Successful Use of Regional Anesthesia for Above-the-Knee Amputation in an ASA 4 patient with Severe Right Ventricular Dysfunction and Metastatic Cancer

Merlyn George, MD; Elilary Montilla Medrano, MD

An ASA 4 patient with a predicted high risk for adverse events undergoing surgery poses several challenges in undergoing a safe and successful anesthesia plan. 

65-year-old female with past medical history significant for Hypertension, CAD s/p CABG, bioprosthetic MVR with severe prosthetic mitral valve stenosis, atrial fibrillation, CKD, CVA with baseline confusion, L ICA stenosis, IDDM2, obesity, pleomorphic liposarcoma on left thigh s/p resection with metastases to the liver, lung and bone on chemotherapy complicated by anthracycline-induced cardiomyopathy and thrombocytopenia, and PAD with chronic LLE limb ischemia presented with worsening ischemic left foot with gangrene.

 

Recent TTE showed moderately decreased ejection fraction, severe right ventricular dysfunction with RV pressure overload, biological mitral prosthesis with severe mitral stenosis, and severe tricuspid regurgitation.

 

The patient was recently admitted at another hospital and was deemed not a surgical candidate due to her cardiovascular history. Cardiology stated that she needs cardiac catheterization, but she is not a candidate because she cannot be on DAPT due to thrombocytopenia and needing frequent blood transfusions. 

 

She was transferred to our hospital for a second opinion.  Vascular surgery recommended a left above-knee amputation. Her hospital course was by respiratory failure and altered mental status requiring intubation and vasopressors due to sepsis from aspiration pneumonia. The patient was successfully extubated after several days. POMA was obtained. Based on the NSQIP surgical risk calculator, this patient is at high risk for adverse events (23.6% risk of mortality, 22.8% risk of serious complications) for an intermediate-risk procedure. Cardiology concurred. She is classified as ASA 4. 

 

Given her comorbidities and her complicated hospital course, she is at high risk of complications from general anesthesia.