Friday, August 28, 2009

Case Report #2

I go into preop to see my next case, a transmetatarsal foot amputation due to gangrene. Looking through the H+P, the patient reads like an oral board certification case presentation. Patient is in his 50's with insulin dependent diabetes. He has ESRF, with dialysis the morning of surgery. They helpfully removed 2 liters of fluid that day. He has ischemic cardiomyopathy with an ejection fraction less than 40%. Of course he has coronary artery disease s/p PTCA and stenting but still has CAD not amenable to any further intervention. He had an internal cardiac defibrillator placed a month ago due to his low ejection fraction. His pulmonary artery pressure was 64 mm Hg. And to top it off, the preop nurse told me his blood pressure is 75/26. Huh?

We measure the BP in the other arm and it is the same. We look through his chart and it shows his BP has been in the 70's for the last five days. We call the floor nurse who was taking care of the patient to see if she had brought up this problem with the primary care doctor. She said she was not aware of his hypotension because she was not the one measuring his BP's. I wanted to report that nurse right there and then but thought that wouldn't really make any difference to the patient now. The cardiologist left a helpful note in the chart that was pretty much illegible chicken scratches other than something about patient being fully optimized for surgery. Gee thanks. The surgeon said the foot is causing sepsis and needs to get amputated now. The patient's mental status is best described as drowsy. I couldn't tell whether that's because he has been receiving narcotics for pain or his brain was not getting adequately perfused. Okay.

So a general anesthetic was pretty much out of the picture as well as a spinal. I didn't feel like experimenting with critical hypotension in the OR tonight. So an ankle block was placed. I attempted an arterial line but of course the patient is vasculopathic. No palpable pulses anywhere and my attempts with blind sticks were not successful. I started a levophed drip to get his BP up into the 90's while giving him just enough sedation with versed and propofol to maintain amnesia. The surgery went well but as expected the ankle block was not all that helpful during the bony amputations. At least the patient doesn't remember.

The surgeon and I agree that the patient should go to the ICU at least overnight. I continued his levophed drip in recovery to maintain some semblence of normotension. The surgeon calls the internist to come write ICU orders. I get a page from recovery saying the internist wants to talk to me. I thought he might want some details about such a challenging case. Instead I get a lecture from him about how bad levophed is. He tells me the patient LIVES on BP's in the 70's. I tell him I wasn't going to give anesthesia to somebody that hypotensive and with CAD and cardiomyopathy. He orders the levophed discontinued. The BP promptly drops into the 60's. He said he was fine with that. I throw up my hands in frustration. Who am I to argue if the patient's primary care doctor doesn't mind having a patient with such critical hypotension? In situations like this, the best thing that can be said is that the patient lived through the surgery. What comes afterwards is out of my hands.

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