How Would You Proceed?

[gasp]

I've been coming across these interesting on here recently and thought I'd post one.

90 y/o F fell (syncopal, not mechanical) and broke her right humerus and is scheduled for ORIF. Pmh is significant for HTN, CAD, DM, Prelim Echo done on admit shows Severe Aortic Stenosis (no numbers given), Severe Mitral Regurge, EF ~50-60% , family states pt has Severe right Carotid Stenosis as well from previous doctor visits. Pt has been in the hospital for 24 hours now awaiting surgery. Family is anxious and wants surgery be done quickly or she wont heal. HgB is 8 at baseline without signs of bleeding. No transfusion has been given. CXR shows pulmonary vascular congestion with b/l small-mod pleural effusions. Primary thinks shes optimized and ready for surgery, no other consults have been placed.

Case is scheduled for 5pm and you are the guy. You learn all this info when you get there. Surgeon says this needs to be done. Next step?

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[urge]

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[deleted171991]

Interscalene block plus some sedation?

Btw, how much of that EF is anterograde? As in did they just look at the shortening, or did they actually measure LVOT flow?

 

[CodeBlu]

Interscalene block plus some sedation?

Btw, how much of that EF is anterograde? As in did they just look at the shortening, or did they actually measure LVOT flow?

I like this plan

 

[psychbender]

Where in the humerus is the fracture. Based on that, supraclavicular vs interscalene block.

What was she doing when she fell? What's her mental status/can she hold still?

 

[PainDrain]

Is there any pulmonary HTN? If so I would be somewhat concerned considering placing an inter scalene you are almost guaranteed to get the phrenic. Diaphragmatic paralysis combined with some sedation and she desats, pulmonary HTN worsens acutely and the death spiral begins.

 

[Morzh]

If her fall was a syncopal manifestation of severe AS then perhaps she needs a valve replacement prior to ortho surgery (how long can humerus repair wait?)?

I'm just a soon-to-be MS4 and definitely not an anesthesiologist nor an orthopedist, but maybe the humerus can be managed non-surgically?

 

[Morzh]

What are her pressures and volume status? If we proceed with surgery then I'd guess the basic goals would be to maintain intravascular volume (+/- blood products?), avoid brady/tachycardia, and make sure she stays in NSR.

 

[chmd]

No reason she can't get a tavr and then have her arm fixed, right? Or whatever just do regional and a bit of a nap.

 

[Planktonmd]

Interscalene block with little or no sedation

 

[Noyac]

This is a typical case at my facility.

What's the case? Rod or plate? What's her body habitus? What position, lateral or seated?

I would most likely do a ISB with lower dose/volume, A-line and LMA ( ETT would be fine but not necessary in my experience) if this were at my facility. I would not necessarily transfuse since she would probably decompensate (CHF). Maybe 1 unit PRBC's slowly over the course of the case.

This pt will not be around next year most likely.

These cases are were I prefer to be a minimalist, until I need more. I feel that if you are very gentle with these pts they will get through the case fine.

 

[teeva]

I would keep it simple too.

I would have a good large IV, do art line, followed by LMA. Phenylephrine in a 500ml bag with micro drip titrated to maintain BP. I find that it doesn't take much more than fentanyl 100-200mcg and 1/2 MAC gas to keep a frail 90yo under anesthesia. Our ortho surgeon is rather gentle and can do the case in an hour, supine or semi sitting.

I'd skip interscelene block because of tenuous pulm status and would rather keep pt spontaneously breathing with an LMA.

 

[PainDrain]

On the subject of AS. How quickly does AS go from moderate to severe? I ask because I have had two cases recently where the patient had an Echo 6 months prior showing moderate AS and then their murmurs worsened and their functional status went down dramatically. In one case a follow up Echo showed severe AS and patient went to TAVR

 

[Noyac]

On the subject of AS. How quickly does AS go from moderate to severe? I ask because I have had two cases recently where the patient had an Echo 6 months prior showing moderate AS and then their murmurs worsened and their functional status went down dramatically. In one case a follow up Echo showed severe AS and patient went to TAVR

6 months seems reasonable.

 

[Noyac]

I would keep it simple too.

I would have a good large IV, do art line, followed by LMA. Phenylephrine in a 500ml bag with micro drip titrated to maintain BP. I find that it doesn't take much more than fentanyl 100-200mcg and 1/2 MAC gas to keep a frail 90yo under anesthesia. Our ortho surgeon is rather gentle and can do the case in an hour, supine or semi sitting.

I'd skip interscelene block because of tenuous pulm status and would rather keep pt spontaneously breathing with an LMA.

The reason I would do the ISB is because these pts do extremely poorly with pain and pain meds. I would attempt to minimize this. They will completely flip their **** with one dose of MS. This can be much worse IMO than wearing BiPAP over night. If they will wear it.