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Final clinical long case 62

Created: 16/2/2018
A 72-year-old man presents with a 5 cm abdominal aortic aneurysm (AAA) with evidence of worsening right lower limb ischaemia. The vascular surgeon wants to take him to the operating theatre urgently.

Past medical history
His exercise tolerance is limited by severe hip arthritis, with nearly complete fusion of hip joints.

Surgical history
He lives with his daughter in a bungalow, and is an ex-smoker of 10 years’ standing.

Drug history
No known drug allergies
Paracetamol 1 g qds

  • Weight 65 kg, 
  • Height 180 cm 
  • Pulse rate 110 bpm 
  • Blood pressure 135/70 mmHg 
  • Temperature 36.5C 
  • Chest clear 
  • Heart sounds normal 
  • Abdomen: pulsatile, expansile mass centrally.
  • Right necrotic big toe
  • Femoral blood pressure: 11.0 mmHg 
  • White cell count: 13.5 (65% granulocytes, 25% lymphocytes) 
  • Platelet count: 240 × 109/L 
  • Na+: 142 mEq/L 
  • K+: 4.5 mEq/L 
  • Urea: 8.0 mmol/L 
  • Creatinine: 101 μmol/L 
  • Liver function tests: Normal 
  • No Chest X-ray 
  • ECG: Atrial fibrillation with isolated ventricular ectopic beats, poor R wave progression and T wave flattening in AvL, V5 and V6 
  • Echocardiogram: Normal left ventricular function, with some concentric hypertrophy; the right ventricle is moderately dilated; both atria are dilated; there are no valvular lesions

1. Summarise the case.
2. How would you approach this man for a preoperative assessment?
3. What further investigations would you carry out?
4. How could you determine maximal oxygen consumption (VO2max) and anaerobic threshold from a cardiopulmonary exercise test?
5. Once the patient has been pre-optimised and is ready for surgery, how would you anaesthetise him?
6. The cross-clamp comes off and the patient is losing blood; what would you do? Discuss the haemorrhage protocol, use of the cell saver, blood products, prothrombin citrate complex and also the use of haemoglobin substitutes.

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