Upcoming case - help a brother out!

[ISoNitrous]

Hi team,

77 yo F, BMI 45 (130kg, ~65") for ORIF v. pin for distal femur fracture.
PMH: OHS (overnight pCO2 130s, 80s in the daytime), pHTN (PASP 70s), diastolic dysfunction, normal biVentricular function, no valvular issues, recent fall, current pulmonary edema. Sats are ~90% on 6L NC.

Her one wish - "I absolutely positively do not want to be intubated."
Surgeon says it's a two hour case.
We both explain to patient that if we go to OR, there is chance you will be intubated. She agrees and if needs intubation, wants tube out in 48h whether palliative extubation or recovering.

Lay it on me. If you want to do neuraxial, how does one position a bedbound obese fractured femur lady who I don't think will tolerate any level of sedation (borderline falling asleep during pre-op conversation)?

Thanks for the help.

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[dchz]

Prop sux tube, enough for two people.

 

[coffeebythelake]

Hi team,

77 yo F, BMI 45 (130kg, ~65") for ORIF v. pin for distal femur fracture.
PMH: OHS (overnight pCO2 130s, 80s in the daytime), pHTN (PASP 70s), diastolic dysfunction, normal biVentricular function, no valvular issues, recent fall, current pulmonary edema. Sats are ~90% on 6L NC.

Her one wish - "I absolutely positively do not want to be intubated."
Surgeon says it's a two hour case.
We both explain to patient that if we go to OR, there is chance you will be intubated. She agrees and if needs intubation, wants tube out in 48h whether palliative extubation or recovering.

Lay it on me. If you want to do neuraxial, how does one position a bedbound obese fractured femur lady who I don't think will tolerate any level of sedation (borderline falling asleep during pre-op conversation)?

Thanks for the help.

Why pulmonary edema? Is patient fluid overloaded? Are they able to lay flat for procedure even after you've done neuraxial? Using VPAP or some other NIPPV device? Sounds like a simple neuraxial and nothing else case with NIPPV support. Realistically positioning will be most challenging in of all this ans if she cannot be adequately positioned she will need GA

 

[dchz]

If you want to do neuraxial, how does one position a bedbound obese fractured femur lady who I don't think will tolerate any level of sedation (borderline falling asleep during pre-op conversation)?

Thanks for the help.

Surgeon says it's a two hour case.

You position her in the way that offloads her and from her diaphragm for 6 hours.

What was her DLCO? Wouldn't doing GA be easier?

She is still alive when her pCO2 is in 130s, that's really reassuring to me. Her RV works normal with that pCO2 and PASP. Her heart is prob better than yours!!!! It's unlikely you'll make her lungs worse during the 6 hour procedure, so just use good mechanics when you extubate.

 

[chocomorsel]

Hi team,

77 yo F, BMI 45 (130kg, ~65") for ORIF v. pin for distal femur fracture.
PMH: OHS (overnight pCO2 130s, 80s in the daytime), pHTN (PASP 70s), diastolic dysfunction, normal biVentricular function, no valvular issues, recent fall, current pulmonary edema. Sats are ~90% on 6L NC.

Her one wish - "I absolutely positively do not want to be intubated."
Surgeon says it's a two hour case.
We both explain to patient that if we go to OR, there is chance you will be intubated. She agrees and if needs intubation, wants tube out in 48h whether palliative extubation or recovering.

Lay it on me. If you want to do neuraxial, how does one position a bedbound obese fractured femur lady who I don't think will tolerate any level of sedation (borderline falling asleep during pre-op conversation)?

Thanks for the help.

She has made it clear to be extubated within 48hours. Put that s hit in writing, have her sign it and prop suxx tube. She made your job easy. Watch your fluids and diurese her to assist w extubation.
How does she get the energy so eat that much damn food with her heart and lung issues. I mean she has gotta fall asleep in the middle of eating. Lol.
This must be the MidWest grandma.

 

[dchz]

How does she get the energy so eat that much damn food with her heart and lung issues.

To be fair, I'm not sure she has any lung or heart issues... 😂

The picture I'm seeing is she's just fat. She puts herself through a nightly hypoventilation test and she passes spectacularly every day.

 

[GassYous]

Ketamine 10, iso bupi 10, check my stocks

 

[chocomorsel]

To be fair, I'm not sure she has any lung or heart issues... 😂

The picture I'm seeing is she's just fat. She puts herself through a nightly hypoventilation test and she passes spectacularly every day.

Until one day she doesn’t. But for real, you gotta park yourself in front of the TV and keep the TV dinners coming like an endless buffet to maintain that weight at that age. That’s a lot of work alone.
I do have to say I was impressed with the size of the old folks up in IN. Even down here in TX they thin out some as they age.

 

[deleted697535]

the trick here is to have a feel of the spine well in advance. some very fat ppl have easily palpable backs and arent difficult spinals at all

you could do a quick lido fnb to help with positioning
or else just bang her off to sleep with an lma or whatever, it doesnt matter

as long as u dont give a tonne of narcs shell be fine. give some lasix if youre concerned

 

[coffeebythelake]

the trick here is to have a feel of the spine well in advance. some very fat ppl have easily palpable backs and arent difficult spinals at all

you could do a quick lido fnb to help with positioning
or else just bang her off to sleep with an lma or whatever, it doesnt matter

as long as u dont give a tonne of narcs shell be fine. give some lasix if youre concerned

You would LMA a big fatty with severe hypoventilation at baseline? I wouldn't.

 

[chocomorsel]

You would LMA a big fatty with severe hypoventilation at baseline? I wouldn't.

He’s in Canada. They don’t sue over there like they do here. Outside of the US they LMA errbody.

 

[deleted697535]

Theres more than one way to eat a cat.

 

[Southpaw]

Theres more than one way to eat a cat.

You canucks are weirdos...

 

[Southpaw]

Hi team,

77 yo F, BMI 45 (130kg, ~65") for ORIF v. pin for distal femur fracture.
PMH: OHS (overnight pCO2 130s, 80s in the daytime), pHTN (PASP 70s), diastolic dysfunction, normal biVentricular function, no valvular issues, recent fall, current pulmonary edema. Sats are ~90% on 6L NC.

Her one wish - "I absolutely positively do not want to be intubated."
Surgeon says it's a two hour case.
We both explain to patient that if we go to OR, there is chance you will be intubated. She agrees and if needs intubation, wants tube out in 48h whether palliative extubation or recovering.

Lay it on me. If you want to do neuraxial, how does one position a bedbound obese fractured femur lady who I don't think will tolerate any level of sedation (borderline falling asleep during pre-op conversation)?

Thanks for the help.

pco2 130s? JFC....lady is CO2 anesthetized at baseline.

 

[coffeebythelake]

pco2 130s? JFC....lady is CO2 anesthetized at baseline.

It's only 130 when sleeping. She must be a sound sleeper.

 

[Lidolover]

THIS PATIENT NEEDS BiPAP starting yesterday. The fact that night values are 50 mmHg higher does not make her daytime values acceptable.
Agreed with CO2 narcosis.

For case, lateral position spinal. No systemic opiates. Precedex gtt or ketamine gtt. Of course continue intra-op BiPAP. Done

of course, if u want to sound predictable , opiate-free GA lol

 

[dabears505]

What is her bicarbonate by chance? I've never heard of a co2 like that before. Is it an error?

 

[chocomorsel]

What is her bicarbonate by chance? I've never heard of a co2 like that before. Is it an error?

Neither have I. The ones with those numbers come to the unit after a code blue for respiratory arrest.

 

[deleted697535]

Intraop bipap? Wow

 

[GassYous]

Intraop bipap? Wow

What do you think pressure support is

 

[PainDrain]

First off I would give her some gentle diuresis over 24 hours in an attempt to get some of the fluid off those lungs. I agree bipap periop would be helpful. Also how accurate is that 130? That seems unbelievable but it would fit with her pulmonary HTN. The fact that her right heart is still functioning fairly well is amazing. Her PA pressure may improve if you can bring that CO2 down. Arterial line for BP monitoring and blood gases maybe. Some low dose ketamine and a small amount of precedex would help with positioning for the spinal. Get out the harpoon and give an iso bupiv spinal.

 

[nimbus]

I’m surprised how many people would do neuraxial. I’d give her a femoral nerve block, Aline, and an opioid free GA/Ett with ketamine/precedex and a little gas. PASP will definitely be better under GA. No thanks on intraop biPAP, I’m not masochistic enough to nurse her for 2 hours without a tube.

 

[aafisahar]

First off I would give her some gentle diuresis over 24 hours in an attempt to get some of the fluid off those lungs.

gentle? put her on a bumex drip at 3mg/hr on Friday, check back on Monday. Chances are all her numbers look better and she feels better.

fat people can hide ****ing gallons of fluid when they are "euvolemic"

 

[deleted697535]

What do you think pressure support is

Well its more the interface between mouth and machine. Bipap to my little furry brain implies a big ol mask that copders wear...
Which well, wouldn't be my first choice

 

[chocomorsel]

gentle? put her on a bumex drip at 3mg/hr on Friday, check back on Monday. Chances are all her numbers look better and she feels better.

fat people can hide ****ing gallons of fluid when they are "euvolemic"

Yeah, uhm no. Terribly ridiculous idea. That is an insane amount to start with and will tank her pressures.
Hypotension with severe Pulm HTN. That’s for sure gonna fix her hip as she won’t feel the pain anymore.

 

[woopedazz]

Every one of these palliative NOF cases that get posted here makes me want to suggest the surgeons pick up a text book and remember what a Girdlestone procedure is.

If we're super worried, we shouldn't be doing anything too exciting. Just do a FI block on the ward, lateral spinal with a miniscule dose of heavy, wait 10 minutes, roll over, operate for 10-15 minutes, collect the 20mL of blood that fell in the ground, DC back to the high level care nursing home they came from (pain free).

In the US surgeons seem more keen on burying expensive implants in the ground, than discharging live patients.

For what it's worth, I'd diurese get over the weekend and trial BiPAP, and the problems probably mostly fix themselves come operating time.

Story time: I had a case almost identical to this as your equivalent of a CA-2. Worlds greatest spinal, everything going beautifully, nasal specs only, CO2 stable. Sent to do an epidural by the boss and on return 30 minutes later they'd started sedation, probably for a good reason --> took a gas, CO2 5billion --> she arrested.

Maybe it was the CO2. Maybe the CO2 was precipitated by the sedation. Maybe it was blood loss/something else. Who knows.

So my advice would be either GA or pure neuraxial... don't get tempted by the tiny bit of sedation that probably will be fine

 

[Arch Guillotti]

lateral spinal with a miniscule dose of heavy, wait 10 minutes,

Yeah the spinal should be a slam dunk by all means

 

[Monterosso]

lateral spinal with a miniscule dose of heavy

Another consideration is that sometimes these cases can run longer, thus can also consider an epidural / CSE (in the lateral position) that you dose up gradually. Perhaps with ultrasound landmarking at the start given her size.

 

[aafisahar]

Yeah, uhm no. Terribly ridiculous idea. That is an insane amount to start with and will tank her pressures.
Hypotension with severe Pulm HTN. That’s for sure gonna fix her hip as she won’t feel the pain anymore.

she doesn't have PAH which where most of the literature on preload dependence comes from.

She has group 2 and 3 PH from longstanding HTN, DMII, being fat as ****, and obstructing her airway at night since she was in high school. The treatment of choice is diuresis in these folks.

And you mention bipap, but bipap is just mechanical diuresis, and has the same effect on PAH as diuresis (eg reduced preload).

this isn't the 40 year old female who was running marathons before her pulmonary arteries decided to caulk up. This is bread and butter medicine. Her numbers aren't even that impressive for a lot of the fat ****s I see on a daily basis and moreover, it's all chronic respiratory acidosis, essentially proving that this is driven by CO2 retention. PAH's hallmark is chronic hypoxia, not CO2 retention, until you get to the point where you have no cardiac output to perform gas exchange.

I stand by my statement. Take 30 liters off before surgery.

 

[chocomorsel]

she doesn't have PAH which where most of the literature on preload dependence comes from.

She has group 2 and 3 PH from longstanding HTN, DMII, being fat as ****, and obstructing her airway at night since she was in high school. The treatment of choice is diuresis in these folks.

And you mention bipap, but bipap is just mechanical diuresis, and has the same effect on PAH as diuresis (eg reduced preload).

this isn't the 40 year old female who was running marathons before her pulmonary arteries decided to caulk up. This is bread and butter medicine. Her numbers aren't even that impressive for a lot of the fat ****s I see on a daily basis and moreover, it's all chronic respiratory acidosis, essentially proving that this is driven by CO2 retention. PAH's hallmark is chronic hypoxia, not CO2 retention, until you get to the point where you have no cardiac output to perform gas exchange.

I stand by my statement. Take 30 liters off before surgery.

So her CO2 of 130s isn’t that impressive. Well knock yourself out. Put her on that crazy high drip and leave for the weekend then for your fishing trip. Go ahead cowboy.
I don’t have a problem with diureses or BiPap. I have a problem with your extremely high dose of Bumex to start where you can accomplish a lot by starting low. And fine, you aren’t worried about her lungs/CV as I am but what about her kidneys? Or will you just drop her off in the Unit and sayonara; to hell with whatever happens next?
But like I said, go ahead w your bad self.

 

[aafisahar]

So her CO2 of 130s isn’t that impressive. Well knock yourself out. Put her on that crazy high drip and leave for the weekend then for your fishing trip. Go ahead cowboy.
I don’t have a problem with diureses or BiPap. I have a problem with your extremely high dose of Bumex to start where you can accomplish a lot by starting low. And fine, you aren’t worried about her lungs/CV as I am but what about her kidneys? Or will you just drop her off in the Unit and sayonara; to hell with whatever happens next?
But like I said, go ahead w your bad self.

I see patients like this daily and the answer is the same. Aggressive diuresis. Sometimes we'll right heart them to prove their AKI is because their RA pressure is 25 and it's all congestive nephropathy. I've taken 20L off patients who everyone said was "dry" and their numbers haven't looked that good since GWB was president.

 

[deleted697535]

I see patients like this daily and the answer is the same. Aggressive diuresis. Sometimes we'll right heart them to prove their AKI is because their RA pressure is 25 and it's all congestive nephropathy. I've taken 20L off patients who everyone said was "dry" and their numbers haven't looked that good since GWB was president.

So what anesthetic would you give her?

 

[deleted875186]

Hi team,

77 yo F, BMI 45 (130kg, ~65") for ORIF v. pin for distal femur fracture.
PMH: OHS (overnight pCO2 130s, 80s in the daytime), pHTN (PASP 70s), diastolic dysfunction, normal biVentricular function, no valvular issues, recent fall, current pulmonary edema. Sats are ~90% on 6L NC.

Her one wish - "I absolutely positively do not want to be intubated."
Surgeon says it's a two hour case.
We both explain to patient that if we go to OR, there is chance you will be intubated. She agrees and if needs intubation, wants tube out in 48h whether palliative extubation or recovering.

Lay it on me. If you want to do neuraxial, how does one position a bedbound obese fractured femur lady who I don't think will tolerate any level of sedation (borderline falling asleep during pre-op conversation)?

Thanks for the help.

Call the pain doctor to do a prone spinal in the OR with X-ray.

 

[chocomorsel]

I see patients like this daily and the answer is the same. Aggressive diuresis. Sometimes we'll right heart them to prove their AKI is because their RA pressure is 25 and it's all congestive nephropathy. I've taken 20L off patients who everyone said was "dry" and their numbers haven't looked that good since GWB was president.

Hmm, you sound like someone I know in real life.

 

[coffeebythelake]

she doesn't have PAH which where most of the literature on preload dependence comes from.

She has group 2 and 3 PH from longstanding HTN, DMII, being fat as ****, and obstructing her airway at night since she was in high school. The treatment of choice is diuresis in these folks.

And you mention bipap, but bipap is just mechanical diuresis, and has the same effect on PAH as diuresis (eg reduced preload).

this isn't the 40 year old female who was running marathons before her pulmonary arteries decided to caulk up. This is bread and butter medicine. Her numbers aren't even that impressive for a lot of the fat ****s I see on a daily basis and moreover, it's all chronic respiratory acidosis, essentially proving that this is driven by CO2 retention. PAH's hallmark is chronic hypoxia, not CO2 retention, until you get to the point where you have no cardiac output to perform gas exchange.

I stand by my statement. Take 30 liters off before surgery.

This patient has Pickwickian syndrome.
PHTN, DD, fluid retention are all part of the package.
I would focus more on measures to resolve hypoventilation and hypoxemia rather than aggressively diuresing the hell out of her. Any anesthetic plan would already involve some measure of dropping the preload.

 

[aafisahar]

So what anesthetic would you give her?

Dunno, my job is to get her optimized for the OR 😜

 

[chocomorsel]

Dunno, my job is to get her optimized for the OR 😜

Oh boy. So you don’t round on your patients on the weekends? You start aggressive diureses and hope they do fine while you enjoy your weekend golf or trip or staycation?

 

[Planktonmd]

Pulmonary edema (if that's really what you think she has) means either left heart failure, fluid overload, or non cardiogenic etiology.
Also make sure she doesn't have COVID pneumonia that the radiology intern interpreted as pulmonary edema on CXR.
Find out what's going on and treat it first.
Then do a fascia iliaca block to facilitate positioning for a spinal in the lateral position, you could instead do a CSE since the epidural needle tends to find the intervertebral space much easier than the thin spinal needle in obese people. If you can't do that then do an LMA and let her breath spontaneously with pressure support.

 

[deleted875186]

Call the pain doctor to do a prone spinal in the OR with X-ray.

Sadly I was not joking

 

[appcan]

If doing a spinal, what do y'all think about using vasopressin as the primary vasopressor (as opposed to phenylephrine) for its relatively spared effect on pulmonary vasculature to counteract that initial BP drop from the sympathectomy?

 

[Hork Bajir]

If doing a spinal, what do y'all think about using vasopressin as the primary vasopressor (as opposed to phenylephrine) for its relatively spared effect on pulmonary vasculature to counteract that initial BP drop from the sympathectomy?

I mean, sure. If you have elevated pulmonary pressures or compromised R heart fxn, the most important thing by far is to maintain your systemic perfusion pressure. Phenylephrine, levo, vaso, whatever... it matters less how you do it, just so long as you don’t let your MAP fall

 

[ethilo]

Sadly I was not joking

No way. I actually laughed out loud when I read that. Find me a pain doc who will come in for that and I'll shake your hand 🤣🤣

 

[GassYous]

No way. I actually laughed out loud when I read that. Find me a pain doc who will come in for that and I'll shake your hand 🤣🤣

You can do it yourself it isn't hard

 

[ISoNitrous]

Case complete. It happened on my post-call day so I signed it out to a colleague who went for it like this:
Surprisingly, positioning for neuraxial was not terrible. She sat on the bed with legs stretched out in front of her, keeled over with the help of staff to support her.
Attempted spinal with 22g needle, unsuccessful.
Successful L2/3 Epidural, bolused up with ~15cc 2% lido in divided doses.
A-line while boluses are going in. Small neo gtt (25mcg/min or so).
Non-rebreather in a touch of reverse T with head propped up enough to keep her comfy without upsetting surgeons.
0 sedation (other than intrinsic CO2)

For those who asked, gas was 7.18 / pCO2 130 / Bicarb 48 overnight 3 days prior to OR.

She thanked us all and plans to get back into triathlons and muscle-ups ASAP.

Thanks for the discussion, everyone.

 

[coffeebythelake]

Case complete. It happened on my post-call day so I signed it out to a colleague who went for it like this:
Surprisingly, positioning for neuraxial was not terrible. She sat on the bed with legs stretched out in front of her, keeled over with the help of staff to support her.
Attempted spinal with 22g needle, unsuccessful.
Successful L2/3 Epidural, bolused up with ~15cc 2% lido in divided doses.
A-line while boluses are going in. Small neo gtt (25mcg/min or so).
Non-rebreather in a touch of reverse T with head propped up enough to keep her comfy without upsetting surgeons.
0 sedation (other than intrinsic CO2)

For those who asked, gas was 7.18 / pCO2 130 / Bicarb 48 overnight 3 days prior to OR.

She thanked us all and plans to get back into triathlons and muscle-ups ASAP.

Thanks for the discussion, everyone.

What was her gas like during thr case ? Why a decision for NRB and not PAP?

 

[coffeebythelake]

Dunno, my job is to get her optimized for the OR 😜

Background? I take it you are not an anesthesiologist?

 

[anbuitachi]

patient isnt even optimized. why even proceed with the case... we dont always have to go ahead with these cases. this patient's chance of dying from something else is far higher than this fracture. was she even in a lot of pain from this fracture?

 

[dhb]

Oh boy. So you don’t round on your patients on the weekends? You start aggressive diureses and hope they do fine while you enjoy your weekend golf or trip or staycation?

That's what real doctors do!

 

[GassYous]

Was it actually 2 hours?

 

[aafisahar]

Background? I take it you are not an anesthesiologist?

2nd Cardiology fellow, I like to look at other forums to see what they do and get a different perspective.