...how one would approach anesthesia for this patient.

Male, early 30's - hx of esophageal stricture/perf w/ repair, DM (uncontrolled), noncompliant w/ pysch meds, polysubstance abuse, ARF.

Presented to the ER w/ n/v and abd pain, admitted then transferred. Preliminary diagnosis DKA vs lactic acidosis w/ possible esophageal perf. Chest tube is placed due to large pleural effusion, immediate return of close to a liter of thin, brown nastyness. Chest xray improved. Tachy in the 140's, bp in the 140's but trending down via a-line, CVP's 5-7, urine output initially low but improved w/ boluses. Docs don't want to start beta-blockers because + for cocaine and think CO is rate dependent because he's so dry. EGD at bedside reveals very large esophageal perf. PEG is placed, diltiazem drip started and patient is off to the OR for esophagectomy. Allergic to fentanyl.

What do you think?