40yo male with severe comorbidities for femoral endarterectomy 

Background

• Severe central sleep apnoea. Previous postoperative respiratory arrest due to same. Home NIV (non compliant) 
• ESRD
  • Haemodialysis.
  • Non-adherent to fluid restriction – high volume fluid removal each session
  • Burnt his feet in the shower and did not realise for 3 days 
• HTN
• PVD with risk of tissue loss
• Peripheral neuropathy – multifactorial. Previous severe burns to feet from same.
• Epilepsy with occasional seizures due to non-adherence 
• AF on DOAC (to cease for 3 days) 

Issues

• Perioperative risks
  • Previously declined for parathyroid surgery due to perioperative risks

• Goals of care
  • Complex as this patient refuses or is non-adherent to therapeutic interventions 

Discussion

• Limb-threatening condition with significant impact on QoL – patient should have procedure

Plan

• Proceed with surgery
• Dialysis day before (wed) 
• To bring in CPAP despite adherence issues
• ICU level 2