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Case note review: pulmonary hypertension and protamine Summary A 75-year-old woman was admitted electively for a right axillobifemoral bypass as treatment for bilateral critical limb ischaemia. In the audit forms, she was reported to have short distance claudication (approximately five metres) and occluded aortoiliac vessels. Her medical history was significant, including ischaemic heart disease with previous stenting of the left anterior descending artery, oesophageal cancer with liver metastases (treated with chemo-radiotherapy and reportedly in remission), paroxysmal atrial fibrillation (anticoagulated with
apixaban and clopidogrel), pulmonary hypertension, gastroesophageal reflux disease, scleroderma, CREST syndrome, type 2 diabetes mellitus, and a permanent pacemaker for sick sinus syndrome. An echocardiogram performed eight months before the operation demonstrated evidence of decreased ventricular function (ejection fraction at 35 per cent, which was likely overestimated due to moderate mitral regurgitation), and severe pulmonary hypertension (right ventricular systolic pressure [RVSP] estimated at 60 mm Hg, also likely masked by moderate tricuspid regurgitation).
The patient was reviewed by the anaesthetic team prior to the procedure and risk stratified as American Society of Anesthesiologists (ASA) physical status 4 given her extensive comorbidities. There was no documentation provided regarding the patient’s review with the vascular surgeon prior to the operation. The admission notes stated that the patient was able to walk 500 metres with a wheelie-walker. This was in contradiction to the booking form, which noted the patient had bilateral critical limb ischaemia. The booking form also stated that the surgeon had requested her apixaban not be ceased prior to the
