Case: Bilateral total knee revision

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ethilo

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83 year old female, 92 kg, history of bilateral total knees 15 years ago, complicated by infection, antibiotic spacers placed 5 years ago with R knee explant, then fall with femur fracture 2 months ago requiring IM rod (NOT periprosthetic). Now undergoing elective bilateral total knee revision for exhausting all conservative strategies at managing infected hardware. Surgery is now being done at a community hospital with a 5 bed ICU, level 3 trauma center. There is a level 2 trauma center in the same hospital system that both our surgeon and anesthesia group work at too that is down the street with 4 icus, cardiac, neuro, etc.

PMH
Afib s/p AV node ablation and pacemaker placement, settings: PPI, minimum HR is 70. No AICD
Emphysema with severe pulmonary HTN, PAP 73 mmhg, TTE with admission for femur fracture showed EF 55%, normal RV function.
DVT LLE 4 months ago
Prev breast cancer in remission
PMR - on 10 mg prednisone daily for last 2 years

Pre-op area exam
BMI 33, awake and alert, looks chronically sick but not acutely ill appearing. States she cannot live with the pain from knees and has to have surgery.
Lungs have trace crackles on exam
Legs 1+ pitting edema bilaterally
Sitting upright, JVD to the jaw, doesn't go down with inspiration.
HR 70 (paced)
She is 10 lbs up from her last admission 2 months ago where she was discharged "euvolemic." Seen by cardiology in follow-up prior to this procedure for clearance and deemed a "moderate" MACE risk.

Labs
WBC 9, HCT 32

Anesthesia plan?
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ethilo said:
83 year old female, 92 kg, history of bilateral total knees 15 years ago, complicated by infection, antibiotic spacers placed 5 years ago with R knee explant, then fall with femur fracture 2 months ago requiring IM rod (NOT periprosthetic). Now undergoing elective bilateral total knee revision for exhausting all conservative strategies at managing infected hardware. Surgery is now being done at a community hospital with a 5 bed ICU, level 3 trauma center. There is a level 2 trauma center in the same hospital system that both our surgeon and anesthesia group work at too that is down the street with 4 icus, cardiac, neuro, etc.

PMH
Afib s/p AV node ablation and pacemaker placement, settings: PPI, minimum HR is 70. No AICD
Emphysema with severe pulmonary HTN, PAP 73 mmhg, TTE with admission for femur fracture showed EF 55%, normal RV function.
DVT LLE 4 months ago
Prev breast cancer in remission
PMR - on 10 mg prednisone daily for last 2 years

Pre-op area exam
BMI 33, awake and alert, looks chronically sick but not acutely ill appearing. States she cannot live with the pain from knees and has to have surgery.
Lungs have trace crackles on exam
Legs 1+ pitting edema bilaterally
Sitting upright, JVD to the jaw, doesn't go down with inspiration.
HR 70 (paced)
She is 10 lbs up from her last admission 2 months ago where she was discharged "euvolemic." Seen by cardiology in follow-up prior to this procedure for clearance and deemed a "moderate" MACE risk.

Labs
WBC 9, HCT 32

Anesthesia plan?
Click to expand...

Delay the case for volume optimization in this patient with clear volume overload in the setting of severe pHTN. Proceed once euvolemic. Epidural for post-op analgesia. Prop, sux, tube. Possible post-op ventilation.
 
SaltyDog said:
Will they be ok putting new hardware in one side without removing the infected hardware on the other? Concern for seeding new implants? Honest question.
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I was wondering this but didn't ask surgeon. May have been nice to have done it stepwise.
 
SaltyDog said:
Will they be ok putting new hardware in one side without removing the infected hardware on the other? Concern for seeding new implants? Honest question.
Click to expand...

Not sure. Worth a consult with your ortho collegues. All our blt tka’s are on healthy patients. Need a good reason to not stagger.
 
beyond delaying for volume optimization, I see no evidence of disseminated/bloodstream infection, which makes CSE a better option than straight spinal. could get bcx pre-op to cya.
 
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I'm inclined to say admit for diuresis, and proceed tomorrow after the internists have had a chance to wring her out some. Make sure they buff the lytes. Staggering these should be discussed, even if only staggered by a day if they're insistent on doing it all in one hospitalization.

Once euvolemic, put in an art line, do a CSE w/ precedex sedation for the case, leave the epidural for postop pain mgmt, norepi gtt to keep her BP w/i 20% of baseline.

When the patient refuses a neuraxial, put in an art line, bilateral adductor canal blocks, prop/sux/tube, norepi gtt to keep her BP w/i 20% of baseline, counsel regarding the risk of postop ventilation.
 
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GETA, agree that volume optimization will be important for this patient.

she has zero rehab potential, if ortho wanted to do bilateral revisions I would do it, see no need to stage them.

I’m concerned about an epidural catheter for postop pain with a chronic infection, although I agree the odds of any bacteremia are highly unlikely since she’s lived many years already. I would opt for bilateral femoral catheters.

I would think this case should be done in the tertiary care center, very likely something will go wrong postop.
 
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Why are you guys diuresing this pulmonary hypertension patient? 1+ pitting edema doesn't faze me. If it were 4+ and she can't lay down without choking on her pulmonary edema then maybe... I'd rather keep her a little more full than empty. With the tourniquet up, blood loss will be minimal but for a 5+ surgery they will have to bring it down and up again. She will get coagulopathic and will suck at making fibrin. Also these patients will probably bleed a bit postop.
 
sevoflurane said:
One knee at a time
Click to expand...
Yes. Or do them simultaneously with two fellowship trained surgeons. We did BL primary TKAs in fellowship. But, this scenario is asking for trouble. Sick, already had infectious... Prepare for AKAs when these get infected.
SaltyDog said:
Will they be ok putting new hardware in one side without removing the infected hardware on the other? Concern for seeding new implants? Honest question.
Click to expand...
Sounds like she already has abx spacers and now needs the new hardware out in. Spacers for years means she's a very u healthy patient. Usually, you do the revision about three months after the explant.

Needless to say. One at a time with a quick surgeon (<120mins) for revision replant.
 
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What’s the CXR look like? What’s the BNP? Home O2 req? Is she on A/C? Can she lie flat? Does she take diuretics or any CHF meds chronically?
 
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This AF patient with a DVT anticoagulated?
 
Main concern is her volume status. Sounds hypervolemic with elevated JVP and peripheral edema and weight gain. Since this is elective, I would ask for optimization. Likely from her severe pulmonary HTN. After bringing her back, my anesthetic plan would be arterial line, CSE with heavy bupi 1.4ml, 100mcg epi and 20mcg fentanyl. I’ll bolus the epidural with 2%lido with epi after a couple hours. Use the epidural for post op pain with dilute local anesthesic. Patient also needs stress dose steroids.
That’s assuming there isn’t issues with anticoagulants which wasn’t mentioned in the presentation.
 
You guys are going to love the ending of this... 😝
 
fakin' the funk said:
Admit, interval TTE, labs, diurese
Optimize for bilateral TKA under general, CVC, postop ICU, do y'all have iNO?
Click to expand...
Would be sure patient is euvolemic before giving NO or Veletri- pulmonary vasodilator can cause flash pulmonary edema when your LA pressure is high
 
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ethilo said:
Haaa, you must have fast surgeons. Booked for 5-6 hours
Click to expand...
ethilo said:
You guys are going to love the ending of this... 😝
Click to expand...

I’m gonna take a guess. Complex surgery with slow surgeons on a sick patient in a podunk community setting. It goes one of two ways:

1. prop succ tube and she does fine
2. Prop succ tube and you transfer after you can’t wean her from the vent or you try to extubate, it fails and you reintubate, and then transfer.
 
I can’t tell but how long did this poor lady have spacers, which you’re not supposed to ambulate on correct? Hard to tell from the story but sounds way too long. Sounds like the best thing for her, in the end, may be skipping all the revision drama and doing bilateral AKAs.
 
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Southpaw said:
I can’t tell but how long did this poor lady have spacers, which you’re not supposed to ambulate on correct? Hard to tell from the story but sounds way too long. Sounds like the best thing for her, in the end, may be skipping all the revision drama and doing bilateral AKAs.
Click to expand...
Spacer for 5 years
vector2 said:
What’s the CXR look like? What’s the BNP? Home O2 req? Is she on A/C? Can she lie flat? Does she take diuretics or any CHF meds chronically?
Click to expand...
Lungs are clear
No home o2 requirement
No anticoag (risks/benefits, high fall risk)
Yes can lie flat
No diuretics. Encouraged to have diet controlled.
 
fakin' the funk said:
Admit, interval TTE, labs, diurese
Optimize for bilateral TKA under general, CVC, postop ICU, do y'all have iNO?
Click to expand...
small community hospital setting, so no. But down the street at the tertiary care center, yes.
 
ethilo said:
Spacer for 5 years

Lungs are clear
No home o2 requirement
No anticoag (risks/benefits, high fall risk)
Yes can lie flat
No diuretics. Encouraged to have diet controlled.
Click to expand...

My understanding is that even if you're at high fall risk, the benefits of ac outweigh the risks
 
ethilo said:
Spacer for 5 years
Click to expand...

Not a surgeon but the risks and benefits aren’t looking good here for bilateral revision surgery at 5-6 hours in this patient. And I don’t care if you tell me she walked out of the hospital pain free and without infection a day after the surgery. I’ll feel the same.
 
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All - I combed the chart a little more to confirm some data: Antibiotic spacer for 5 MONTHS. and NO DVT in record at all, I'm not sure how I got those things off, she had unilateral leg swelling at some point but no confirmed DVT. Not that it changes a whole lot but still... sorry!
 
ethilo said:
All - I combed the chart a little more to confirm some data: Antibiotic spacer for 5 MONTHS. and NO DVT in record at all, I'm not sure how I got those things off, she had unilateral leg swelling at some point but no confirmed DVT. Not that it changes a whole lot but still... sorry!
Click to expand...

spacers for 5 months vs 5 years is a big difference. not that it makes the anesthesia any different.
 
How long the spacers have been in matters less than what it is a proxy for: how de-conditioned and frail is she? What is her exercise tolerance? Is she walking or otherwise ambulatory in any form? Doing independent ADLs, or totally bed-bound and sarcopenic? Ultimately those are the things that will determine whether or not she is able to recover from this surgery. Personally I would put a lot of weight on the eyeball test here... No doubt we can put in an ETT and get her to the PACU/ICU du jour, but that’s only the beginning of this case...
 
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GassYous said:
What's the difference?
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5 months, basically a standard revision for PJI.. An extra month or two to optimize or busy practice.

5 years = someone who is unhealthy, can't have revision sx, or can't clear the infection... Which may mean AKAs. Original surgeon may have said spacers for life because you are too sick, and now she's at a revision specialist who will attempt replant
 
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GassYous said:
What's the difference?
Click to expand...

what @ChiDO said. My surgeons have told me that it's a spacer, not a joint. It's not intended to be there forever, just a short period of time. Weight bearing isn't the same. Flexion/extension isn't the same. 5 months, on both legs, is bad enough. 5 years seems too far gone.
 
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So, I had a long conversation with patient, surgeon, and a more experienced anesthesiologist partner of mine. We all decided to proceed as this 10 lb increase was within what she has had on and off in the last 2 years. With stable vitals, no respiratory distress I felt she had maybe mild CHF exac but not outside of her norm.

I chose to perform a CSE with 2 mL 0.5% bupi + 25 mcg fentanyl and redose with epidural later using 0.5% bupi to maintain negative pressure ventilation, avoid GA and intubation / mech ventilation, reduce risk of post op delirium, and ran a low dose propofol infusion (35 mcg/kg/min).

She required some phenylephrine intraop, no surprise, but not much. I ran it at about 0.5 mcg/kg/min for the whole case and maintained pressures pretty well.

At the end we estimated between 600-1000 mL blood loss, though she remained hemodynamically stable and off pressors on lifting sedation at the end of the case. We checked a HCT which was 21 and transfused 2 units pRBC in PACU. Incidentally, her WBC on the CBC was 60 (1.5 months ago it was 9).

While waiting for blood she slowly grew more hypotensive. Initially responsive and answering all questions on arrival, starting to have waxing / waning mental status. Slight ST dep on EKG, BP with MAP at 61. Drew trops which peaked at 0.4 by the next day and came down. ST depressions resolved with blood. Echo normal RVF with RVSP estimated at low 40s and LVF normal.

Unfortunately her WBC increased to 115 by the next day, transferred to our tertiary center for BMB and rasburicase for tumor lysis syndrome and acute AML with blast crisis, K elevated so got TDC and emergent dialysis started. WBC increased to 160 the next day, complaints of abdominal pain and found to have infarcted bowel, liver, and splenomegaly. Code called overnight for unresponsiveness and hypotension and she was declared deceased shortly thereafter.
 
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ethilo said:
So, I had a long conversation with patient, surgeon, and a more experienced anesthesiologist partner of mine. We all decided to proceed as this 10 lb increase was within what she has had on and off in the last 2 years. With stable vitals, no respiratory distress I felt she had maybe mild CHF exac but not outside of her norm.

I chose to perform a CSE with 2 mL 0.5% bupi + 25 mcg fentanyl and redose with epidural later using 0.5% bupi to maintain negative pressure ventilation, avoid GA and intubation / mech ventilation, reduce risk of post op delirium, and ran a low dose propofol infusion (35 mcg/kg/min).

She required some phenylephrine intraop, no surprise, but not much. I ran it at about 0.5 mcg/kg/min for the whole case and maintained pressures pretty well.

At the end we estimated between 600-1000 mL blood loss, though she remained hemodynamically stable and off pressors on lifting sedation at the end of the case. We checked a HCT which was 21 and transfused 2 units pRBC in PACU. Incidentally, her WBC on the CBC was 60 (1.5 months ago it was 9).

While waiting for blood she slowly grew more hypotensive. Initially responsive and answering all questions on arrival, starting to have waxing / waning mental status. Slight ST dep on EKG, BP with MAP at 61. Drew trops which peaked at 0.4 by the next day and came down. ST depressions resolved with blood. Echo normal RVF with RVSP estimated at low 40s and LVF normal.

Unfortunately her WBC increased to 115 by the next day, transferred to our tertiary center for BMB and rasburicase for tumor lysis syndrome and acute AML with blast crisis, K elevated so got TDC and emergent dialysis started. WBC increased to 160 the next day, complaints of abdominal pain and found to have infarcted bowel, liver, and splenomegaly. Code called overnight for unresponsiveness and hypotension and she was declared deceased shortly thereafter.
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Crazy case. This is obviously not my area of expertise, but I can’t help wondering if the mechanical effects of revision ortho surgery (mucking around in her marrow compartments for several hours) had anything to do with the timing of this presentation? Or was it just from surgical stress? Or just coincidence?
 
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Hork Bajir said:
Crazy case. This is obviously not my area of expertise, but I can’t help wondering if the mechanical effects of revision ortho surgery (mucking around in her marrow compartments for several hours) had anything to do with the timing of this presentation? Or was it just from surgical stress? Or just coincidence?
Click to expand...
I was wondering the same. Truly no evidence of acute leukemia happening before surgery. It came about so aggressively, I've never seen it quite like this.

I think the message that I take away from this sort of thing is "you never know" what's going on underneath.

Also after reading about AML with blast crisis, apparently hyperviscosity syndrome / leukostasis is the usual cause for bowel infarction - hypoperfusion from sluggish blood from too many WBCs.
 
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Did she get decadron in OR? Dexamethasone has been shown to precipitate tumor lysis syndrome in patients with lymphoproliferative disorders.

It’s definitely rare, but something to keep in the back of your mind.
 
Beeftenderloin said:
Did she get decadron in OR? Dexamethasone has been shown to precipitate tumor lysis syndrome in patients with lymphoproliferative disorders.

It’s definitely rare, but something to keep in the back of your mind.
Click to expand...
Thanks for asking, I had to look back end check. I didn't actually give decadron. I normally would have but I think bc I did a sedation then I just gave zofran. I tend to be pretty consciencious about post op delirium in elderly and I probably didn't give it for that reason, similar to avoiding GA.
 
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Sounds like a crazy case but I would say that I have never seen a bilateral revision and I am now 8 years into orthopaedics. I have not heard of one in any nearby hospitals or while I was in training. I am sure it has happened but a patient in their 80s with multiple cardiac and pulmonary comorbidities? I would be concerned about doing a primary joint on them, let alone a bilateral revision. Just my $0.02.
 
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Related question: bilateral hip? Can’t say I’ve done one before. Patient is healthy enough, I suppose; obese and GERD. Would anyone do this with a CSE or epidural?
 
cchoukal said:
Related question: bilateral hip? Can’t say I’ve done one before. Patient is healthy enough, I suppose; obese and GERD. Would anyone do this with a CSE or epidural?
Click to expand...

With good surgeons - sure.
 
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I think you can eke out 5 hours with spinal if you do iso bupi 15 mg, epi wash and 100 of duramorph.
 
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