Advice for case tomorrow...

[sigrhoillusion]

So looking up my only case scheduled for tomorrow... and find what could be a disaster in the making.

67 yo female with several year hx of worsening fatigue and weight loss. Had a spinal fusion in August at OSH and imaging showed lucencies. (no records in chart). Then presented to OSH with hip fracture a few days ago. Transferred to current institute and is being worked up for mulitple myeloma.

So looking through the notes, she had received some PRBC earlier that day and had received lasix at the time for her anemia with goal Hgb>10.0 per heme/onc and ortho notes. Then later that night it she had an RRT due to AMS secondary to either cumulative effects of opioids vs. CHF/pulmonary edema. She received Narcan and lasix at that time with improvement in condition. Recent CXRs from that day state opacifications and effusions with either multifocal PNA vs. pulmonary edema. Of course an ECHO has been ordered and has either not been performed or has not been read... No EKG or other cardiac workup seen in record. Notes today state she appears better with no complaints of SOB/wheezing. However, she is also receiving another unit of PRBC with goal again >10.0.

Tomorrow she is scheduled for IR embolization followed by left hip hemiarthroplasty.

Other info:
HTN appears well controlled from VS chart. On triamterene(?) at home per notes but nothing in hospital.
Asthma appears well controlled on Singulair

Labs
Hgb varying between 7-9
Plts 250
BNP 1364*
BMP wnl except mild hypokalemia of 3.4 (getting K riders on floor)
LFTs wnl except mildly elevated AP
INR 1.4...


My biggest concern is her pulmonary status. Very suspicious of pulmonary edema with no history of cardiac disease except HTN which apparently is well controlled but she's on triamterene at home which I tend to think is more likely for patients with edema. Would love to have that ECHO...

I'm not overly concerned about the hemoglobin level. A bunch of notes say prefer 10.0+ but if she's 9 tomorrow... That being said, if 3 people say prefer 10, and I go with 9 and something happens then I look like an @$$. The dilemma is getting her Hgb at an appropriate level while balancing her pulmonary status.

Finally, assuming she is optimized pre-operatively and her lungs sound clear and she has a Hgb of 11... there are zero guarantees that things go smoothly intraop and especially post-op. She's a post-op vent waiting to happen, which might be the best thing in the short run. Even if she flies during the operation, they lose a little blood (LOL) and finish in 2 hours (ROFLMAO) I could see her getting a whiff of pain medicine in recovery and crumping. I'd love to have an epidural on board for post-op pain but between the consistent 1.4 INR pre-op, and the poor epidural management on the floors at this institute I'm very hesistant. Any info on regional and multiple myeloma/lytic lesions in vertebra? I'm about to do a search.

Again, I'm mostly concerned about her pulm status. She's getting a tube no doubt. Last thing I need is her to crump intraop in the lateral position...

Well? Thoughts?

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[GravelRider]

What was her calcium level with the delirium? Patients with multiple myeloma often have hypercalcemia, which can cause delirium. It sounds like she has had a pathological fracture due to her multiple myeloma.

She may have had a case of TACO from the blood transfusions. I would still like to see an echo pre-op given her elevated BNP. Why transfuse to a hgb >10? Find out the rationale.

If her respiratory status has improved, I would lean more towards doing a spinal in this patient, assuming she has an easy airway. The spinal may reduce bleeding and thus your need for transfusion. Recheck an INR and perhaps a TEG if you are still unsure about it, but I think risk/benefit favors a spinal here. You can consider an epidural, but it sounds like your institution is not familiar with them, so that's an obstacle. This patient needs early PT, so an epidural may be counterproductive anyway. Use non opioids adjuncts for pain control.

If her pulmonary status is still crummy then talk about delaying. If delaying isn't really an option then you may have to intubate. Make sure the patient is aware of a possible ICU admission.

There are not many regional techniques for multiple myeloma pain. Radiation, chemotherapy, bisphosphonates, and palliative surgery are usually the options beyond pain meds.

 

[sigrhoillusion]

What was her calcium level with the delirium? Patients with multiple myeloma often have hypercalcemia, which can cause delirium. It sounds like she has had a pathological fracture due to her multiple myeloma.

She may have had a case of TACO from the blood transfusions. I would still like to see an echo pre-op given her elevated BNP. Why transfuse to a hgb >10? Find out the rationale.

If her respiratory status has improved, I would lean more towards doing a spinal in this patient, assuming she has an easy airway. The spinal may reduce bleeding and thus your need for transfusion. Recheck an INR and perhaps a TEG if you are still unsure about it, but I think risk/benefit favors a spinal here. You can consider an epidural, but it sounds like your institution is not familiar with them, so that's an obstacle. This patient needs early PT, so an epidural may be counterproductive anyway. Use non opioids adjuncts for pain control.

If her pulmonary status is still crummy then talk about delaying. If delaying isn't really an option then you may have to intubate. Make sure the patient is aware of a possible ICU admission.

There are not many regional techniques for multiple myeloma pain. Radiation, chemotherapy, bisphosphonates, and palliative surgery are usually the options beyond pain meds.

I meant if there were contraindications for regional and multiple myeloma with lytic fractures.

Her calcium has surprisingly been low in the 7-8 range. No ionized calciums recorded.

I think spinal would be the best option, but these surgeons are slow and I'm just worried that if she's teetering on the edge she could get acutely worse, so I think I'd rather have the secured airway (especially if the case is gonna go 3+ hours). I am planning on explaining the higher than usual risk of post-op ventilation. Also, with the INR I'm just hesitant to stick her back. Think I'd rather lean towards being cautious and tube her, cause we can always manage her fluid/resp status in the ICU post-op if she remains intubated. Harder to manage the hematoma, albeit it low risk. Perhaps if I was in the room the whole time, I'd be more likely to go spinal, but I have another room and haven't worked with this CRNA before. Not sure where they rank.... any signs of hypotension and they might end up with a liter of crystalloid in 5 minutes.

 

[pgg]

Tomorrow she is scheduled for IR embolization followed by left hip hemiarthroplasty.

Embolization of what? I know people with MM sometimes get spinal tumors embolized prior to surgery, but it sounds like all they're doing is the hip. Is something else going on?

I wouldn't do a spinal in her with an INR of 1.4 and maybe a blood dyscrasia to boot. People with MM often have other coagulation deficiencies.

GETA it is. I'd do an asleep fascia iliaca block, it's a more or less zero bleeding risk block. It might or might not help with the acetabular pain but it'll get all of the incision in the lateral femoral cutaneous disribution. 10 or 20 mg of ketamine up front for some more opiate sparing.

An echo would be nice but if you can't hear a murmur the odds of really severe valvular disease are about nil. Consider an a-line, not just for your concern of coronary disease but also to run easy blood gases, since you seem most concerned about her pulmonary status.

Be specific with your vital and fluid parameters with the CRNA, it'll be fine.

 

[vector2]

Was her fusion for pathologic fractures? Do you have access to her previous anesthetic record? What are you embolizing now? Why in god's name doesn't she at least have an EKG in the chart by now with a bnp > 1000? Do we have any idea what her fluid balance has been since she's been back in the hospital? Any chance she's had a transfusion reaction? Does she have any signs of having an infection, respiratory or otherwise?

Since you have zero cardiac workup, I'd at least have it in the back of my mind that she has decompensated diastolic HF which has been semi-stabilized due to all the lasix she's been getting, and now you're gonna have to take her to the OR after she's gotten another unit overnight.

 

[Ezekiel2517]

Aside from the unclear reasons for the IR embolization, I feel like you may be making this more complicated than it is. I don't feel the patient is all that sick. Pretty routine case in PP. I'd clinically assess the patient, look at her latest CXR myself, look at her labs and go from there. Based on your assessment, you can probably go regional/GETA/spinal or a combination thereof. If you are so concerned about her cardiac function, you can stick a probe on her chest and within minutes get a gross assessment of her EF, contractility, and volume status.

 

[sigrhoillusion]

Aside from the unclear reasons for the IR embolization, I feel like you may be making this more complicated than it is. I don't feel the patient is all that sick. Pretty routine case in PP. I'd clinically assess the patient, look at her latest CXR myself, look at her labs and go from there. Based on your assessment, you can probably go regional/GETA/spinal or a combination thereof. If you are so concerned about her cardiac function, you can stick a probe on her chest and within minutes get a gross assessment of her EF, contractility, and volume status.

Nobody is saying the case is overly difficult. The patient will make it through. Clearly my biggest concern is her Resp issue since ours not 100% clear what the cause is and it appears she ACUTELY decompensated and had an RRT this weekend while routinely sitting in her bed probably watching TV and not undergoing surgery...

I mentioned my concerns based on her latest notes, labs and findings and what I viewed as possible complications and sought advice and thoughts on what to do based on them. But I'll be sure to do either x, y, or z on this B+B private practice case

 

[Hoya11]

Nobody is saying the case is overly difficult. The patient will make it through. Clearly my biggest concern is her Resp issue since ours not 100% clear what the cause is and it appears she ACUTELY decompensated and had an RRT this weekend while routinely sitting in her bed probably watching TV and not undergoing surgery...

I mentioned my concerns based on her latest notes, labs and findings and what I viewed as possible complications and sought advice and thoughts on what to do based on them. But I'll be sure to do either x, y, or z on this B+B private practice case

Here are your debates: GA vs Regional. Id choose GA. I just prefer that approach from the get go vs spinal and sedation due to pt cooperation, ability to give sevo instead of other less friendly stuff, prior spine surgery and spine issues. just my preference.

So general. ETT or LMA? Depending on how much of a big deal pulmonary edema is, likely lead toward ETT with post op vent discussion but hopefully not. Id consider LMA if this was only mild edema or infiltrate. Probably not given recent RRT.

No matter what approach, I would get an EF somehow, yourself or a current echo, before proceeding. Its a fracture case they are not bringing her right into the OR so you have some time.
Etomidate, roc, tube. Neo gtt. Try to extubate if shes looking good.

Why are you so concerned about the diagnosis of pulmonary infiltrate or the etiology of her RRT incident? If she has a low EF or bad valvular abnormalities (as mentioned) sure this is going to change your management. Otherwise weather its CHF, PNA, pHTN with vol overload, opiates, or all of the above why do you have to have this pinned down? The big picture is still the same, she has some lung process that might mean low oxygenation or needing post op ventilation which you have to deal with.

 

[Magnus67]

You lost me at "my only scheduled case tomorrow ".......


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[sigrhoillusion]

You lost me at "my only scheduled case tomorrow ".......


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Lol... well my other room was the urgent/emergent room which filled up with a thoracotomy when I arrived. And two more hips added after i posted this. Never just one case...

So patient got delayed for the embolization so they flipped cases so still waiting. And they either got an echo or read the echo and otherwise normal EF. Still not sure where all this sudden edema came from but no difference... coags still suck so GETA it will be.

And I just saw her and she's 65 going on 95... she looks like she's knocking at the gate. Very odd since she was supposedly fine a few days ago. Should be a blast...

 

[PainDrain]

Why is her BNP so sky high? This isn't just a case of them giving her to much fluid/volume. Her heart is not normal. Remember an EF can be completely normal and you can have severe diastolic dysfunction leading to CHF, which is what this sounds like. Knowing that be careful with fluids and maintain rhythm and she will be fine. Also don't make her any promises about getting extubated.

 

[sigrhoillusion]

Why is her BNP so sky high? This isn't just a case of them giving her to much fluid/volume. Her heart is not normal. Remember an EF can be completely normal and you can have severe diastolic dysfunction leading to CHF, which is what this sounds like. Knowing that be careful with fluids and maintain rhythm and she will be fine. Also don't make her any promises about getting extubated.

Exactly... doesn't make sense. Of course the TTE RV fx is indeterminate. She's zonked out in pre-op.

 

[GravelRider]

Lol... well my other room was the urgent/emergent room which filled up with a thoracotomy when I arrived. And two more hips added after i posted this. Never just one case...

So patient got delayed for the embolization so they flipped cases so still waiting. And they either got an echo or read the echo and otherwise normal EF. Still not sure where all this sudden edema came from but no difference... coags still suck so GETA it will be.

And I just saw her and she's 65 going on 95... she looks like she's knocking at the gate. Very odd since she was supposedly fine a few days ago. Should be a blast...

It still sounds like TACO...transfusion-associated circulatory overload. You will see elevated BNPs with TACO, but you may not necessarily see a reduction in EF on echo...especially after the fact. TACO is not completely understood and is likely multifactorial (what isn't?). There is probably some amount of diastolic dysfunction involved here and the moderate increase in blood volume associated with the transfusion acted as a tipping point. It would be interesting to watch her heart on a TEE during a transfusion. Often there is an associated increase in blood pressure during the transfusion. If you do have to transfuse, keep an eye on the BP and consider using lasix and nitrates as the hemodynamics indicate. I've changed my mind and agree with GETA. I would put an a-line and use a pulse pressure variation monitor.

Other things to keep on your differential would be transient myocardial ischemia. She could have underlying CAD. By increasing the blood volume during transfusion, you may have increase the myocardial oxygen demand...possibly during a time where she was mildly hypoxic from the opioids? I don't know if I would delay the case for a stress test without knowing more information, but it is something to keep in mind.

Multiple myeloma can be a lousy disease at the end stage. There are treatment options if it caught early, but it sounds like she has fairly extensive disease with a lot of bone involvement.

 

[sigrhoillusion]

Update...

As I mentioned earlier, Because of the arterial embolization, they flipped the case order. The intermedullary nail took about 3 hours, and then there was about another hour delay between cases. As they are rolling the new OR bed into the room one of my colleagues tapped me on the shoulder to relieve me from all this mental masturbation.

I told him my concerns and bid him adieu... I will probably stalk the chart later tonight, possibly tomorrow.

Moral of the story: Academics...

 

[deleted162650]

The intermedullary nail took about 3 hours

Dude WTF? That is a 12min case. Like really, a 12min case.

 

[sigrhoillusion]

Dude WTF? That is a 12min case. Like really, a 12min case.

Ho hum...

 

[teeva]

I'm in PP. Ortho surgeon is somewhere between 60-70yo. Does about a dozen hip fractures a month that I'm aware of at my one hospital. Nails take 15 min and hemiarthroplasty take 35 min. One recent one was a little more challenging. Took 50min but felt like eternity.

 

[Psai]

Update...

As I mentioned earlier, Because of the arterial embolization, they flipped the case order. The intermedullary nail took about 3 hours, and then there was about another hour delay between cases. As they are rolling the new OR bed into the room one of my colleagues tapped me on the shoulder to relieve me from all this mental masturbation.

I told him my concerns and bid him adieu... I will probably stalk the chart later tonight, possibly tomorrow.

Moral of the story: Academics...

Did they have the circulator doing the case?

 

[jthedestroyr]

I'm in PP. Ortho surgeon is somewhere between 60-70yo. Does about a dozen hip fractures a month that I'm aware of at my one hospital. Nails take 15 min and hemiarthroplasty take 35 min. One recent one was a little more challenging. Took 50min but felt like eternity.

At my academic place, i had a gs tske 2.5hours for a MAC/local anesthesia femoral hernia repair.

Yes.... 2.5hours. And they say us ca1 arw slow. This surgeon has been a surgeon probably longer than ive been alive as well.

 

[sigrhoillusion]

So update from yesterday per my colleague.

Patient developed temp of 101+ during case but otherwise did well. He did take patient to PACU intubated (couldn't figure out if it was due to VS/oxygenation/time reasons) and ended up extubating after about 30 minutes when she was more awake. CXR again showed infiltrates/edema/effusion so they started her on abx for PNA. It also appears that they drew a blood culture during that RRT that grew gram+, but they only did one culture so not sure if contaminant. She has two more cultures coming from today.

But otherwise extubated, still AAOx1-2 and moaning in pain.

 

[Planktonmd]

What is an RRT??? and what is an AMS?
They must be bad since they require Narcan and Lasix!
And why did you think that this was such a disastrous case???
And why did an IM nail take 3 hours???

 

[sigrhoillusion]

RRT = rapid response team/treatment. Essentially it's a pre-code intervention. Many hospitals will call an RRT when patient condition is deteriorating but not to code level (yet...) So worsening breathing, seizures, altered mental status (AMS) or any other ominous conditions.

You'll have to take that up with the surgeon to figure out what took so long...

 

[norwood]

And why did an IM nail take 3 hours???

Moral of the story: Academics...