<p>
<br> <br>
If possible, further control of the present pulmonary edema is recommended before this procedure. <br>
Given the provided information, this patient is at high risk for anesthetic complications including sudden death. Dental disease, however, can certainly affect a patient’s quality of life thus requiring a surgical procedure. I would recommend limiting the surgery time to less than one hour total.<br>
Please give the oral Lasix the morning of surgery. Oral Cerenia and Gabapentin can also be given in the morning before surgery to prevent nausea and limit anxiety. <br>
1.5 units of Prozinc SC should be given in the morning before surgery. Blood glucose should be tested before and after the procedure, with the goal glucose range being 150-250 mg/dL. <br>
Enalapril should be discontinued 24 hours before surgery.

</p>
<p> PREOPERATIVE MEDICATIONS: <br>
Buprenorphine: 0.02 mg/kg IM or IV. <br>
Midazolam: 0.1 mg/kg IV. <br>
Midazolam is reversible with Flumazenil, 0.02 mg/kg IV <br>

</p>
<p> INDUCTION: <br>
Propofol OR Alfaxalone: 2-4 mg/kg IV
<br>

Please provide supplemental oxygen (100 %) via face mask for 5-10 minutes before induction. It is important that the face mask remains on the patient’s face through the induction period to prevent hypoxemia if the patient becomes apneic.

</p>
<p> MAINTENANCE: <br>
Isoflurane: 1.3-1.8 % <br>
Sevoflurane: 2.4-3.0 % <br>

</p>
<p> FLUID THERAPY: <br>
Isotonic crystalloid fluids – 1 mL/kg/hr during surgery <br> I do not recommend fluid boluses in this patient which may exacerbate its concurrent congestive heart failure.

</p>
<p>INTRAOPERATIVE MONITORING:<br>
MONITORING: pulse oximetry, ECG, noninvasive blood pressure, end-tidal CO2 and temperature <br>
For intraoperative bradycardia (Heart Rate < 90 bpm), I would consider giving Atropine (0.01 mg/kg IV) OR Glycopyrrolate (0.005 mg/kg IV).<br>

</p>
<p> Locoregional Techniques:<br>
Bupivicaine 0.5%: 1 mg/kg total dose for dental blocks.
</p>
<p> POSTOPERATIVE PLAN:<br>
Oral NSAIDs are not recommended given that this patient is on Lasix and it can lead to kidney damage. <br>
Buprenex 0.01 mg/kg IV may be given for postoperative pain.
<br><br>Please continue to monitor the patient with pulse oximetry in the postoperative period for 30 minutes. If her SPO2 reading falls below 95%, please provide supplemental oxygen via face mask. <p/>