There Is a Fracture.

[OB1🤙]

Case for the residents, inspired by the other thread.

94 year old dude comes in with a busted hip.

Ortho books hip hemiarthroplasty.

Pt is clear as a bell.

Last echo a year ago documented severe aortic stenosis. Good LV function. Other valves fine.

Pt is about as active as 94 year olds get, which is not very. But doesn't seem to have cardiac symptoms doddering around in the garden.

Waddya do?

Residents first.

---

Members don't see this ad.

 

[Arch Guillotti]

How severe?

 

[Planktonmd]

Case for the residents, inspired by the other thread.

94 year old dude comes in with a busted hip.

Ortho books hip hemiarthroplasty.

Pt is clear as a bell.

Last echo a year ago documented severe aortic stenosis. Good LV function. Other valves fine.

Pt is about as active as 94 year olds get, which is not very. But doesn't seem to have cardiac symptoms doddering around in the garden.

Waddya do?

Residents first.

a little bit of some induction agent... then LMA ---> sevo ---> call it a day

 

[ZzzPlz]

General with ET tube. RSI. Run gas low, remi and propofol gtt if needed to decrease inhalational requirements.

Bag of neo spiked and ready

 

[Arch Guillotti]

General with ET tube. RSI. Run gas low, remi and propofol gtt if needed to decrease inhalational requirements.

Bag of neo spiked and ready

Why do you want to decrease inhalational requirements?

I think any method of anesthesia is ok as long as you take it slowly and incrementally.

In a perfect world I would place an arterial line and slowly dose a spinal catheter.

 

[ZzzPlz]

I probably wouldn't use the drips mentioned above unless patient required more than about half Mac of gas. Wouldn't this theoretically decrease post op cognitive issues?

I agree about the low dose spinal, neuraxial would be nice. What about dosing up an epidural slowly instead?

 

[Doctor4Life1769]

I would not use remi

as long as anti-coagulation and coag panel isn't an issue - epidural
pre-induction arterial line
careful titration for induction, GETA
depends on how long surgeon takes to do the procedure... ETT vs. LMA, but i prefer ETT.
iso/nitrous, titrate up on LA via epidural for analgesia

 

[deleted171991]

General with ET tube. RSI. Run gas low, remi and propofol gtt if needed to decrease inhalational requirements.

You would give remi and propofol in a patient with severe aortic stenosis, doctor? Do you want to kill the patient? Would you put in an a-line, at least?

The surgeon insists he only does these cases under regional anesthesia, because the surgical field is much better and there is less DVT, and he threatens to get another anesthesiologist. And even with neuraxial anesthesia, he wants the patient to get SC heparin pre-incision. What do you do?

 

[D P356]

The title of the thread reminds me of this video. "There is a fracture...I need to fix it."

 

[Promethean]

The title of the thread reminds me of this video. "There is a fracture...I need to fix it."

Could be a reason for that.

 

[chmd]

The surgeon insists he only does these cases under regional anesthesia, because the surgical field is much better and there is less DVT, and he threatens to get another anesthesiologist. And even with neuraxial anesthesia, he wants the patient to get SC heparin pre-incision. What do you do?[/QUOTE]


I can't imagine this demand being made. If it were made I'd tell him that if he wants a spinal that he should delay surgery until patient gets a tavr. Also I'd get really pissed and it'd probably ruin my call day.

If I had to do a regional technique I'd place and Aline and slowly dose up and epidural.

 

[deleted171991]

That was an oral boards question for the residents.

 

[ZzzPlz]

Maybe I need to study up on these drugs more. In the setting of Aortic stenosis, assuming we are going general with ETT, how would adding narcotic place the patient at increased risk? Seems safer than blasting them with volatile. I understand your reasoning with prop.

Pre-induction a-line... I concur, doctor.

 

[Planktonmd]

General with ET tube. RSI. Run gas low, remi and propofol gtt if needed to decrease inhalational requirements.

Bag of neo spiked and ready

Why do you need an ETT and RSI?

 

[deleted171991]

Maybe I need to study up on these drugs more. In the setting of Aortic stenosis, assuming we are going general with ETT, how would adding narcotic place the patient at increased risk? Seems safer than blasting them with volatile. I understand your reasoning with prop.

Pre-induction a-line... I concur, doctor.

You can give even propofol, not a problem, as long as you do it slowly, with a pre-induction a-line. 94 year-old patient will go to sleep just from showing him the bottle.

You can give almost anything, as long as you titrate it carefully based on the patient's age and weight, and you correct cardiovascular changes promptly.

Anyway, I was bullying you just to give you a taste of the oral boards.

 

[Libertas]

surgical density lumbar plexus and parasacral sciatic peripheral nerve blocks. ASRA guidelines allow sc heparin 5000u. No to extremely limited sedation.

 

[OB1🤙]

Good range of responses.

AVA is in the 0.9-1 cm sq range. Not critical, but definitely severe.

So here's what I did.

Preop surface echo myself, just to see if any interval change since last echo. LV was banging away, EF 65%ish.

Pressure 150/80.

Decided to KISS. GETA. Keep the pressure up. Get in, get out, get on with life.

I did not put in an arterial line. I could have, and I would have on the orals, and I would have made a resident under my supervision go through the exercise of doing it.

Into the room, preox, ASA monitors, neo stick ready, 2 ccs of propofol, then breathed her down with sevo. Frequent cycling of the cuff. Pressures stayed fine. Inhalational inductions are VERY stable.

Intubated, moved over, did the case, gave some IV tylenol (berating the company in my head for jacking up its price, but felt this was a good case for it), 50mcg total fentanyl. Extubated, went to PACU, pt comfy and stable. Went home, had a Macallan.

In the back of my mind was all the academic chatter about what could be done. A-line, spinal catheter? I love that technique, but not necessary for this particular heart for this particular case. Peripheral regional? Too complex, positioning too painful, not worth the effort IMO.

Isolated aortic stenosis with a good ventricle is something to be very respected. But keep the pressure up, and you'll be OK.

Sometimes, best to just keep it simple.

 

[Arch Guillotti]

surgical density lumbar plexus and parasacral sciatic peripheral nerve blocks. ASRA guidelines allow sc heparin 5000u. No to extremely limited sedation.

Way too complicated for me. Not without risk either if there is significant epidural spread of the LP block.

 

[Arch Guillotti]

Good range of responses.

AVA is in the 0.9-1 cm sq range. Not critical, but definitely severe.

So here's what I did.

Preop surface echo myself, just to see if any interval change since last echo. LV was banging away, EF 65%ish.

Pressure 150/80.

Decided to KISS. GETA. Keep the pressure up. Get in, get out, get on with life.

I did not put in an arterial line. I could have, and I would have on the orals, and I would have made a resident under my supervision go through the exercise of doing it.

Into the room, preox, ASA monitors, neo stick ready, 2 ccs of propofol, then breathed her down with sevo. Frequent cycling of the cuff. Pressures stayed fine. Inhalational inductions are VERY stable.

Intubated, moved over, did the case, gave some IV tylenol (berating the company in my head for jacking up its price, but felt this was a good case for it), 50mcg total fentanyl. Extubated, went to PACU, pt comfy and stable. Went home, had a Macallan.

In the back of my mind was all the academic chatter about what could be done. A-line, spinal catheter? I love that technique, but not necessary for this particular heart for this particular case. Peripheral regional? Too complex, positioning too painful, not worth the effort IMO.

Isolated aortic stenosis with a good ventricle is something to be very respected. But keep the pressure up, and you'll be OK.

Sometimes, best to just keep it simple.

Good case.

Aortic valve area of 1.0 could be a lot worse.

I actually think that a spinal (if done properly) is not absolutely contraindicated here. Of course if the patient did poorly you would have no defense.

 

[CaliDreamin4Life]

I read in textbooks about epidurals being an option for hips. Does anyone do this? Do you really get a dense enough block? What would you use?

 

[Doctor4Life1769]

I read in textbooks about epidurals being an option for hips. Does anyone do this? Do you really get a dense enough block? What would you use?

I would've placed an epidural. however, if they are going to give anti-coagulation then probably not worth placing a catheter unless the patient is going to remain in the hospital. In this case, apparently the patient went home.

 

[Triple AAA]

Definitely a good case to remind us of the more dilemmas we might encounter on a day to day basis. I personally agree with GETA, aline, +/- TIVA. RSI if appropriate, depending on his NPO status. I have not done Pain or Regional fellowships, so I would not feel comfortable doing any of the fancy lumbar plexus blocks mentioned above.

One thing that occurred to me later on, as I was reading all this: my management probably wouldn't change even if the guy didn't have severe AS. Even with healthy valves, a 94 yr old probably would not be able to tolerate large fluctuations in BP, and we would probably want to keep their MAP higher than 65 consistently. Furthermore, hip fractures (particularly traumatic), have HUGE bleeding potential, as well as possible risks for fat embolus, all of which could cause significant hemodynamic derangements. A spinal anesthetic could be playing with fire here.

 

[fakin' the funk]

Preop surface echo myself, just to see if any interval change since last echo. LV was banging away, EF 65%ish.

I'm curious about this, HB.

I'm in a CCM fellowship where we use bedside TTE every day. I couldn't overstate its usefulness in ICU patients. My impression is that it's not that common in mainstream anesthesiology, whether in academics or outside. But my feeling is that anesthesiologists should DEFINITELY be trained in perioperative echo, whether TTE/TEE, to go along with our USRA and line skills.

So, my questions: How often do you do a surface echo on OR patients? What views? What machine? Who owns/provides the machine? Did you bill for your exam? Do you document your findings?

 

[sevoflurane]

If you have an active cardiac OR, you can just bring one of the machines to holding and use a TTE probe. We carry TEE, TTE and epiaortic probes on our machines (they are all interchangable with our machines- and can hook multiple at the same time ie epiaortic and tee). I do think this is an excellent area to expand and it can be very useful in pre-op (trauma, septic, unknown pre-existing heart conditions, old fragile hip fx's that are not doing so well, etc.).

 

[OB1🤙]

Great points, fake. I agree that TTE can be extremely valuable, and ought to be more widely adopted by a specialty that 1) is always very interested in cardiac function, hemodynamics, and volume status, and 2) is already facile with ultrasound.

I think that more and more, core residencies around the country are realizing this and providing basic cardiac ultrasound to their residents.

I taught myself TTE. As a fellow, I'd do a quick echo of male patients while the resident did the a-line. Spent since time reading echo with the cardiologists. Hung out with echo techs every so often to try and get their positioning expertise.

I usually get parasternal short and long axis views, and an apical 4 chamber view. If the situation calls for it, I'll do a more involved exam. I generally don't get subxyphoid views unless there's a compelling reason.

We also have access to a GE VScan, which is a nifty little device. Resolution isn't phenomenal and you can't do Doppler other than simple color, but its portability makes it very useful.

So yeah. I think we as a specialty should be doing a lot more cardiac ultrasound, and I think things are heading in that direction.

 

[OB1🤙]

Oh, and the hospital owns the machine. I usually don't bill for this, but do when I do a more involved exam.

I'm usually using surface echo in lieu of a stethoscope, as I did for this dude. Just wanted to take a quick peek at his valve and ventricle. I didn't bill for that.

If I bill, I do a full echo report. If I don't, I just report my findings in the narrative on the anesthesia record.

 

[ChiDO]

Answer: Cemented hip hemi....oh this was a gas question. New Answer: Spinal and quickly; I have more weights to lift after this case.

 

[Yangkower]

I had a similar case awhile back. 95 year old, severe AS for BKA. The patient also had a 200 pack year hx of tobacco with severe COPD. Tachypnea on 2L NC. After extensive discussion with the Son and patient of my rock and hard place I opted for a spinal with 1.2 cc of 0.75% bupivacaine. Gave a small bolus of NS and some neo after the spinal. Patient did fine. Incidentally he required an AKA about 1 month later and I did the same thing.



P.S. A bedside ECHO would have been fun and interesting but I'm not sure how it would have made a difference for this patient.

 

[DrBeaker]

Hawaiian,

Thanks for posting the case. Just curious, did you get diastolic function? AS with elevated filling pressures is a different beast.

I also want to echo the value of echo. I went to an echo heavy program. Today was my first case as an attending. Decided to put an echo probe on the patients chest. Saved me and the patient trouble, at least for today.

 

[OB1🤙]

Didn't do any formal diastology, probably wouldn't have been very high yield for this particular pt. Indirectly related to diastolic function- the right heart looked great, hardly any TR, and PA size looked normal. Additionally, there was hardly any MR and the left atrial size seemed normal, so pretty unlikely for there to be substantial pulmonary venous hypertension as a consequence of elevated filling pressures. I suspect that had I looked, there would have been the usual impaired relaxation, along with a reasonable E/E' ratio.

That and I just kinda wanted to get the case going (as did everyone else), so I kept my exam to a cursory look, just to make sure the ventricular function hadn't fallen off a cliff since her last study and that the AVA wasn't suddenly critical.

Congrats on new attendinghood! Nice to finally take off the training wheels, huh?

 

[DrBeaker]

Thanks HB. It does feel nice but it's also terrifying in a good way. I postponed the case, patient had previously undiagnosed severe AS until I did a TTE on her. Didn't feel good to do that on my first case, but right thing to do.

 

[drmwvr]

Good range of responses.

AVA is in the 0.9-1 cm sq range. Not critical, but definitely severe.

So here's what I did.

Preop surface echo myself, just to see if any interval change since last echo. LV was banging away, EF 65%ish.

Pressure 150/80.

Decided to KISS. GETA. Keep the pressure up. Get in, get out, get on with life.

I did not put in an arterial line. I could have, and I would have on the orals, and I would have made a resident under my supervision go through the exercise of doing it.

Into the room, preox, ASA monitors, neo stick ready, 2 ccs of propofol, then breathed her down with sevo. Frequent cycling of the cuff. Pressures stayed fine. Inhalational inductions are VERY stable.

Intubated, moved over, did the case, gave some IV tylenol (berating the company in my head for jacking up its price, but felt this was a good case for it), 50mcg total fentanyl. Extubated, went to PACU, pt comfy and stable. Went home, had a Maca

Good range of responses.

AVA is in the 0.9-1 cm sq range. Not critical, but definitely severe.

So here's what I did.

Preop surface echo myself, just to see if any interval change since last echo. LV was banging away, EF 65%ish.

Pressure 150/80.

Decided to KISS. GETA. Keep the pressure up. Get in, get out, get on with life.

I did not put in an arterial line. I could have, and I would have on the orals, and I would have made a resident under my supervision go through the exercise of doing it.

Into the room, preox, ASA monitors, neo stick ready, 2 ccs of propofol, then breathed her down with sevo. Frequent cycling of the cuff. Pressures stayed fine. Inhalational inductions are VERY stable.

Intubated, moved over, did the case, gave some IV tylenol (berating the company in my head for jacking up its price, but felt this was a good case for it), 50mcg total fentanyl. Extubated, went to PACU, pt comfy and stable. Went home, had a Macallan.

In the back of my mind was all the academic chatter about what could be done. A-line, spinal catheter? I love that technique, but not necessary for this particular heart for this particular case. Peripheral regional? Too complex, positioning too painful, not worth the effort IMO.

Isolated aortic stenosis with a good ventricle is something to be very respected. But keep the pressure up, and you'll be OK.

Sometimes, best to just keep it simple.

Ye gods... grousing about the cost of iv app just after a performing a TTE that wouldn't have changed a thing you did? Three cheers for being thorough, if not a little extravagant?

 

[OB1🤙]

I didn't bill for the quick and dirty echo, so I can grouse about cost all I want, thank you very much.

And it did change my management to some degree actually- had there been evidence of pulmonary hypertension, rv dysfunction, etc I would have put in the arterial line.

And IV acetaminophen still costs too much.

 

[Arch Guillotti]

And it did change my management to some degree actually- had there been evidence of pulmonary hypertension, rv dysfunction, etc I would have put in the arterial line.

What degree of pulm htn would have changed your management?

 

[OB1🤙]

Enough to make the RV struggle.

 

[Arch Guillotti]

Enough to make the RV struggle.

How about a pretty high PA pressure with normal RV function?

 

[OB1🤙]

No, probably not. Would depend on Spidey sense, to be scientific about it.

 

[drmwvr]

If you could even get an accurate estimate of right sided pressures with DE in that setting... I'd tell the new one's to save the money (right, you didn't bill) and proceed as if his AS had worsened if his physical exam indicated it. The days of justifying ourselves are upon us, at least here in PP. I won't be surprised if one day I have to pay a facility fee for a "quick and dirty" pre op echo. Honestly not looking for a confrontation, just the reality where I am.

 

[Arch Guillotti]

No, probably not. Would depend on Spidey sense, to be scientific about it.

OK, just interested in what others do. Mild pulmonary hypertension isn't uncommon and usually not that big of a deal. If I have an echo with right-sided dysfunction I proceed very cautiously.

 

[DrBeaker]

We billed for my TTE. Limited trans thoracic with CFD and PW/CW. Did a report, it's in the chart.