Recent case, How would you proceed?

[gasp]

I'd like to hear how some of you would handle this case:

96yo female s/p unwitnessed fall (fam say they think she tripped) is scheduled for ORIF hip and admitted to floor for next day surgery. Next day prior to surgery time Pt has an episode of acute desaturation ~ high 80's, hypotension ~90/60, lethargic, AMS. Surgery was cancelled for that day and she was worked up. CXR shows congestion, Trop bump (cardio says NSTEMI), CT head shows Acute lobar ischemic stroke (placed on Lovenox and ASA), Next day Swallow eval failed, pt a bit more responsive but still altered, Trop come down a bit, still broken hip, surgeon wants to do the case, Neuro says keep BP's higher than norm, CC primary says she should not get GETA due to CVA, Cardio says she is not a candidate for anything cardiac wise, EF still preserved at 55% with some septal hypokineses, no valvular abnormalities. Family asks you what should we do??

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[jl lin]

 

[WholeLottaGame7]

I'd like to hear how some of you would handle this case:

96yo female s/p unwitnessed fall (fam say they think she tripped) is scheduled for ORIF hip and admitted to floor for next day surgery. Next day prior to surgery time Pt has an episode of acute desaturation ~ high 80's, hypotension ~90/60, lethargic, AMS. Surgery was cancelled for that day and she was worked up. CXR shows congestion, Trop bump (cardio says NSTEMI), CT head shows Acute lobar ischemic stroke (placed on Lovenox and ASA), Next day Swallow eval failed, pt a bit more responsive but still altered, Trop come down a bit, still broken hip, surgeon wants to do the case, Neuro says keep BP's higher than norm, CC primary says she should not get GETA due to CVA, Cardio says she is not a candidate for anything cardiac wise, EF still preserved at 55% with some septal hypokineses, no valvular abnormalities. Family asks you what should we do??

No offense, but I feel like this exact case comes up every 3 months on this forum. Some people will argue for a priest, some will say prop/sux/tube, some people will do regional of some sort.

 

[chfo]

No offense, but I feel like this exact case comes up every 3 months on this forum. Some people will argue for a priest, some will say prop/sux/tube, some people will do regional of some sort.

Yep.

 

[ZzzPlz]

Consult palliative care.

 

[gasp]

No offense, but I feel like this exact case comes up every 3 months on this forum. Some people will argue for a priest, some will say prop/sux/tube, some people will do regional of some sort.

Non taken. I'm sure all types of difficult cases show up consistently (sometimes with a new twist). Its nice to be reminded of the different ways these things can be handled not only from the same people who say "prop,sux,tube..etc " but also from new people joining the forum and for the purpose of teaching residents of the possibilities..

 

[Consigliere]

Prop, sux, tube. Next!

 

[PainDrain]

Regional with fascia iliaca block if family wants to proceed. This perfect storm will likely kill her in a few weeks but you can probably fix her hip. I would also have a little fentanyl and ketamine ready just in case. Tell surgeon no bull****ing around and if she starts to show slightest signs of crumping then abort.

 

[Noyac]

Agree with PainDrain. Block her but at that point I would put in an LMA for the case.

The way I look at these cases is this. I can get these pts though the case in one way or another. I'd rather die from a surgical attempt to make me more comfortable than to die lying in bed in pain.

 

[narcusprince]

Is she complaining of hip pain? Is she even able to walk or move lower extremities after stroke? How about see if she recovers from stroke then fix the hip? Playing devils advocate.

 

[Planktonmd]

LMA, with homeopathic doses of everything

 

[teeva]

1/2 MAC via LMA.

 

[Psai]

96 year old female with a stroke and an mi and you want to fix her hip? wtf?

 

[gasp]

96 year old female with a stroke and an mi and you want to fix her hip? wtf?

I dont but the surgeon does.

 

[gasp]

1/2 MAC via LMA.

From this formula, I gather we can also do a full MAC via ETT?

 

[lobelsteve]

IV PCA with baseline pain control. No NSAID, no surgery. No chance for functional improvement. If it were my grandma that died in surgery.....

Give me her chance of survival on the consent that states she just had an MI and a stroke.

 

[Random Anesthesiologist]

There is a fracture. I must fix it.

 

[Mman]

IMHO the only important point on this case is to have a nice long talk with the family. There are plenty of ways to do the anesthetic that will have her alive in PACU, but her life expectancy is measured in weeks to months at this point (at best). Her body is failing and there is no way to fix it. I'd be OK with proceeding with the case as long as the family understands that the patient may never walk out of the hospital either way.

 

[caligas]

IMHO the only important point on this case is to have a nice long talk with the family. There are plenty of ways to do the anesthetic that will have her alive in PACU, but her life expectancy is measured in weeks to months at this point (at best). Her body is failing and there is no way to fix it. I'd be OK with proceeding with the case as long as the family understands that the patient may never walk out of the hospital either way.

Well said. Also, don't be surprised when this all comes as news to the family.

 

[Mman]

Well said. Also, don't be surprised when this all comes as news to the family.

I usually have a combined conversation with the surgeon so we are all on the same page. Acute stroke, acute MI, acute fracture, old as dirt. It ain't gonna go well. I just want to be sure the family didn't talk to the surgeon and take home the message that if they ever want to walk again we must do surgery right now to fix it. Because they probably aren't going to walk ever again anyway.

This is one of those situations where if it was one of our own loved ones, we'd probably just give them comfort care. And often families don't realize that doing nothing is actually a reasonable option at times.

 

[chfo]

Consult palliative care.

96 year old female with a stroke and an mi and you want to fix her hip? wtf?

IV PCA with baseline pain control. No NSAID, no surgery. No chance for functional improvement. If it were my grandma that died in surgery.....

Give me her chance of survival on the consent that states she just had an MI and a stroke.

IMHO the only important point on this case is to have a nice long talk with the family. There are plenty of ways to do the anesthetic that will have her alive in PACU, but her life expectancy is measured in weeks to months at this point (at best). Her body is failing and there is no way to fix it. I'd be OK with proceeding with the case as long as the family understands that the patient may never walk out of the hospital either way.

If Noyac was presenting this case, at this point he would say that he did xyz anesthetic, and patient is now doing well, out of the hospital, going to Bingo, SCUBA diving, and now has the sex life of a 25 year-old.

 

[jl lin]

Agree with PainDrain. Block her but at that point I would put in an LMA for the case.

The way I look at these cases is this. I can get these pts though the case in one way or another. I'd rather die from a surgical attempt to make me more comfortable than to die lying in bed in pain.

IDK, this seems like something to consider. I mean surgery can be palliative. We did this for my GM, and she lived another 3.5 years at >90 y.o.a w/ good quality of life at home w/ people that loved her. I will say that she did not have the other co-morbid factors of the patient in the OP.
But remember that if the person is going to survive the MI and stroke, they will have to live w/ some quality of life--meaning decreasing the obvious pain factor--even if they aren't ambulating or able to ambulate well. They can get out of bed with assistance, and it is good that they should be able to turn in bed without agony. People's other bodily functions will continue, and they will have to move. Agony in movement would not be a great way to live out the rest of one's life.

It's just not as easy as it may seem on the surface. If the woman will be sent back to a place with crappy care, as IMHO many "rehab" places give, that is also a factor to me. Who will be caring for her?

But it still sucks to be stuck in bed in agony waiting to die, when at least there can be a surgical approach that may make her a bit more comfortable when it comes to any movement at all. I mean it isn't like she is just going to lay there still until she dies. God, I hope not. Immobility kills people too. Her picture looks sucky all the way around, but perhaps a surgical approach may make it a little less sucky, though unquestionably it is highly risky.

 

[Arch Guillotti]

Consult palliative care.

Are you going to do that? If you don't how will you manage the consult?

 

[Colba55o]

You're lucky family was even involved..I get similar cases where patients have no one, or if they do its an estranged relative across the country.

 

[ZzzPlz]

Are you going to do that? If you don't how will you manage the consult?

Am I going to consult palliative? Yes, I think that would be appropriate.
For the second question, you mean the palliative consult? If palliative care isn't available and I talked to them myself, it would be a conversation like the one Mman said above.
Just in my few months of PP, I've had this conversation with several families during the middle of the night. They are usually quite receptive and appreciate the honesty.

 

[DocFocker]

Mh I fix fracture.

 

[Arch Guillotti]

Am I going to consult palliative? Yes, I think that would be appropriate.
For the second question, you mean the palliative consult? If palliative care isn't available and I talked to them myself, it would be a conversation like the one Mman said above.
Just in my few months of PP, I've had this conversation with several families during the middle of the night. They are usually quite receptive and appreciate the honesty.

No way in the world that I would consult palliative care myself. The orthopod wanting to fix the fracture may be a bozo but presumably this patient is on the medicine service and i would not consult a service for a patient that isn't even mine.

I would do like Mman said. Read the family the riot act in the presence of the surgeon. If she does OK, then you are a star. If not, then at least the stage was set.

For the case I would do a spinal as long as she met the generally accepted guidelines for neuraxial anesthesia in anticoagulated patients. Otherwise put her to sleep.

 

[ZzzPlz]

No way in the world that I would consult palliative care myself. The orthopod wanting to fix the fracture may be a bozo but presumably this patient is on the medicine service and i would not consult a service for a patient that isn't even mine.

I would do like Mman said. Read the family the riot act in the presence of the surgeon. If she does OK, then you are a star. If not, then at least the stage was set.

For the case I would do a spinal as long as she met the generally accepted guidelines for neuraxial anesthesia in anticoagulated patients. Otherwise put her to sleep.

I see what you mean about the consult. I definitely wouldn't do it without talking to the surgeon. That might not go over very well

 

[Mman]

I see what you mean about the consult. I definitely wouldn't do it without talking to the surgeon. That might not go over very well

I think he's referring to the medicine team. Many (most?) hospitals have sick old broken hip patients on the medicine service, not the ortho service. The surgeon is just a consultant on those patients and you'd want to talk to the primary team if you thought a consult might be appropriate.

 

[fakin' the funk]

Someone who is CURRENTLY HAVING AN ACUTE STROKE ought not to have surgery unless it is to save life or limb. This is neither.

Whoever actually knows this patient and his/her social situation and family situation best -- whether it's the primary care doc, a hospitalist, the ICU doc, maybe even the ortho -- is your go-to.

If this patient was super functional, cognitively intact etc (granted, seems unlikely) then I'm a lot more likely to go for a guns-blazing approach as is suggested.

If the patient had low QOL and functionality, family is wishy washy about goals of care, then palliation is due. Some might argue that fixing the hip is part of palliation, and it may well be, but that bring us back to non-emergent conditions that can at least wait a couple days.

 

[ZzzPlz]

I think he's referring to the medicine team. Many (most?) hospitals have sick old broken hip patients on the medicine service, not the ortho service. The surgeon is just a consultant on those patients and you'd want to talk to the primary team if you thought a consult might be appropriate.

Right. Thanks.
No more overhead paging to palliative care from this guy.

 

[caligas]

I did four Similar cases ( without the acute stroke part) on call yesterday and night. Four LMAs, 2/3 MAC, a little neo. sleep em in their bed then move them over, no biggie.

Those of you that prefer spinal's are you doing so based on the literature? I just find it so much more painful to do this. Patient positioning, blood pressure drop etc. I know it's a great way to do it for those that like it and I know there is some literature on it, I just don't "feel it" personally. I guess I'm beating a dead horse here on this topic.

 

[Mman]

I did four Similar cases ( without the acute stroke part) on call yesterday and night. Four LMAs, 2/3 MAC, a little neo. sleep em in their bed then move them over, no biggie.

Those of you that prefer spinal's are you doing so based on the literature? I just find it so much more painful to do this. Patient positioning, blood pressure drop etc. I know it's a great way to do it for those that like it and I know there is some literature on it, I just don't "feel it" personally. I guess I'm beating a dead horse here on this topic.

I do them both ways depending patient (and/or family) preference. For a spinal it doesn't hurt much if you do it lateral position, especially if you use isobaric and put the broken leg up. 50 mcg of fentanyl and 20 mg of propofol will get most elderly people to tolerate positioning for it just fine.

 

[Ignatius J]

Someone who is CURRENTLY HAVING AN ACUTE STROKE ought not to have surgery unless it is to save life or limb. This is neither.

Whoever actually knows this patient and his/her social situation and family situation best -- whether it's the primary care doc, a hospitalist, the ICU doc, maybe even the ortho -- is your go-to.

If this patient was super functional, cognitively intact etc (granted, seems unlikely) then I'm a lot more likely to go for a guns-blazing approach as is suggested.

If the patient had low QOL and functionality, family is wishy washy about goals of care, then palliation is due. Some might argue that fixing the hip is part of palliation, and it may well be, but that bring us back to non-emergent conditions that can at least wait a couple days.

This where I practice "what would I want for my family?" Medicine. To have an aging family member go through what she is and sit there in pain from a broken hip (studies show delaying surgery increases mortality) is something I would not do. I would have a frank discussion with the family and put my best foot forward in what is a non-ideal circumstance.

Had a 104F my first few months of private practice actually on hospice very similar to this lady. We got her done and checked a few months later with the surgeon and the lady was doing great. Even cooking Turkey for her family on Thanksgiving. It felt great and although I know they won't all go well, I have no regrets about my decisions. Sometimes you have to sprinkle humanity into the science of it.

 

[Gimlet]

I do them both ways depending patient (and/or family) preference. For a spinal it doesn't hurt much if you do it lateral position, especially if you use isobaric and put the broken leg up. 50 mcg of fentanyl and 20 mg of propofol will get most elderly people to tolerate positioning for it just fine.

That's my usual induction dose for GA in a 90+ year old hip fracture patient!

 

[pgg]

Isobaric bupiv, 20 of ketamine, broken hip up, spinal. GETA + a fascia iliaca block is easier though. I can't convince myself either one is "better" for these patients.

 

[nimbus]

Isobaric bupiv, 20 of ketamine, broken hip up, spinal. GETA + a fascia iliaca block is easier though. I can't convince myself either one is "better" for these patients.

I agree. If after decades of asking the question, we still don't have an answer, the techniques are probably equal in terms of overall safety.