA (awaiting sleep study) requires careful planning
• Reduced functional residual capacity and increased oxygen consumption due to obesity will lead to rapid desaturation 2
• Consider preoperative CPAP if signs of significant sleep-disordered breathing are present 1

Metabolic Assessment

• HbA1C of 6.3% indicates adequate glycemic control
• Continue metformin until the evening before surgery
• Monitor blood glucose perioperatively 2

Anesthetic Plan

Induction

• Position patient in ramped position with tragus of ear level with sternum to optimize airway management and ventilation 2
• Preoxygenate thoroughly with positive end-expiratory pressure (PEEP) to maximize safe apnea time 2
• Administer propofol based on lean body weight (not total body weight), titrated to effect 3
• Use rocuronium for neuromuscular blockade with sugammadex immediately available for emergency reversal 2
• Consider rapid sequence induction if high aspiration risk is identified 4

Airway Management

• Secure airway with endotracheal intubation (size based on ideal body weight) 2
• Video laryngoscopy should be considered as first-line approach due to obesity and potential difficult airway 1
• Ensure proper tube position with end-tidal CO2 monitoring and auscultation

Maintenance

• Use desflurane or sevoflurane for maintenance due to faster offset in obese patients 1
• Consider total intravenous anesthesia (TIVA) with propofol if PONV risk is high
• Titrate propofol maintenance at 50-100 mcg/kg/min based on lean body weight 3
• Implement depth of anesthesia monitoring (BIS) to ensure adequate anesthesia and minimize awareness risk 2
• Use neuromuscular monitoring throughout the case 2

Ventilation Strategy

• Pressure-controlled ventilation with tidal volumes of 6-8 mL/kg ideal body weight 1
• Apply PEEP (8-10 cmH2O) to reduce atelectasis 2
• Perform recruitment maneuvers periodically to improve oxygenation 1
• Maintain head-up position when possible to optimize respiratory mechanics 1

Fluid Management

• Implement goal-directed fluid therapy using balanced crystalloids 1
• Avoid excessive fluid administration due to risk of pulmonary edema
• Consider vasopressors for management of hypotension once normovolemia is established 1

Pain Management

• Implement multimodal analgesia to minimize opioid requirements:
  • Local anesthetic infiltration at surgical site
  • Scheduled acetaminophen and NSAIDs (if not contraindicated)
  • Dexamethasone for PONV prophylaxis and analgesic effect
  • Minimal use of long-acting opioids to reduce respiratory depression risk 2, 1

Postoperative Plan

Emergence

• Ensure full reversal of neuromuscular blockade with appropriate monitoring before extubation
• Consider extubation in semi-upright position to optimize respiratory mechanics 2
• Have emergency airway equipment immediately available for potential reintubation

Postoperative Monitoring

• Consider post-anesthesia care unit (PACU) with extended monitoring due to multiple comorbidities
• Monitor oxygen saturation continuously until patient is fully mobile 1
• Maintain head-up position to optimize respiratory mechanics 1
• Continue multimodal analgesia with opioid-sparing techniques 1

Thromboprophylaxis

• Early mobilization to reduce VTE risk 2
• Pharmacological prophylaxis with LMWH and mechanical prophylaxis with compression stockings 1

Special Considerations

CLL Management

• Monitor WBC count (currently elevated at 64 but downtrending)
• Be vigilant for signs of infection
• Consider perioperative antibiotics based on surgical procedure

Obesity and OSA

• Maintain vigilance for postoperative respiratory depression
• Consider postoperative CPAP if signs of obstruction occur 1
• Minimize use of sedatives and long-acting opioids 2

Cardiovascular Risk

• Monitor for arrhythmias given ECG findings
• Maintain hemodynamic stability throughout the perioperative period

Common Pitfalls to Avoid

• Dosing medications based on total body weight rather than lean body weight
• Inadequate preoxygenation leading to rapid desaturation
• Failure to anticipate difficult airway despite reassuring initial assessment
• Overreliance on opioids for pain management
• Inadequate reversal of neuromuscular blockade
• Failure to implement VTE prophylaxis
• Inadequate monitoring in the postoperative period for respiratory depression

This comprehensive anesthesia plan addresses the patient's multiple comorbidities while focusing on optimizing respiratory function, maintaining cardiovascular stability, and ensuring adequate pain control with minimal respiratory depression risk.