Acute on Chronic Pain and Respiratory Failure in a 70-Year-Old Male with Bilateral Above-Knee Amputations and Calciphylaxis: A Case Report

Case Diagnosis: A 70-year-old male with a complex medical history, notable for bilateral above-knee amputations (AKA) and calciphylaxis.

Case Description or Program Description: The patient had recently been diagnosed with influenza A infection and was admitted for worsening shortness of breath, fatigue, and severe pain in his left residual limb that had become increasingly red and tender. His past medical history was significant for hypertension, congestive heart failure, atrial fibrillation, dyslipidemia, end-stage renal disease on hemodialysis, type 2 diabetes, gout, degenerative disc disease post-laminectomy, and cervical degenerative disc disease. His clinical course was complicated by suspected aspiration pneumonitis/bronchitis, development of a pleural effusion, and ultimately, acute hypoxic hypercapnic respiratory failure. His pain management regimen over typical 24 hours included acetaminophen 650 mg (once), oxycodone 10 mg (once) and 15 mg (four times). He also required midodrine 5 mg (three times) to address hypotension.

Setting: Tertiary care hospital.

Assessment/Results: The pain in his left residual limb remained poorly controlled, and his overall clinical condition continued to deteriorate. After extensive discussions with his care team and family, he decided to forego further aggressive interventions in favor of a palliative approach focused on comfort.

Discussion (relevance): Managing acute on chronic pain in a patient with extensive comorbidities and complex surgical history is challenging. The patient’s bilateral AKA and calciphylaxis added unique challenges in controlling localized pain. Additionally, his respiratory failure compounded the difficulty in titrating systemic analgesics without exacerbating sedation and respiratory depression. The failure of conventional multimodal analgesia—using a combination of acetaminophen, opioids, and adjuvant agents—to provide adequate symptom relief necessitated a shift in goals of care.

Conclusions: Early integration of palliative care for patients with intractable symptoms in the context of complex medical and surgical histories is paramount to adequate pain control.