Severe HFrEF for emergency laparotomy78-year-old man, 70 kg, urgent laparotomy for small bowel obstruction; vomiting

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A 78-year-old with EF 25% ischaemic cardiomyopathy and a full stomach, for urgent laparotomy. Patient
   • At 78, breathless at 50 metres with EF 25%, he has little reserve; I screen frailty and cognition.
   • Urgency: urgent, so hours to reduce his risk, not days to postpone. Stem trigger
   • Active conditions? No orthopnoea and only mild oedema: severe but compensated failure, so no. Disease
   • Risk score: heart failure, coronary disease and intraperitoneal surgery are three RCRI items; RCRI 3, elevated.
   • Functional capacity: breathless after 50 metres, far under 4 METs.
   • Decision: proceed today, optimised in the time available, with ICU booked afterwards.

2. Prepare

   How will you prepare him in the time you have?

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   • Bedside echo for his LV function and filling before he goes to theatre. Disease
   • Furosemide has dropped his potassium to 3.3; 20–40 mEq IV over 30 minutes, by pump, with ECG monitoring.
   • Dapagliflozin was taken today: I check ketones and anion gap, since his glucose may look normal.
   • His ICD is interrogated; tachy-therapies are suspended and external pads go on.
   • Arterial line before induction and central access for infusions.
   • Noradrenaline running and milrinone drawn up before I induce him. Crisis

3. Plan

   How do you anaesthetise him?

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   • Aspirate his NG tube, preoxygenate well and do a rapid sequence induction. Airway
   • Reduced-dose etomidate, 0.15–0.2 mg/kg, with rocuronium 1.2 mg/kg straight after.
   • No full propofol bolus; his ventricle can't compensate for sudden vasodilation. Disease
   • For hypotension, vasopressor first to restore his tone after induction.
   • Fluids guided by echo or cardiac output monitoring, not fixed boluses.
   • ICU afterwards; heart failure drugs restart once he can swallow. After surgery
   • ICD therapies restored after surgery; pads stay on until then.

4. Crisis

   Five minutes after induction BP is 72/48, HR 96, despite noradrenaline 0.2 mcg/kg/min. What do you do?

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   • Call for help; check depth, airway pressures and ETCO2 for obvious causes. (Crisis)
   • Echo now: a dilated, poorly contracting LV means low output, not vasodilation.
   • Filled but still low: he needs an inotrope added to the noradrenaline.
   • On bisoprolol, milrinone works better than dobutamine: infusion 0.3–0.7 mcg/kg/min, no bolus, noradrenaline holding pressure.
   • Dobutamine 2.5–5 mcg/kg/min is the fallback if milrinone isn't available.
   • Fluid only if his ventricle looks empty on echo.
   • Climbing lactate on two drugs means cardiogenic shock; cardiology to discuss mechanical support.

5. Crisis

   At the end, as you lighten him, SpO2 is 84% on 60% oxygen, pink froth is in the tube, BP 170/100. What do you do?

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   • Acute pulmonary oedema: keep him asleep and ventilated on 100% oxygen. Crisis
   • Add PEEP, and give a loop diuretic to offload his lungs.
   • His BP allows nitroglycerin at 0.5–5 mcg/kg/min to cut preload and afterload.
   • Echo, ECG and troponin to look for new ischaemia or mitral regurgitation.
   • Back to ICU ventilated; extubate when his oxygenation and filling improve. After surgery