Hip Case

[ChiDO]

No doubt the surgeon was trying to reach back deep to his medical school days to figure out what DKA meant

Rule #1.5 of being an ortho attending. Always play dumb. Oh, and rule #1 blame anesthesia.

Bone broke, me fix. 😬

This way, the hospitalists always admit my patients 🤓😘

---

Members don't see this ad.

 

[coffeebythelake]

After doing TAVRs for the past 10 years these are the patients who I don't take a shortcut and not carefully listen to their hearts. I also auscultate every TAVR so my radar for low flow low cardiac output aortic stenosis is fully tuned in. I obviously put a lot of patients to sleep safely with critical AS for cardiac procedures but I don't want to do a spinal in a patient with an aortic valve area of 0.5 cm2.

Its actually the severe-critical AS patients going for non-cardiac surgery that's much more scary. When you don't have the luxury of having CPB capabilities in the room, when the patient isn't going to get the full set of lines CVC, PAC, TEE that you do in the cardiac rooms.

Also... while it is good practice to auscultate all your patients in preop, it doesn't always catch AS. I had a patient cleared by his primary doctor for elective surgery, had longstanding AF and new worsening SOB/DOE which was attributed to AF and started on lasix. Regular cardiologist visits. What the PCP and the cardiologist apparently did not catch was pt's echo report from 2 years prior (pt's most recent echo) which showed severe AS. I cancelled the case, spoke with the cardiologist (the same one who ordered that echo btw) who basically said "whoops I didn't see that, yes his new symptoms could be due to worsening AS". The pt got a TAVR later. Interestingly there was no murmur on auscultation even after knowing he has severe AS and going back to listen for one. This patient could have easily died from routine induction of GA. If a story like this doesn't freak you out about errors in medicine and near misses, I don't know what will.

 

[ranvier]

Ortho wants 2g TXA prior to incision. Do you give it in hypercoaguable states?

 

[deleted697535]

Interestingly there was no murmur on auscultation even after knowing he has severe AS and going back to listen for one.

With the greatest of respect... Why is that interesting? Its reasonably common to not have a murmur. Especially in low flow AS, or at end stage AS.

This patient could have easily died from routine induction of GA. If a story like this doesn't freak you out about errors in medicine and near misses, I don't know what will.

Also why would this freak you out? Isnt the natural history of AS that a sizeable percentage of 80 year olds will have at least moderate AS and this increases year on year...

Just treat them all like they have at least moderate AS and youll be fine...

At the end of the day a #nof repair is a palliative procedure. You have 48 hours to optimize as you can but then someone has to put their big boy pants on and do their job

 

[GassYous]

Ortho wants 2g TXA prior to incision. Do you give it in hypercoaguable states?

You can give txa anywhere anytime except intrathecally.

 

[nimbus]

With the greatest of respect... Why is that interesting? Its reasonably common to not have a murmur. Especially in low flow AS, or at end stage AS.


Also why would this freak you out? Isnt the natural history of AS that a sizeable percentage of 80 year olds will have at least moderate AS and this increases year on year...

Just treat them all like they have at least moderate AS and youll be fine...

At the end of the day a #nof repair is a palliative procedure. You have 48 hours to optimize as you can but then someone has to put their big boy pants on and do their job

Yes. Severe AS is so common that it is routine. TAVRs and AVRs don’t typically crash on induction. Start an Aline, put some phenylephrine or norepi in line and avoid hypotension and tachycardia.

 

[coffeebythelake]

With the greatest of respect... Why is that interesting? Its reasonably common to not have a murmur. Especially in low flow AS, or at end stage AS.


Also why would this freak you out? Isnt the natural history of AS that a sizeable percentage of 80 year olds will have at least moderate AS and this increases year on year...

Just treat them all like they have at least moderate AS and youll be fine...

At the end of the day a #nof repair is a palliative procedure. You have 48 hours to optimize as you can but then someone has to put their big boy pants on and do their job

Would you give 2 mg/kg propofol to induce this patient without a preinduction art line? This patient did not have a diagnosis of AS, let alone severe AS with symptoms concerning of heart failure. If all we did was read the clearance note from the PCP and cardiologist, without actually looking at the echo report, that's what the patient would have received.

 

[ChiDO]

Ortho wants 2g TXA prior to incision. Do you give it in hypercoaguable states?

Newest ortho literature shows no increase in complications in any patients with previous "contraindications" patients. IV or PO in all patients is acceptable.

 

[coffeebythelake]

Yes. Severe AS is so common that it is routine. TAVRs and AVRs don’t typically crash on induction. Start an Aline, put some phenylephrine or norepi in line and avoid hypotension and tachycardia.

Yes it is safer when you know the patient has it and has been medically optimized beforehand

 

[Blockit]

Would you give 2 mg/kg propofol to induce this patient without a preinduction art line? This patient did not have a diagnosis of AS, let alone severe AS with symptoms concerning of heart failure. If all we did was read the clearance note from the PCP and cardiologist, without actually looking at the echo report, that's what the patient would have received.

I wouldn’t give 2 mg per kilogram of propofol to ANY 89 year old.
In my experience it is simply not necessary. Titrate in a little fentanyl as you are going back, and then maybe give 100 mg of propofol and once they lose consciousness mask them down with sevo.

 

[Hork Bajir]

Agree with the above. It’s impressive how little propofol you can get away with if you’re patient. I rarely give more than 50 as an initial induction dose in the heart room. Patients (old frail ones) reliably lose consciousness, but it takes a min or so.

 

[abolt18]

I wouldn’t give 2 mg per kilogram of propofol to ANY 89 year old.
In my experience it is simply not necessary. Titrate in a little fentanyl as you are going back, and then maybe give 100 mg of propofol and once they lose consciousness mask them down with sevo.

Seriously, with old people I'm starting with 0.5-1.0 mg/kg of propofol and waiting a couple minutes to see what that gets us. The older or more frail, the closer to that 0.5 my/kg dose i get.

 

[deleted697535]

Would you give 2 mg/kg propofol to induce this patient without a preinduction art line? This patient did not have a diagnosis of AS, let alone severe AS with symptoms concerning of heart failure. If all we did was read the clearance note from the PCP and cardiologist, without actually looking at the echo report, that's what the patient would have received.

Would I give a demented 89 yo with a nof# 2 per kilo? Absolutely not. Even if recent echo has ava 2 with lvef 60.

Enough to close her eyes then roc tube phenyl. The incidence of awareness in this age group is basically 0

Hypertension basically never killed anyone outside of an acute aorta or head so this lady is getting 10 ephedrine, 200 phenyl on spec for induction. I cycle bp q1min after pushing roc. If the reading prior to tubing is ok i would probably give another 30mg ppf but that's it...

Im sorry but this is our bread and butter. I did 3 of these yesterday similar ish. All around 50kg... Preop tte doesn't improve outcomes... Just kicks the can down the road til the next shift

 

[coffeebythelake]

Would I give a demented 89 yo with a nof# 2 per kilo? Absolutely not. Even if recent echo has ava 2 with lvef 60.

Enough to close her eyes then roc tube phenyl. The incidence of awareness in this age group is basically 0

Hypertension basically never killed anyone outside of an acute aorta or head so this lady is getting 10 ephedrine, 200 phenyl on spec for induction. I cycle bp q1min after pushing roc. If the reading prior to tubing is ok i would probably give another 30mg ppf but that's it...

Im sorry but this is our bread and butter. I did 3 of these yesterday similar ish. All around 50kg... Preop tte doesn't improve outcomes... Just kicks the can down the road til the next shift

I think we are talking past each other here?? I'm talking about a separate case. Severe undiagnosed AS (nobody was aware he had any valvular issue at all) with heart failure symptoms, not optimized, for a pure elective surgery. And my patient isn't 89 years old. He was actually about 60. Anyways read my post #52. I don't think I was overly conservative. Kudos to you if you still proceed as above.

 

[nimbus]

Agree with the above. It’s impressive how little propofol you can get away with if you’re patient. I rarely give more than 50 as an initial induction dose in the heart room. Patients (old frail ones) reliably lose consciousness, but it takes a min or so.

Yep…I typically give propofol 40-50mg for cardioversion and almost everyone loses consciousness if you wait long enough.

 

[deleted697535]

I think we are talking past each other here?? I'm talking about a separate case. Severe undiagnosed AS with heart failure symptoms, not optimized, for a pure elective surgery. And my patient isn't 89 years old. He was actually about 60. Kudos to you if you still proceed as above.

Ok yeah thats totally different case... Didnt see that, apologies