This patient presents with multiple organ systems at risk and is relying on you to understand their etiologies and anesthetic considerations. She needs a thorough chart review, not just a cursory glance. The latter will miss key considerations that can seriously impact her care. For an inpatient, imagine yourself not just as the patient’s anesthesiologist, but as an extension of her primary hospital medicine team.

In reading her chart, you note that her white blood cell count is highly elevated at 80,000 per . You are thus prompted to read about hyperleukocytosis and how at extreme levels it can result in leukostasis and end-organ ischemia. You note that aseptic necrosis, a sequelae of this, was actually considered on the differential for the etiology of her femoral head fracture. You will note the management of such states includes hydration and monitoring for tumor-lysis syndrome (TLS) and disseminated intravascular coagulation (DIC). You see that those conditions have been ruled out by the primary team by checking uric acid, potassium, phosphate, and coagulation panels.

You note her AKI is resolving, but her creatinine of 1.0 mg/dL in a patient her size is still on the cusp of a normal GFR. Her AKI was likely due to sepsis, compounded by her leukemia. Sepsis leads to nephrotoxicity due to a low flow state and possibly direct tubular injury. Leukemic nephrotoxicity can be direct, from tumor infiltration, or related to chemotherapeutic agents. This is relevant because it means you should avoid intraoperative hypotension, which may act as a “second hit” to her renal perfusion, which is already vulnerable. It also means you should avoid ketorolac or other potentially nephrotoxic agents.

Knowing her baseline pain management regimen is essential to optimizing postoperative pain control. In this case, you anticipate that it will be very challenging. You note her basal rate infusion of hydromorphone 0.4 mg per hour, scheduled gabapentin, and 18 mg of hydromorphone in demand, plus clinician boluses from her PCA over the last 24 hours. Using these, you make a rough estimate of her daily morphine milliequivalents, which will help you at least match her baseline requirements on her day of surgery. You read in the notes that during a previous surgery, she did well with a ketamine infusion.

You note recent microbiology data from blood and urine samples, her antibiotic regimen, and when they are next due. You might ask the orthopedic team if they are planning on sending an intraoperative tissue culture.

You read that this procedure could involve significant blood loss, and anticipate that she has a low threshold to become coagulopathic. While reviewing the type and screen, you note that she has a history of non-ABO, non-Rh antibodies. You realize this could significantly delay blood product availability, leading to procedural delay or prolonged anemia. As such, you reach out to the inpatient team and ask them to order blood products now, so there is not a time crunch on the morning of surgery.

Noting that the patient has been on the “add-on” list for 3 days and has recently been septic, you might rightfully suspect that she is intravascularly dry from prolonged NPO status. You might consider optimizing her with fluid during the first phase of your anesthetic to prevent the additive effect of hypovolemia and vasodilation of your anesthetic, especially with the potential for blood loss.

You read the surgeon’s note, which mentions the use of Methylmethacrylate (cement). This prompts you to learn about bone-cement implantation syndrome (BCIS). This complication, which occurs during pressurized cement implantation, is postulated to result from the methylmethacrylate monomers themselves or the result of fat, air, and bone emboli entering the bloodstream. It can cause a wide spectrum of symptoms: vasodilation, hypoxemia, cardiogenic shock, and even cardiac arrest. This informs your anesthetic for a few reasons. First, it prompts you to be extra vigilant during the time of cementation. Second, it allows you to optimize the patient in the event of a BCIS hemodynamic crisis, by making sure the patient is hydrated, ventilated appropriately, has a robust BP (perhaps not just barely maintaining a MAP of 65 but maybe augmented to 75 or 85), and is not severely anemic.

You could get by in this case with a quick review of auto-populated numbers that are pulled from the EMR into your anesthesia note. Then, you could ask the surgeon, “What do you plan on doing? Will there be blood loss? What is cement?” You could assume the pain team will manage the blocks and multimodal analgesia. You could manage things expectantly in the OR and hope for the best. This approach is defensible and meets the standard of care, but it is weak and disjointed. It will lead to a career of unnecessarily morbid and untoward complications that will greatly harm your patients. Early in your career, you should make an effort to review charts thoroughly and put yourself on a path to good clinical practice.