Emergency Hernia Repair in Severe Cardiorespiratory Disease

You are the anaesthetist in the emergency theatre at a tertiary hospital. Your first case is a planned open right inguinal hernia repair in a 73-year-old man who presented overnight with an incarcerated hernia. Conservative management has failed. The surgeon wishes to proceed urgently to prevent strangulation. Medical History Severe smoking related COPD with type II respiratory failure ABG on room air: pH 7.32 (7.35-7.45), pCO2 49 mmHg (35-45 mmHg), pO2 81 mmHg (80-100 mmHg), HCO3- 29 mmol/L (22-26 mEq/L) Coronary artery disease - right coronary artery 80% stenosis Valvular heart disease - severe mitral regurgitation - severe tricuspid regurgitation - normal left ventricular ejection fraction - mild right ventricular systolic dysfunction Pulmonary hypertension - right ventricular systolic pressure (RVSP) 60 mmHg Paroxysmal atrial fibrillation Stage 2 chronic kidney disease - GFR 65 ml/minute, creatinine 100 micromoles/litre Medications Amiodarone 200 mg once daily Digoxin 62.5 mcg once daily Frusemide 20 mg once daily Metoprolol 25 mg bd Rivaroxaban 15 mg once daily Rosuvastatin 40 mg once daily Tiotropium inhaler 18 mcg once daily