88 y/o with femoral fracture..crap

So, where does he fall on the list of "10 Sickest Patients I've Ever Seen"?

Why the stress echo? Sounds like most folks that age. Prop fent roc tube gas ?

Easy. Spinal. Next!

Carefully dosed spinal catheter.

Retrograde wire...

cchoukal said:

Retrograde wire...

Click to expand...

Hahaha.
Fent, prop, lido, sux, tube. Unless you drown him, he sounds like he'll extubate.
Or, Epidural, MAC.
Glad to be done with these cases.

pent sux tube...


Just kidding.


Spinal catheter.

I'm as big a fan of spinal catheters as anyone, but I don't see a need in this case.

They're great for when you MUST avoid hypotension- tight AS, pulm HTN, etc.

I don't see that here.

I'd do an isobaric spinal with 10mg of bup and call it a day.

If there was some reason regional was contraindicated, I'd go the GA/LMA route.

I look at the family like I'm Ivan Drago and tell them "If he dies, he dies."

But I don't think he will.

I also think getting a stress echo is way overkill. What were you gonna do with that? Take him to the cath lab, stent him, plavix load him, then fix his hip?

wait did you really get (or even ask for) a stress echo or just a bedside echo?

This is a routine case in Florida. Single shot Spinal. Case will take under an hour. If you saw how many patients I take care of weekly who are worse than this patient you would understand this is routine.

We don't delay these cases for work ups unless absolutely necessary. This patient is at risk of a complication the longer he sits around waiting for his surgery.

epidural man said:

Agreed, stress echo overkill. I mostly wanted a look at his aortic valve to see if neuraxial technique would kill him. as far as stress echo, I love to know what heart rate they can tolerate. It makes me feel warm and fuzzy.

Any takers on a femoral nerve catheter?

Click to expand...

88 year olds rarely have a lot of post op pain. A single shot FICB is all this guy needs along with some good fortune he doesn't get a postop pneumonia or DVT and die in the hospital.

Single shot spinal for the anesthetic.

In a retrospective study that included 3,997 consecutive patients with a hip fracture, 272 (6.8%) were confirmed to have a previously undiagnosed aortic stenosis as a result of echocardiography to investigate a previously undiagnosed heart murmur [20]. While it is recommended that echocardiography should be performed as part of a preoperative assessment if aortic stenosis is suspected, to allow confirmation of diagnosis, risk stratification, and possible cardiac intervention


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2974919/

The benefit of preoperative cardiac screening is ques- tionable. In our study, the major complication rate was 27% (6/22) for patients delayed for additional cardiac evaluation versus 10% for patients who were not delayed (P = .04). It has been suggested that elderly patients without major risk factors for cardiac complications be treated as if they had underlying moderate cardiac dysfunction—instead of having them undergo preoperative cardiac clearance


http://www.ecardiologynews.com/fileadmin/qhi_archive/ArticlePDF/AJO/037010032.pdf

Following hip fracture, it has been demonstrated that
patients with dementia go on to experience increased
frequency and severity of complications. They experience
higher rates of mortality and psychological morbidity
post-operatively [26, 27]. Dementia was the highest
independent cause of death following hip fracture in a
study by Llewellyn et al [28]. Patients with dementia
experience longer hospital stays [29], increased risk of
institutionalisation [30] and higher rates of post-operative
complications including infection [31] and pulmonary
embolism [32]. There is also increased risk of second
fracture in this population [33, 34].

http://www.medsurgemergencies.co.uk...an-adapting-acute-management-improve-outcome/

Anesthesiology. 2012 Jul;117(1):72-92. doi: 10.1097/ALN.0b013e3182545e7c.
Comparative effectiveness of regional versus general anesthesia for hip fracture surgery in adults.
Neuman MD, Silber JH, Elkassabany NM, Ludwig JM, Fleisher LA.
Source
Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA. [email protected]
Abstract
BACKGROUND:
Hip fracture is a common, morbid, and costly event among older adults. Data are inconclusive as to whether epidural or spinal (regional) anesthesia improves outcomes after hip fracture surgery.
METHODS:
The authors examined a retrospective cohort of patients undergoing surgery for hip fracture in 126 hospitals in New York in 2007 and 2008. They tested the association of a record indicating receipt of regional versus general anesthesia with a primary outcome of inpatient mortality and with secondary outcomes of pulmonary and cardiovascular complications using hospital fixed-effects logistic regressions. Subgroup analyses tested the association of anesthesia type and outcomes according to fracture anatomy.
RESULTS:
Of 18,158 patients, 5,254 (29%) received regional anesthesia. In-hospital mortality occurred in 435 (2.4%). Unadjusted rates of mortality and cardiovascular complications did not differ by anesthesia type. Patients receiving regional anesthesia experienced fewer pulmonary complications (359 [6.8%] vs. 1,040 [8.1%], P < 0.005). Regional anesthesia was associated with a lower adjusted odds of mortality (odds ratio: 0.710, 95% CI 0.541, 0.932, P = 0.014) and pulmonary complications (odds ratio: 0.752, 95% CI 0.637, 0.887, P < 0.0001) relative to general anesthesia. In subgroup analyses, regional anesthesia was associated with improved survival and fewer pulmonary complications among patients with intertrochanteric fractures but not among patients with femoral neck fractures.
CONCLUSIONS:
Regional anesthesia is associated with a lower odds of inpatient mortality and pulmonary complications among all hip fracture patients compared with general anesthesia; this finding may be driven by a trend toward improved outcomes with regional anesthesia among patients with intertrochanteric fractures.

Prop 50mg, LMA, Sevo. PSVPro with 5 of PEEP and 5-10 of support as necessary. Ofirmev 1gm. Phenylephrine gtt if necessary. Fent only after wake up IF necessary.

Tuck

BLADEMDA said:

This is a routine case in Florida. Single shot Spinal. Case will take under an hour. If you saw how many patients I take care of weekly who are worse than this patient you would understand this is routine.

We don't delay these cases for work ups unless absolutely necessary. This patient is at risk of a complication the longer he sits around waiting for his surgery.

Click to expand...

I too was kinda wondering why this guy is so "sick". This is like every other patient in our institution. I have not taken care of an ASA 1 patient in a very long time.

Depending on the type of fracture, one could consider non-operative management. However, I'm assuming that wasn't an option. Either way, a stress echo is a little much. What if there was something positive ... you going to delay the case for at least 2-6 weeks for stents or angioplasty? It is a very rare event that I order stress testing on pre-op patients anymore. I've had one, maybe two positive results in the last two years (and I see hundreds to thousands of pre-op patients in our clinic). Most of the people who are going to infarct in the peri-op period are not going to have positive stress tests anyway. Patient has poor functional capacity but only 0-1 ACC/AHA risk factors. This wouldn't buy him a stress test from me.

Depending on length of surgery, I would either do single shot spinal or spinal catheter. I would prefer not to intubate this guy. Who knows how bad is lung function truly is and with increasing sputum production, it's worrisome.

Honestly, I'm more worried this guy has a COPD exacerbation or a developing pulmonary infection. That will be what kills him before his heart.

loveumms said:

I too was kinda wondering why this guy is so "sick". This is like every other patient in our institution. I have not taken care of an ASA 1 patient in a very long time.

Depending on the type of fracture, one could consider non-operative management. However, I'm assuming that wasn't an option. Either way, a stress echo is a little much. What if there was something positive ... you going to delay the case for at least 2-6 weeks for stents or angioplasty? It is a very rare event that I order stress testing on pre-op patients anymore. I've had one, maybe two positive results in the last two years (and I see hundreds to thousands of pre-op patients in our clinic). Most of the people who are going to infarct in the peri-op period are not going to have positive stress tests anyway. Patient has poor functional capacity but only 0-1 ACC/AHA risk factors. This wouldn't buy him a stress test from me.

Depending on length of surgery, I would either do single shot spinal or spinal catheter. I would prefer not to intubate this guy. Who knows how bad is lung function truly is and with increasing sputum production, it's worrisome.

Honestly, I'm more worried this guy has a COPD exacerbation or a developing pulmonary infection. That will be what kills him before his heart.

Click to expand...

Agree. These types of patients may get a pneumonja or DVT/PE postop. Those are statistically much more likely to kill him than a cardiac event after this operation.

tucker27705 said:

Prop 50mg, LMA, Sevo. PSVPro with 5 of PEEP and 5-10 of support as necessary. Ofirmev 1gm. Phenylephrine gtt if necessary. Fent only after wake up IF necessary.

Tuck

Click to expand...

My partners do it your way. Usually about 1 mg/kg of propofol then an LMA. I feel these patients do better with a FICB and a spinal if not contraindicated. The risk of pulmonary complication and a DVT are decreased with a neuraxial block. However, the majority of my partners prefer an LMA anesthetic for these cases.

tucker27705 said:

Prop 50mg, LMA, Sevo. PSVPro with 5 of PEEP and 5-10 of support as necessary. Ofirmev 1gm. Phenylephrine gtt if necessary. Fent only after wake up IF necessary.

Tuck

Click to expand...

That's how I'd do it.

Numerous studies have shown that early fixation of hip fractures leads to better outcomes, even in the sick population. There was a study out of Canada that I can't seem to find about 3 years ago where they found similar rates of perioperative issues with pts suffering from multiple medical comorbidities ie chf, dm, etc... as compared to 'healthy' patients. As you guys are saying, a nice spinal can do the trick, and we can typically place a unipolar arthroplasty in about 30 minutes or a cemented bipolar in about 60 minutes.

http://www.ncbi.nlm.nih.gov/pubmed/20837683

http://www.ncbi.nlm.nih.gov/pubmed/8374488

100 mg propofol, lma, next.

This case is like every night on call where I work. Spinal would probably be ok too but this is faster and the sooner they get off the table the better.

Surfer said:

100 mg propofol, lma, next.

This case is like every night on call where I work. Spinal would probably be ok too but this is faster and the sooner they get off the table the better.

Click to expand...

100 mg of propofol? Even on a 90 year old female weighing 40 kg? I prefer to use 1 mg/kg as that is plenty in this population.

+1 to low dose PPF, LMA, FICB, low or no dose fent.

BLADEMDA said:

This is a routine case in Florida. Single shot Spinal. Case will take under an hour. If you saw how many patients I take care of weekly who are worse than this patient you would understand this is routine.

We don't delay these cases for work ups unless absolutely necessary. This patient is at risk of a complication the longer he sits around waiting for his surgery.

Click to expand...

This.

Echo for AS eval is overkill. If I can't hear it on auscultation it's not tight enough to kill him.

Prep, pinch, pop..

Trisomy13 said:

Echo for AS eval is overkill. If I can't hear it on auscultation it's not tight enough to kill him.

Prep, pinch, pop..

Click to expand...

I do the same as you. Listen over the chest for aortic stenosis. No murmur then proceed with case. If I do get an echo I simply have the tech stand there while I look at the heart on the screen . No formal read as I don't want to delay the case.

Certainly, if you prefer to wait until the TTE is completed the next morning that is reasonable.
But, you shoud try and expedite these cases within 48 hrs. 95 percent of our hip fractures are operated upon in 24 hours or less and I can tell you they are old, sick patients in general.

Med student review:

http://m.youtube.com/watch?v=ApomG3ci3Eg&desktop_uri=/watch?v=ApomG3ci3Eg


The murmur of aortic stenosis is typically a mid-systolic ejection murmur, heard best over the "aortic area" or right second intercostal space, with radiation into the right neck. This radiation is such a sensitive finding that its absence should cause the physician to question the diagnosis of aortic stenosis. It has a harsh quality and may be associated with a palpably slow rise of the carotid upstroke. Additional heart sounds, such as an S4, may be heard secondary to hypertrophy of the left ventricle which is caused by the greatly increased work required to pump blood through the stenotic valve. Because the second heart sound is largely generated by the sudden closing of the aortic valve, a poorly mobile and stenotic aortic valve may cause S2 to become quieter or even absent. Although S2 is normally created by the closure of the aortic valve followed by the pulmonary valve, if the closure of the aortic valve is delayed enough, it may close after the pulmonary, creating an abnormal paradoxical splitting of S2.

Trisomy13 said:

Echo for AS eval is overkill. If I can't hear it on auscultation it's not tight enough to kill him.

Prep, pinch, pop..

Click to expand...

Actually ... there is no correlation between the intensity of the murmur and the severity of the aortic stenosis and severe aortic stenosis could exist with no murmur at all.
But I agree that doing an echo to screen every old patient for AS is not necessary.

Almost all patients with moderate or severe aortic stenosis have an audible systolic murmur.6 However, the site of maximum intensity does not aid differentiation from mitral regurgitation, and the murmur of aortic stenosis may be most easily audible in the &#8216;mitral area'. This may cause a mistaken diagnosis of ischaemic mitral regurgitation in a patient with severe aortic stenosis and angina. The absence of a murmur over the right clavicle can help to exclude aortic stenosis.7 It has been suggested that the grade of murmur and timing of peak intensity may correlate to the severity of stenosis. However, in 123 asymptomatic patients with aortic stenosis examined by a single consultant cardiologist, a grade 3/6 murmur or above predicted a peak gradient of more than 64&#8201;mmHg with 90% specificity but only 29% sensitivity.8 In this series, mild stenosis was usually associated with a short soft murmur, but murmur intensity can be a poor predictor of the severity of aortic stenosis in an unselected population if patients with left ventricular failure are included.9

Aortic stenosis is common in the elderly and potentially fatal soon after or even before the onset of noticeable symptoms. The classical signs of severe aortic stenosis are often absent, and, in particular, systemic hypertension is common.

Every patient aged over 70 years should be auscultated routinely if they visit their general practitioner, and, if a systolic murmur is detected, questioned carefully for exertional symptoms. The genuinely asymptomatic patient with a combination of a quiet grade 1 or 2/6 murmur, normal carotid amplitude and a normal second heart sound is very unlikely to have severe aortic stenosis, and does not require an echocardiogram. For all other patients, a routine echocardiogram should be requested to exclude significant aortic stenosis. All patients with suspected heart failure and a murmur should have an echo before an angiotensin&#8208;converting&#8208;enzyme inhibitor is commenced.

http://qjmed.oxfordjournals.org/content/93/10/685.full

Planktonmd said:

Actually ... there is no correlation between the intensity of the murmur and the severity of the aortic stenosis and severe aortic stenosis could exist with no murmur at all.
But I agree that doing an echo to screen every old patient for AS is not necessary.

Click to expand...

A patient wth no murmur with auscultation may still have aortic stenosis. That said, the vast majority of patients with severe AS do have murmurs with auscultation.


Summary
The prevalence and severity of aortic stenosis in unselected patients admitted with a hip fracture is unknown. Derriford Hospital operates a routine weekday, pre-operative, targeted bedside echocardiography examination on all patients admitted with a hip fracture. We carried out a prospective service evaluation for 13 months from October 2007 on all 501 admissions, of which 374 (75%) underwent pre-operative echocardiography. Of those patients investigated, 8 (2%) had severe, 24 (6%) moderate and 113 (30%) had mild aortic stenosis or aortic sclerosis. Eighty-seven of 278 (31%) patients with no murmur detected clinically on admission had aortic stenosis on echocardiography and of the 96 patients in whom a murmur was heard pre-operatively, 30 (31%) had a normal echocardiogram. Detection of a murmur does not necessarily reflect the presence of underling aortic valve disease. However, if a murmur is heard then the likelihood of the lesion's being moderate or severe aortic stenosis is increased (OR 8.5; 95% CI 3.8&#8211;19.5). Forty-four (12%) of our unselected patients with fractured femur had either moderate or severe aortic stenosis (with or without moderate or severe left ventricular failure), or mild stenosis with moderately or severely impaired left ventricular
Function.

Anaesthesia 2012, 67, 51&#8211;54

In the study listed above only 1 patient had severe AS without a murmur.

Our results show there were no significant differences in 30-day mortality rates between the aortic stenosis groups and the control group. This may have been because of alterations in anaesthetic, surgical and medical management in the peri-operative period made as a result of knowledge of the echocardiographic findings. The significantly greater age of the patients in the aortic stenosis groups compared to the control group makes this finding even more encouraging as we could have expected greater mortality in the aortic stenosis groups as a consequence of increasing age alone. There were also no statistically significant differences between the 1 year mortality rates between the groups. A larger sample size may have revealed different findings, but we do present the complete data from a 4-year period in a hip fracture unit admitting almost 1000 hip fractures per year, so we stand by the clinical relevance of our results.

Previously undiagnosed aortic stenosis revealed by auscultation in ...
onlinelibrary.wiley.com &#8250; ... &#8250; Anaesthesia &#8250; Vol 64 Issue 8 &#8250; Abstract
by ME McBrien - &#8206;2009 - &#8206;Cited by 25 - &#8206;Related articles
Jul 8, 2009 - M. E. McBrien1,; G. Heyburn2,; M. Stevenson7,; S McDonald3, ... the patient details, management and outcome of the 272 hip fracture patients ...

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Arch Gerontol Geriatr. 2008 May-Jun;46(3):401-8. Epub 2007 Jul 12.
Aortic stenosis in elderly hip fractured patients.
Adunsky A, Kaplan A, Arad M, Mizrahi EH, Gottlieb S.
Source
Department of Geriatric Medicine and the Orthogeriatric Unit, Sheba Medical Center, Tel-Hashomer, Ramat Gan 52561, Israel. [email protected]
Abstract
Aortic stenosis (AS) and hip fractures are unrarely seen in elderly patients. The decision whether to operate these patients or not remains difficult. The present study examined the characteristics of such patients and the possible interrelations with management and outcome. This retrospective chart review study was conducted in a tertiary hospital during a 10-year period. We looked for demographic, clinical and echocardiographic characteristics of the patients, as well as their in-hospital course, compared with 100 hip fracture patients without AS. We identified 71 patients with AS hospitalized for acute hip fractures, 62 out of whom were included in the final analysis. Mean age of AS patients was 85.9+/-7.4. Mean and peak AV gradient were 35.8+/-16.3 and 59.0+/-26.7 mmHg, respectively. Mean valve area was 0.97+/-0.64. Fifty-six AS patients (91%) were operated. Rate of major in-hospital complications was 8% compared with 3.6% in non-AS patients. In-hospital mortality was 6.5% compared with 3.3% in non-AS patients (p=0.01), respectively. One-year mortality was 17.7% (11/62) among AS patients and 16.1% in non-AS patients. Death of AS patients was not interrelated with age, gender, pre-fracture function or echocardiographic data (mean and peak AV gradients, ejection fraction and valve area). We conclude that surgery of hip fractured elderly with AS was associated with increased rate of major complications and in-hospital mortality rates, compared with controls; however, 1-year mortality rate was similar in both groups. It remains to be determined whether a more careful medical and surgical management of such patients will result in less eventful hospital course.

Can a patient with severe AS tolerate a 1.5cc 0.75% hyperbaric bupivacaine spinal?

epidural man said:

mostly echo was to look at valves and EF to make sure spinal didn't hurt him.

I was mostly worried about COPD and intubation - high likelyhood he may not be extubatable.

Anyway, he got a spinal - worked like a charm as expected.

I rarely do these cases so it was a little more anxiety provoking for me than probably most private practice hospital based anesthesiologists.

Click to expand...

not to belabor this, but you originally said stress echo, which i think would be a great way to punt the case to the next day, but probably not very helpful here. i could see simple TTE if you were worried about the things you referenced above.

did anyone mention awake retrograde and low tidal volume ventilation yet?

Oggg said:

Can a patient with severe AS tolerate a 1.5cc 0.75% hyperbaric bupivacaine spinal?

Click to expand...

at some point it becomes riskier than a simple general anesthetic. its probably also harder to defend the decision should there be a negative outcome.

but anything is possible.