This is a tough one – a clinical scenario that is unfortunately a bit too common in my part of the world. I want to know how you would go about balancing the fluids in this case, what will you use to measure the adequacy of the resuscitation / fluid administration. It is a tight rope with not much safety net! Here we go:
The Back story
Mr Beans - 60 yo. man with end-stage renal disease, he has been on HD for 3 years in a small country town satellite dialysis unit. He has the usual comorbidities: uncontrolled type 2 DM, bad peripheral neuropathy, hypertension, has had 2 separate angioplasties for coronary stenoses now > 10 years ago (no recent angina), obesity – BMI 37 with marked central adiposity, probable sleep apnoea on history – not diagnosed yet! He is on all the usual renal failure meds and calcium-control agents and beta-blocked, on aspirin but not clopidogrel.
His last admission was for APO following a week of missed dialysis which got better with BiPAP and some dialysis.
Has had multiple AV fistual formations and failures, central venous stenosis requiring a surgical bypass – so not really able to do central access about the neck! Difficult periphreal venous access.
The recent history:
Mr Beans was going well until he trod on something a week or two ago (no shoes ever worn). He developed a soft tissue infection on the sole of his right foot which was drained in ED and placed on oral ABs. The swabs came back with: MRSA, mixed coliforms and some anaerobic bacterium. He then went bush for a week for some family business, missed 2 doses of dialysis (usually 3 times a week). He returned for dialysis and got started on the machine when he spiked a fever – he had a nasty looking swollen right foot with superficial blistering and a nasty odour. The team pressed on with dialysis and decided to give him a dose of vancomycin at the end of the session. Two hours later he was becoming hypotensive. He was removed from the machine and sent over to ED.
The problem now:
Mr Beans clearly has a large purulent collection with subcut. emphysema over the whole dorsum of his foot. There is a small draining wound on the sole of the foot. His Obs: Temp = 38.2 pulse = 75 in SR, BP – 110/70, RR 20/min, he is 3 kg over his preferred ideal body weight. He lookes flushed and feels warm all over
A VBG is surprisingly normal aside from a lactate of 3.9 mmol/l. His K+ is 4.8
Of course we do an USS of the foot – which shows a lot of artefact from the soft tissue gas. On some views we can see deep fluid collections extending down between the metatarsals. It stinks, not a nice fruity Staph smell – but something else!
The way forward:
The surgeon is keen to get Mr Beans to the OR for debridement / amputation tonight. This sounds like a good idea until you realise that you are the Anaesthetic guy on call! You have just heavily sedated a Psych patient and a 27-weeker has rocked in with contractions – it is not going to be a fun night!
Questions that need answers:
(1) How are you going to assess Mr Bean’s current fluid status or need for fluid resuscitation?
(2) How are you going to decide when enough fluid is enough / or when to give some vasopressors?
(3) What are your initial / preferred plans for anaesthesia. Looking at the spine there is a large fat pad, no palpable spinous processes below the chest.
(4) Antibiotic preferences for this scenario with ESRF? Has been on vancomycin for 2 doses now, was on oral Augementin (in theory; last week)
Do you have any pearls to share on this case? Hit me on the comments, email or twitter
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