Part 1: Case Presentation and Systems Breakdown

Case Snapshot

Imagine a 55-year-old man facing an urgent mission: emergency surgery to clean infected wounds on both lower limbs, with the possibility of amputation looming. His body is a battleground of complex conditions. He’s got acute-on-chronic liver disease with grade 3 ascites—think of his belly swollen like an overfilled water balloon, tapped just five days ago. Jaundice paints his skin yellow, and grade 1 hepatic encephalopathy fogs his mind. Labs paint a grim picture: total bilirubin at 10.6 mg/dL (direct 7.7), albumin down to 2.6 g/dL, total protein 5 g/dL, prothrombin time prolonged at 61% index, INR elevated, and platelets at 109,000 per microliter.

His kidneys are failing, producing just 15 mL of urine per hour, and he’s been on continuous renal replacement therapy (CRRT) for three days—a slow, steady blood cleaner. Post-dialysis, creatinine is 1.8 mg/dL, BUN 62 mg/dL, bicarbonate 16 mmol/L signaling metabolic acidosis, and potassium steady at 4.5 mmol/L.

Cardiovascularly, he’s a diabetic with HbA1c 6.8%. His heart’s in trouble: echocardiography shows severe left ventricular systolic dysfunction with an ejection fraction of just 20%—like a pump barely pushing out water. There’s global hypokinesia, dilated ventricles, TAPSE at 10 mm showing right ventricular dysfunction, moderate pulmonary hypertension with RVSP around 45 mmHg plus right atrial pressure, grade II tricuspid regurgitation, mild mitral regurgitation, and a BNP of 4630 pg/mL screaming heart failure.

Infections are the enemy: a right diabetic foot ulcer with cellulitis, post-left leg amputation stump cellulitis, and urosepsis with white blood cells at 23,000 per microliter and procalcitonin 1.3. Hematology shows anemia with hemoglobin 8.1 g/dL, LDH 174, troponin I 0.02, APTT 30.6, and low-normal fibrinogen. Clinically, he’s got swollen arms from edema, a weak radial artery pulse, no ulnar artery signals, pulse 75 per minute, blood pressure 127 over 86 mmHg, and SpO2 95% on room air. Access includes a right internal jugular dialysis catheter and a left internal jugular central venous catheter.

The surgery: emergency debridement, possibly amputation. His ASA status is IV E—severe systemic disease threatening life, and it’s an emergency. This is a high-stakes case with multi-organ failure, sepsis like a wildfire, dialysis dependency, severe heart dysfunction with pulmonary hypertension, blood clotting issues, and low reserves, like a car running on fumes.

Cardiovascular Breakdown

His heart’s ejection fraction of 20% means it’s pumping weakly, relying on high filling pressures and adrenaline-like drive to keep going, like a tired engine revving hard. Right ventricular dysfunction with pulmonary hypertension increases strain, making the right heart struggle like a balloon overinflated against resistance. Too little or too much fluid can tip it over. BNP at 4630 signals severe heart failure from stretched heart walls.

For drugs, etomidate is the go-to for induction since it keeps the heart’s drive steady and ensures blood flow to the heart itself. Propofol is risky—it depresses the heart and widens blood vessels, potentially causing collapse like pulling a plug. Ketamine ramps up heart rate, blood pressure, and lung vessel resistance, dangerous with pulmonary hypertension. Norepinephrine is first-choice, tightening vessels to maintain pressure without over-revving the heart. Dobutamine can boost heart contraction but may lower blood pressure, so it’s a backup.

Clinically, avoid fluid overload to prevent lung flooding, keep vessel tone with norepinephrine, steer clear of fast heart rates or lung vessel constriction from low oxygen, high carbon dioxide, acidosis, or pain. Brainwave monitoring with BIS prevents overdosing anesthesia, which could crash the heart further.

Respiratory Insights

He’s holding at 95% oxygen saturation on room air, but pleural effusions and pulmonary hypertension complicate things. Cirrhosis can cause hepatopulmonary syndrome, where lung blood vessels shunt blood past oxygen pickup, like a detour skipping a gas station. Ascites and effusions shrink lung capacity, collapsing air sacs and risking low oxygen during anesthesia induction. Pulmonary hypertension heightens the chance of right heart failure under anesthesia.

Ventilation needs care: high pressures block right heart filling, high carbon dioxide or acidosis tightens lung vessels, and low oxygen strongly constricts them, worsening hypertension. Preoxygenate for five minutes with 100% oxygen, use low tidal volumes and minimal pressure, keep carbon dioxide and oxygen normal, and have inhaled nitric oxide or prostacyclin ready for heart crises.

Renal Realities

On CRRT for three days, his kidneys are barely functioning, with creatinine at 1.8 post-dialysis and urine output minimal. Electrolytes are stable—potassium 4.5, magnesium 2.1, phosphate 2.3—but bicarbonate at 16 shows acidosis, like the body’s pH dipping too low.

CRRT clears toxins and fluids gently, unlike regular dialysis’s quick flush. Drugs cleared by kidneys, like morphine or certain muscle relaxants, linger longer, while low albumin lets protein-bound drugs build up. Lipophilic drugs like fentanyl and propofol are safer, and cisatracurium is ideal since it breaks down independently of organs. Acidosis dulls adrenaline-like drugs and tightens lung vessels.

Monitor potassium closely—succinylcholine is safe at 4.5 mmol/L. Avoid kidney-toxic drugs like NSAIDs, adjust antibiotic doses, and keep CRRT running if possible.

Hepatic Challenges

With bilirubin at 10.6, albumin 2.6, prolonged prothrombin time, and tapped ascites, his liver’s struggling. Grade 1 encephalopathy clouds his thinking. Cirrhosis slows drug clearance, increases free drug levels due to low albumin, and messes with clotting—though INR overstates bleeding risk since clotting and anti-clotting factors are both low. N-acetylcysteine boosts liver protection, and cryoprecipitate supplies clotting factors like fibrinogen for stable clots.

Avoid long-acting liver-processed drugs like benzodiazepines, use short-acting fentanyl, correct fibrinogen with cryoprecipitate, and skip spinal anesthesia due to clotting and infection risks.

Hematology Hurdles

Hemoglobin at 8.1 g/dL means low oxygen-carrying capacity, critical with a weak heart. Platelets at 109,000 are okay for minor surgery but need watching if bleeding escalates. Prolonged prothrombin time and low-normal fibrinogen signal clotting issues. In a heart pumping at 20%, low hemoglobin slashes oxygen delivery, like starving a fire of fuel. Advanced tests like TEG or ROTEM guide transfusions better.

Transfuse red cells to keep hemoglobin at 8 or above, use cryoprecipitate for fibrinogen, and prepare a massive transfusion protocol if bleeding spirals.

Sepsis and Infection Control

Infections rage: right foot ulcer, amputation stump cellulitis, and urosepsis, with white cells at 23,000 and procalcitonin 1.3. He’s on broad-spectrum antibiotics. Sepsis causes vessel widening, heart depression, and poor oxygen use, worsened by cirrhosis slowing lactate clearance. Guidelines stress early infection source control, norepinephrine as the top vasopressor, and avoiding fluid overload in weak hearts.

This surgery is life-saving to clear infection. Start norepinephrine before induction, and use brainwave monitoring to avoid anesthetic overdose.

Reference Roundup

We’re leaning on key sources like the 2021 Surviving Sepsis Campaign in Intensive Care Medicine, the 2024 ACC/AHA Perioperative Guidelines in Circulation, and Morgan & Mikhail’s Clinical Anesthesiology, 7th edition, for evidence-based guidance.

Part 2: Risk Assessment and Anesthetic Strategy

Risk Stratification

This patient’s ASA IV E status marks severe, life-threatening disease plus an emergency. Bedridden from sepsis, his functional capacity is under 2 METs—barely enough to climb a step. The Revised Cardiac Risk Index scores 5 points: high-risk surgery, heart dysfunction at 20% ejection fraction, heart failure, dialysis-dependent kidney failure, and diabetes, signaling over 11% chance of major heart complications.

Child-Pugh score hits 12—Class C, severe liver decompensation—based on bilirubin, albumin, ascites, encephalopathy, and clotting issues. MELD-Na around 28 flags high mortality risk. This is an extreme-risk case, and clear communication with family and team is critical.

Anesthetic Plan: Preoperative Prep

Resuscitation and optimization come first. Broad-spectrum antibiotics hit the sepsis bundle. N-acetylc apresentou infusion protects the liver by restoring glutathione. Three units of cryoprecipitate fix fibrinogen deficiency. Packed red blood cells are cross-matched and ready.

Monitoring prep includes a femoral arterial line due to swollen arms and missing ulnar pulses, a left internal jugular line for vasopressors, a right internal jugular line for CRRT, and brainwave monitoring to avoid anesthetic overdose in low heart output.

Drug prep involves norepinephrine infusion, pre-diluted at 8 mg in 50 mL, started at 4 mL per hour—about 10.7 micrograms per minute—before induction. Vasopressin and dobutamine are backups. Induction drugs include etomidate, fentanyl, succinylcholine, and cisatracurium.

Induction Approach

Key threats are sudden blood pressure drops from vessel widening or heart depression, aspiration risk from encephalopathy and ascites, and hyperkalemia with succinylcholine. Preoxygenate for five minutes with 100% oxygen, keep norepinephrine running, give 100 micrograms fentanyl IV to blunt stress, titrate sevoflurane to a BIS of 55 before intubation, use 50 mg succinylcholine—safe at potassium 4.5—intubate with an 8.0 mm endotracheal tube fixed at 22 cm, and give 4 mg cisatracurium for ongoing relaxation.

Brainwave monitoring is vital: low heart output delays anesthetic spread, risking overdose and severe pressure drops. BIS at 55 ensures balanced depth.

Maintenance Phase

Keep sevoflurane titrated to BIS 40-60, using minimal volatile to lessen heart depression. Continue norepinephrine at 10.7 micrograms per minute, maintain MAP above 65 mmHg, and use minimal fluids for a restrictive strategy. Transfuse one unit of red cells to keep hemoglobin at 8-9 g/dL, critical for oxygen delivery in a weak heart.

Surgery wraps in one hour with debridements done, no amputation needed, and minimal to moderate blood loss.

Emergence and Extubation

Extubation criteria for sepsis and 20% ejection fraction include stable blood pressure on low-dose norepinephrine under 0.1 micrograms per kg per minute, BIS recovery to 90, strong breathing with normal carbon dioxide and oxygen levels, and normal temperature. Neuromuscular blockade was reversed, the patient extubated safely, and shifted to ICU with norepinephrine continued.

Postoperative Care

In ICU, titrate norepinephrine, keep dobutamine ready for low heart output. Resume CRRT to manage fluids, electrolytes, and acidosis, checking electrolytes every six hours. Continue N-acetylcysteine infusion, avoid liver-toxic drugs. For pain, use IV paracetamol up to 3 g daily, reduced for liver safety, and fentanyl infusion, avoiding NSAIDs and morphine. Start mechanical compression for clot prevention immediately, delaying drugs like heparin until bleeding stops. Redose antibiotics based on CRRT clearance, send wound cultures.

Key Lab Implications

Hemoglobin at 8.1 needs red cell transfusion intraop to maintain oxygen capacity. Platelets at 109,000 are borderline—avoid spinal blocks, monitor bleeding. Prolonged INR reflects liver dysfunction—correct with cryoprecipitate, skip regional anesthesia. Low albumin increases free drug levels, requiring careful dosing. Bicarbonate at 16 signals acidosis, dulling adrenaline response and tightening lung vessels. Creatinine at 1.8 on CRRT means dose adjustments and avoiding kidney-cleared drugs. Potassium at 4.5 allows succinylcholine. BNP at 4630 flags severe heart failure—avoid fluid overload, use norepinephrine for pressure.

Drug Choices for CRRT and Liver Disease

Safe induction agents are etomidate for stability and low-dose ketamine; avoid propofol boluses and thiopental. Use fentanyl or remifentanil for opioids, skip morphine and meperidine due to active metabolites. Cisatracurium or atracurium for muscle relaxation, avoid vecuronium and pancuronium. Paracetamol up to 3 g daily for pain, avoid NSAIDs and high-dose opioids. Norepinephrine, vasopressin, and cautious dobutamine for vasopressors, avoid dopamine due to arrhythmia risk.

Pre-Induction Checklist

Administer antibiotics, give N-acetylcysteine infusion, transfuse cryoprecipitate, have red cells ready, start norepinephrine, prep vasopressin and dobutamine, insert femoral arterial line, apply brainwave monitoring, ready airway for rapid sequence intubation, and brief the team on high-risk status.

Reference Roundup

Sources include the 2021 Surviving Sepsis Campaign, 2024 ACC/AHA Guidelines, 2022 EASL Guidelines on bleeding in cirrhosis, and Morgan & Mikhail’s Anesthesiology, 7th edition.

Part 3: Crisis Management Strategies

Handling Intraoperative Hypotension

Picture sudden blood pressure drops during induction or surgery in this septic patient with a 20% ejection fraction and cirrhosis. Sepsis widens vessels, cardiomyopathy limits heart output, cirrhosis causes fluid leaks from low albumin, and anesthetics like volatiles or propofol depress the heart and vessels.

Mean arterial pressure depends on cardiac output times vascular resistance. With output limited, resistance must be propped up with vasopressors. Norepinephrine tightens vessels and slightly boosts heart contraction, vasopressin restores tone when adrenaline fails, and dobutamine increases contraction but needs norepinephrine to counter vessel widening.

Steps: check anesthesia depth with brainwave monitoring, assess blood loss and fluid response with echo if available, give immediate norepinephrine bolus or increase infusion, add vasopressin at 0.03 units per minute if resistant, start dobutamine for low output shown by low end-tidal CO2 or poor echo contractility, and correct acidosis and low calcium to boost drug response.

Key lesson: in septic low-ejection fraction patients, vasopressors trump fluids to avoid heart overload.

Managing Acute Right Ventricular Failure

Imagine during debridement: sudden low pressure, high central venous pressure, low end-tidal CO2, and echo showing right heart dilation. The right heart needs fluid to pump but fails under high lung vessel resistance from pulmonary hypertension, anesthesia, or acidosis. A swollen right heart squashes the left, dropping output further.

Lung vessel resistance rises with low oxygen, high carbon dioxide, acidosis, high ventilation pressures, or adrenaline surges. Right heart blood flow needs systemic pressure above right heart pressure.

Steps: maximize oxygen with 100% FiO2, normalize carbon dioxide and pH with ventilation and bicarbonate or CRRT, reduce lung resistance by avoiding high pressures, use norepinephrine for systemic pressure, add milrinone for contraction and lower lung resistance with norepinephrine to prevent low pressure, use inhaled nitric oxide or prostacyclin to selectively ease lung vessels, and consider ECMO if all fails.

Key lesson: anticipate right heart crises in pulmonary hypertension and low ejection fraction; have inhaled vasodilators ready.

Tackling Bleeding and Coagulopathy

Significant surgical bleeding hits. Cirrhosis cuts fibrinogen, platelets, and clotting factors, with messy clot breakdown. INR and prothrombin time exaggerate bleeding risk—don’t correct blindly. Cryoprecipitate delivers fibrinogen and clotting factors for stable clots, platelets aid initial clot formation, and TEG or ROTEM guide specific needs: prolonged reaction time means fresh frozen plasma, low alpha angle means cryoprecipitate, low maximum amplitude means platelets. Massive transfusion protocol balances red cells, plasma, and platelets 1:1:1.

Steps: measure blood loss, check surgical field, send urgent labs for blood count, prothrombin time, fibrinogen, and TEG or ROTEM, transfuse red cells for hemoglobin under 8, cryoprecipitate for fibrinogen under 150, platelets for counts under 50k, keep body warm to avoid clotting worsening, and limit fluids to prevent dilution.

Key lesson: in cirrhosis, use TEG or ROTEM for targeted transfusions, prioritizing fibrinogen.

Emergency Workflow Flowchart

Preoperative: antibiotics, N-acetylcysteine, cryoprecipitate, red cells ready, femoral arterial line, left jugular for vasopressors, right jugular for CRRT.

Induction: preoxygenate, norepinephrine running, fentanyl 100 micrograms, sevoflurane to BIS 55, succinylcholine 50 mg, intubate, cisatracurium.

Maintenance: sevoflurane BIS 40-60, norepinephrine with vasopressin if needed, restrictive fluids, transfuse red cells, monitor with TEG or ROTEM.

Rescue: for hypotension, increase norepinephrine, add vasopressin; for right heart failure, optimize oxygen, carbon dioxide, pH, use inhaled nitric oxide, milrinone; for bleeding, targeted transfusion.

Emergence: extubate if stable, BIS recovered, pressure over 65, norepinephrine under 0.1, or ventilate in ICU.

Postoperative: ICU with CRRT, norepinephrine with dobutamine if needed, paracetamol and fentanyl for pain, cultures and antibiotic redosing, mechanical to pharmacologic clot prevention.

Crisis Management Lessons

For hypotension in septic cardiomyopathy, prioritize early norepinephrine over fluids. For right heart failure, treat lung vessel resistance with inhaled agents. For cirrhotic bleeding, INR misleads—use TEG or ROTEM, correct fibrinogen first. Always start norepinephrine pre-induction in septic low-ejection fraction cases. Brainwave monitoring prevents overdose in low output states.

Reference Roundup

Sources include Price et al on non-cardiac surgery and pulmonary hypertension in British Journal of Anaesthesia 2021, Vahanian et al on 2022 ESC/ERS pulmonary hypertension guidelines, EASL 2022 on cirrhosis bleeding, and Carson et al on transfusion thresholds in Cochrane 2021.

Part 4: Clinical Pearls and Detailed Postoperative Plan

Clinical Pearls for Anesthesia Practice

Preoperative: ASA IV E signals severe risk and emergency—anticipate instability, involve ICU early. Cryoprecipitate beats fresh frozen plasma for fibrinogen in cirrhosis. N-acetylcysteine protects the liver. Start norepinephrine before induction, not as a rescue.

Induction: Etomidate trumps propofol for stability in 20% ejection fraction. Fentanyl at 100 micrograms offers safe analgesia. Succinylcholine is fine at potassium 4.5—always check in dialysis patients. BIS at 55 before intubation prevents overdose in low output.

Maintenance: Cisatracurium’s organ-independent breakdown is ideal for liver-kidney issues. Sevoflurane at BIS 40-60 avoids deep anesthesia’s heart depression. Restrictive fluids and vasopressors work best in septic low-ejection fraction cases. Transfuse red cells to keep hemoglobin at 8 or above for oxygen delivery.

Emergence: Extubate only if stable—pressure over 65, norepinephrine under 0.1 micrograms per kg per minute, strong breathing, BIS over 90. ICU backup is a must.

Postoperative: Resume CRRT early for electrolyte, acidosis, and fluid control. Analgesia ladder: paracetamol up to 3 g daily short-term, fentanyl infusion for renal...