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Had an interesting case recently, wondering how others would have tackled it:
72 yo M with poorly controlled HTN, IDDM, morbidly obese (190kg), pAF, CAD s/p remote CABG complicated by ischemic CM (LVEF 25% w/ RWMAs), post-capillary pulmonary HTN (mPAP ~50, R heart dilated and mildly reduced fxn), and AS s/p TAVR now w/ severe prosthetic valve stenosis. ESRD on HD, however he is now progressively volume overloaded because he has been getting hypotensive during attempts at ultrafiltration over the past week (despite trials of midodrine pre-HD), thus limiting how much volume could be pulled off. Had a RHC several days ago, wedge pressure 32mmHg, CI 2.2 by Fick. Currently admitted for expedited workup of possible valve-in-valve TAVR, however before proceeding with any cardiac intervention, his non-healing and chronically infected lower extremity ulcers need to be dealt with... Hence why he is now coming to the OR for a left BKA.
When I go to see him the evening before, vascular surgeon has him on a heparin drip for his critical limb ischemia. He's borderline encephalopathic after having gotten some morphine for leg pain, alert and oriented x 2. Can lay flat, but doesn't love doing it. O2 sat is 94% on 4L NC with bibasilar crackles.
Clearly, this man is dying sooner or later... However, I prefer not to have him die in the OR during the BKA. Patient and his family are determined that they want to proceed with all interventions. How will you do this case?
72 yo M with poorly controlled HTN, IDDM, morbidly obese (190kg), pAF, CAD s/p remote CABG complicated by ischemic CM (LVEF 25% w/ RWMAs), post-capillary pulmonary HTN (mPAP ~50, R heart dilated and mildly reduced fxn), and AS s/p TAVR now w/ severe prosthetic valve stenosis. ESRD on HD, however he is now progressively volume overloaded because he has been getting hypotensive during attempts at ultrafiltration over the past week (despite trials of midodrine pre-HD), thus limiting how much volume could be pulled off. Had a RHC several days ago, wedge pressure 32mmHg, CI 2.2 by Fick. Currently admitted for expedited workup of possible valve-in-valve TAVR, however before proceeding with any cardiac intervention, his non-healing and chronically infected lower extremity ulcers need to be dealt with... Hence why he is now coming to the OR for a left BKA.
When I go to see him the evening before, vascular surgeon has him on a heparin drip for his critical limb ischemia. He's borderline encephalopathic after having gotten some morphine for leg pain, alert and oriented x 2. Can lay flat, but doesn't love doing it. O2 sat is 94% on 4L NC with bibasilar crackles.
Clearly, this man is dying sooner or later... However, I prefer not to have him die in the OR during the BKA. Patient and his family are determined that they want to proceed with all interventions. How will you do this case?