Post-ICU Triple Amputation for Vasopressor-Induced Ischaemia

You have been contacted by a vascular surgeon to inform you of an upcoming case at your metropolitan hospital. The patient is a 50-year-old previously well man who had a ten-day ICU admission for severe sepsis due to COVID-19 pneumonitis with Streptococcus pneumoniae superinfection, for which he was intubated and ventilated as well as treated with inotropes and vasopressors. He was extubated one week ago and vasopressor support was weaned. He is currently on a medical ward. He requires bilateral below-elbow amputations and a right below-knee amputation for vasopressor-induced irreversible ischaemia associated with intractable pain. He has a resolving lung injury and remains on oxygen at 3 L/minute via nasal prongs. Current observations: SpO2 89% on room air SpO2 95% on oxygen 3L/minute Weight 80 kg (premorbid weight 85 kg) Height 179 cm BMI 25 kg/m2 (premorbid BMI 26.5) Medications: Ampicillin 1 g QID Paracetamol 1 g QID Pregabalin 50 mg TDS Oxycodone/naloxone 20 mg/10 mg BD Oxycodone infusion – 4 mg per hour intravenously (Note - ketamine was trialled and removed due to nightmares and dysphoria) The surgeon anticipates a surgical time of eight hours and will involve the use of bilateral upper limb tourniquets and skin grafting.