what's your plan for this case?

[furfur]

80 y.o. female with HTN, hyperlipidemia, 40 pk-yr smoking history,COPD(s/p wedge-resection x 2) s/f emergency IM nail for femur fracture. Patient with good exercise tolerance(able to slowly climb 2 FOS and takes care of herself at home), denies SOB/DOE/PND. VSS(sat 97% on RA). On exam, III/VI systolic murmur at LLSB. EKG: NSR; RBBB(unchanged from prior). Your thoughts?

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[dhb]

Turn to side; lumbar plexus block , sciatic block , turn supine, read newspaper...

 

[DrRobert]

If there's an echo report somewhere in the records, I proceed to the OR now. If no echo can be found, I order an echo and then proceed to the OR following the report. This is an urgent case that should be done within 24 hours if possible, but it is not a true emergency that needs to be done NOW. If it were a true emergency case then you proceed to OR no matter what.

 

[amyl]

new murmur?

 

[dhb]

The problem is what are you going to do with the echo?
Unless she's in overt cardiac failure (which appears she's not) there is no modifiable factor.
Are you going to change a valve before the femur?

 

[Arch Guillotti]

I wouldn't get an echo.

 

[Planktonmd]

Induce GA, place LMA.
The best thing you can do for this lady is to fix her femoral fracture regardless of the etiology of her systolic murmur.

 

[Frank Rizzo]

Induce GA, place LMA.
The best thing you can do for this lady is to fix her femoral fracture regardless of the etiology of her systolic murmur.

agree

 

[SleepIsGood]

Geta.

 

[thegasman]

The problem is what are you going to do with the echo?
Unless she's in overt cardiac failure (which appears she's not) there is no modifiable factor.
Are you going to change a valve before the femur?

I agree with the management in this case - I would proceed without an echo with GA, however -in general an echo MAY change your management even if you would not replace a valve. If the echo came back with severe AS, you would probably manage the case a little differently. This patient has some exercise tolerance, and without history of syncope or concerning murmur characteristics standard monitoring should be ok.

 

[Pilot Doc]

Got an attending at my place that will do a spinal catheter and titrated 2% lidocaine for such cases. Works very well from what I've been told.

 

[Robert Loblaw]

80 y.o. female with HTN, hyperlipidemia, 40 pk-yr smoking history,COPD(s/p wedge-resection x 2) s/f emergency IM nail for femur fracture. Patient with good exercise tolerance(able to slowly climb 2 FOS and takes care of herself at home), denies SOB/DOE/PND. VSS(sat 97% on RA). On exam, III/VI systolic murmur at LLSB. EKG: NSR; RBBB(unchanged from prior). Your thoughts?

what's there to think about? if the surgeon says it has to be done now, do the case, but be gentle. if the surgeon says it can be done in the morning, ask his intern/PA to get more history/information, then, regardless of whether you get it or not, do the case in the morning, but be gentle...honestly, looks like a pretty healthy 80 year old.

 

[Robert Loblaw]

If there's an echo report somewhere in the records, I proceed to the OR now. If no echo can be found, I order an echo and then proceed to the OR following the report. This is an urgent case that should be done within 24 hours if possible, but it is not a true emergency that needs to be done NOW. If it were a true emergency case then you proceed to OR no matter what.

you don't need an echo. assume it's a 'now' case and tell me your management. then, order an expensive test and tell me your management--it should be the same.

let's say your ears need a cleaning and the echo is crystal clear--are you still going to slug an 80 year old with your all-systems go anesthetic? you should be gentle with all 80 year olds...

 

[InductionAgent]

Since it has not yet been mentioned, I would include an arterial line as part of my management, for the following reasons:

1) Unknown cardiac status warrants close BP monitoring
2) diminished pulmonary reserves, possible need for ABGs
3) possible pre-op and intraop blood loss and need to check HCT

 

[Robert Loblaw]

I agree with the management in this case - I would proceed without an echo with GA, however -in general an echo MAY change your management even if you would not replace a valve. If the echo came back with severe AS, you would probably manage the case a little differently. This patient has some exercise tolerance, and without history of syncope or concerning murmur characteristics standard monitoring should be ok.

i would respectfully disagree. every 80 year old should be treated as though they are a four-minute hypotensive spell away from (1) stroke or (2) AKI or (3) MI or (4) RV failure or (5) aortic stenosis death spiral...

 

[Robert Loblaw]

Since it has not yet been mentioned, I would include an arterial line as part of my management, for the following reasons:

1) Unknown cardiac status warrants close BP monitoring
2) diminished pulmonary reserves, possible need for ABGs
3) possible pre-op and intraop blood loss and need to check HCT

this is probably excessive. MAYBE if the hgb is 8 i would consider it. c'mon, we're rodding a femur, here...

 

[Pooh & Annie]

80 y.o. female with HTN, hyperlipidemia, 40 pk-yr smoking history,COPD(s/p wedge-resection x 2) s/f emergency IM nail for femur fracture. Patient with good exercise tolerance(able to slowly climb 2 FOS and takes care of herself at home), denies SOB/DOE/PND. VSS(sat 97% on RA). On exam, III/VI systolic murmur at LLSB. EKG: NSR; RBBB(unchanged from prior). Your thoughts?

I'm not worried about severe valve disease in this patient. The only thing that MIGHT worry me about that murmur would be a MV regurge possibly post subacute MI or new dysrhythmia, but her EKG is fine. I'd offer her a spinal with femoral catheter (at least a single-shot). COPD and a smoker? I'd go for the regional over the GA/LMA.

 

[Pooh & Annie]

i would respectfully disagree. every 80 year old should be treated as though they are a four-minute hypotensive spell away from (1) stroke or (2) AKI or (3) MI or (4) RV failure or (5) aortic stenosis death spiral...

It's a good point, but you don't need invasive monitoring to tell you your patient's hypotensive and needs treatment.

 

[jennyboo]

80 y.o. female with HTN, hyperlipidemia, 40 pk-yr smoking history,COPD(s/p wedge-resection x 2) s/f emergency IM nail for femur fracture. Patient with good exercise tolerance(able to slowly climb 2 FOS and takes care of herself at home), denies SOB/DOE/PND. VSS(sat 97% on RA). On exam, III/VI systolic murmur at LLSB. EKG: NSR; RBBB(unchanged from prior). Your thoughts?

Emergency = if indeed a true emergency (doubtful) rather than an urgent case, you may proceed with the case without further testing.

IM nail = low risk surgery, and since she does not have an "active cardiac condition" you may proceed without further testing.

climbs 2 flights = good functional capacity (4 METS), you may proceed without further testing.

ACC/AHA is of course a guideline, not a standard of care, so if the case can wait and you feel more comfortable with an echo then by all means get one. But ACC/AHA would support you if you decide not to obtain further testing.

ACCA/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for non-cardiac surgery

She can also have any type of anesthetic you choose -- general, neuraxial or regional (assuming no contraindications to neuraxial or regional techniques). Hell, after a failed spinal in a guy with awful lungs I even got through one of these with "local" by the surgeon.

A-line is a soft call -- would depend for me on what the patient looks like. If she looks like she sounds (healthy) I would not place one; if she looks worse than she sounds then I would consider placing one.

 

[thegasman]

Since it has not yet been mentioned, I would include an arterial line as part of my management, for the following reasons:

1) Unknown cardiac status warrants close BP monitoring
2) diminished pulmonary reserves, possible need for ABGs
3) possible pre-op and intraop blood loss and need to check HCT

not necessary.

 

[thegasman]

i would respectfully disagree. every 80 year old should be treated as though they are a four-minute hypotensive spell away from (1) stroke or (2) AKI or (3) MI or (4) RV failure or (5) aortic stenosis death spiral...

I actually agree with you for the most part and this is how I generally practice. That being said - the "aortic stenosis death spiral" can be pretty scary and takes WAY less than four minutes to cause in the right patient. Severe AS and severe Left main disease are two things that I pay very close attention to because of previous personal experience. These patients can go bad VERY quickly and are difficult to resuscitate. I would definitely place an a-line in a severe AS patient prior to induction. This is where the echo would change my management. I would also consider etomidate (a drug I hate) and would choose particular vasoactive drugs in a severe AS patient.

But I have gotten a little off topic here and in THIS patient I would not get an echo, I would induce gently with prop, place an lma (without contraindication) watch the bp for a bit and then go get some coffee.

 

[Pilot Doc]

[soapbox]

The AHA emergency guidelines seem to be poorly understood. Yes, if the case is an emergency, you proceed to the OR without further testing. That does not mean that you proceed without further thought.

Neither a 20yo GSW SBP=50 nor an 80 year old open femur fracture with severe AS need an echo/stress test/cath etc. That doesn't mean they get the same anesthetic.

[/soapbox]

 

[Planktonmd]

[soapbox]

The AHA emergency guidelines seem to be poorly understood. Yes, if the case is an emergency, you proceed to the OR without further testing. That does not mean that you proceed without further thought.

Neither a 20yo GSW SBP=50 nor an 80 year old open femur fracture with severe AS need an echo/stress test/cath etc. That doesn't mean they get the same anesthetic.

[/soapbox]

You are right, the 80 Y/O with AS should get a little bit less Propofol for induction.

 

[Robert Loblaw]

It's a good point, but you don't need invasive monitoring to tell you your patient's hypotensive and needs treatment.

I agree with you (and myself) WRT the aline (see above). I'm certain I've done this exact case numerous times except that I never listened for a murmur. Old peoples' valves are loud--fact. If the patient van climb two flights of stairs and is independent in her ADLs, there is low likelihood of her having any significant gradient. I'd be willing to bet the hemodynamics stress from the pain of the fracture is enough to tell you whether she can handle an anesthetic.

I would add to the AS plus LM disease that anyone with AS and MR and a "normal" LV be on the high risk list. I fear the right ventricle more, by the way. It's very easy to kill someone with RV dysfunction...a little hypoventilation for example.

 

[Surfer]

general anesthesia with an ETT. done in 2 hours. she doesn't need an a-line. she doesn't need an echo. she needs a rod in her femur.

i'm most worried about her COPD. it could be difficult to extubate her, but i'm going to go with her exercise tolerance and just risk/benefit that general anesthesia is probably safer than neuraxial in this case.

 

[Planktonmd]

general anesthesia with an ETT. done in 2 hours. she doesn't need an a-line. she doesn't need an echo. she needs a rod in her femur.

i'm most worried about her COPD. it could be difficult to extubate her, but i'm going to go with her exercise tolerance and just risk/benefit that general anesthesia is probably safer than neuraxial in this case.

If you are worried about her COPD why did you choose an ETT versus LMA?

 

[Noyac]

My .02
I'd do a general. I wouldn't care if it was with an LMA or a ETT. A well managed ETT even in the worst COPD'r can be not stimulating.

 

[Consigliere]

Jesus H. Christ you boys must all work in academia...A-lines, echos, spinal catheters...for crying out loud, scale down your induction dose of propofol, throw an LMA in grandma and move on to your next case. I do 3 of these a week in my little community hospital. SHEESH!

 

[dhb]

i'm most worried about her COPD. it could be difficult to extubate her

I've never seen a COPDer that was difficult to extubate

 

[dillpickles]

Jesus H. Christ you boys must all work in academia...A-lines, echos, spinal catheters...for crying out loud, scale down your induction dose of propofol, throw an LMA in grandma and move on to your next case. I do 3 of these a week in my little community hospital. SHEESH!

Thanks for my first hard laugh of the day.

 

[ssmallz]

Why all the hate on the A-line? Takes 2 seconds to pop one in and it gives you beat to beat bp monitoring which can be extremely useful on our lol during induction and other parts of the case. If you had an echo saying no issues then don't bother with the A-line. If I couldn't get the A-line, I would still proceed with the case but just because its urgent and risks of delaying are worse than the risks of doing this case w/out one.

 

[aredoubleyou]

preop echo, pft's, cxr, chest CT, nuclear stress, cardiac cath, cards consult, pulm consult, and rheumatology consult. Preeop CABG and valve replacement depending on results. A-line, double stick tripple lumen and PA catheter, with fem a-line on opposite side before induction.

this case is pretty damn simple. any reasonable plan (spinal or GA) with a stick of phenylephrine available should work well.

 

[Bertelman]

Why all the hate on the A-line? Takes 2 seconds to pop one in and it gives you beat to beat bp monitoring which can be extremely useful on our lol during induction and other parts of the case. If you had an echo saying no issues then don't bother with the A-line. If I couldn't get the A-line, I would still proceed with the case but just because its urgent and risks of delaying are worse than the risks of doing this case w/out one.

Because it's unnecessary. 80 y/o, HTN, COPD, smoker, murmur, unchanged ECG. Straightforward ortho case.

This happens every day. If you can't put that to sleep w/o an a-line, you may need some help with your induction.

 

[thegasman]

My .02
I'd do a general. I wouldn't care if it was with an LMA or a ETT. A well managed ETT even in the worst COPD'r can be not stimulating.

Agree - but remember a lot of us are supervising crnas. Maybe you, me or some of the crnas can do this, but some of them would have this copd'er coughing bucking and in bronchospasm before you could sign the chart. I would probably use an lma.

 

[Planktonmd]

Agree - but remember a lot of us are supervising crnas. Maybe you, me or some of the crnas can do this, but some of them would have this copd'er coughing bucking and in bronchospasm before you could sign the chart. I would probably use an lma.

Agree

 

[Planktonmd]

Emergency + Trauma = RSI + ETT? No?

These fractures are frequently done 12-24 hours after the injury or even longer.

 

[Pooh & Annie]

Agree

What, are you guys spraying the hell out of the cords during induction?

 

[ssmallz]

Because it's unnecessary. 80 y/o, HTN, COPD, smoker, murmur, unchanged ECG. Straightforward ortho case.

This happens every day. If you can't put that to sleep w/o an a-line, you may need some help with your induction.

I'm not saying it can't be done, just that it might be better to do it with an a line. The risk and time of an A-line is minimal and the benefit can be great.

 

[Robert Loblaw]

I'm not saying it can't be done, just that it might be better to do it with an a line. The risk and time of an A-line is minimal and the benefit can be great.

reminds me of my one of my high-school science teachers favorite things to say to me: just because you can, doesn't mean you should. it might be better to do it with a RIC, but would you put that in, too? after all, the risk and time of a RIC is minimal and the benefit can be great...the point is that the risk (and cost) of putting in an aline in every one of these patients outweighs the benefit. minimal risk does not mean no risk. have you done any hot thrombectomies for these yet? have you done hand amputations on patients with ischemic complications from an IV infiltration? **** DOES happen. if you take enough small risks, eventually you will get burned. you better hope that when it finally does happen, there was a justifiable reason for taking the risk.

for the LMA guys, do the surgeons not complain about not having NMB? we typically intubate these patients because (1) the surgeons are slow and (2) they whine if the patient isn't relaxed...