Clinical Case 077: Fluid balancing act

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

Casey

 

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