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Planktonmd

Planktonmd

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Nothing too exotic just an everyday type of case:
83 Y/O for femoral neck ORIF after a fall.
PMH:
HTN, DM type 2, MI 3 months ago after ORIF of the other hip under GA.
Since her MI she has been doing fine, she denies C.P. and S.O.B., she walks around the house and can climb 1 flight of stairs.
She is on betablockers.
The Cardiologist sent a note sying she is cleared for surgery and to avoid hypotension and hypoxia :)
She had a cardiac catheter but the results are not avilable.
The cardiologist office is not open yet.
The patient is in the holding area not in acute distress, BP= 94/50, HR= 60, SPO2 = 96% on RA.
EKG shows NSR and no electric evidence of new or old ischemia.
On exam she has a 4/6 systolic murmur at the apex.
she looks dehydrated.
CBC and electrolytes are normal.
She agrees to any anesthetic plan we choose.
what's next?
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Planktonmd said:
Nothing too exotic just an everyday type of case:
83 Y/O for femoral neck ORIF after a fall.
PMH:
HTN, DM type 2, MI 3 months ago after ORIF of the other hip under GA.
Since her MI she has been doing fine, she denies C.P. and S.O.B., she walks around the house and can climb 1 flight of stairs.
She is on betablockers.
The Cardiologist sent a note sying she is cleared for surgery and to avoid hypotension and hypoxia :)
She had a cardiac catheter but the results are not avilable.
The cardiologist office is not open yet.
The patient is in the holding area not in acute distress, BP= 94/50, HR= 60, SPO2 = 96% on RA.
EKG shows NSR and no electric evidence of new or old ischemia.
On exam she has a 4/6 systolic murmur at the apex.
she looks dehydrated.
CBC and electrolytes are normal.
She agrees to any anesthetic plan we choose.
what's next?
Click to expand...

Ask for old echo results or any echo results post MI. That should be standard of care for evaluation of somebody who has had an MI and sees a cardiologist. Although her symptoms do not suggest anything omenous, I'd like to have me some echo/perfusion study baby. It is elective right?

Echo/Neuc perfusion in hand, if no filling defect or severe RWMA then go ahead with GA or regional if she hasn't taken her PLAVIX or COUMADIN. CSE if you wish to guarantee you're in the right place, or straight epidural to avoid big drop in pressure.

A-line plus or minus.

If its an ORIF and not just a femoral rodding and the surgeon is a blood letter then have 2 units on hold.
 
Put a 2 MHz surface ultrasound probe on the chest, figure out where the murmur is from...

put her to sleep.

done.
 
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VentdependenT said:
Ask for old echo results or any echo results post MI. That should be standard of care for evaluation of somebody who has had an MI and sees a cardiologist. Although her symptoms do not suggest anything omenous, I'd like to have me some echo/perfusion study baby. It is elective right?

Echo/Neuc perfusion in hand, if no filling defect or severe RWMA then go ahead with GA or regional if she hasn't taken her PLAVIX or COUMADIN. CSE if you wish to guarantee you're in the right place, or straight epidural to avoid big drop in pressure.

A-line plus or minus.

If its an ORIF and not just a femoral rodding and the surgeon is a blood letter then have 2 units on hold.
Click to expand...

ok ...or do it the academic way.
 
I'll bite:

Elderly patient with a history of CAD, DM, and HTN, no known major clinical predictors, 2 intermediate predictors, an intermediate risk surgery, good functional status, and evidence of perioperative beta-blockade in effect. On exam you noted a narrow-ish pulse pressure, a murmur, and hypoxemia.

My assessment and plan:

Her age and exam raise the possibility of aortic stenosis which, depending upon the severity, increases the risk of hypotension and hypoperfusion during induction of a GA or following a neuraxial anesthetic. If she has AS with LVH (and the ensuing subendocardial hypoperfusion), it is not unreasonable to think this may have contributed to her last MI. The good news is that although the card's office is not yet open, it should be soon, and the cath report will clarify the issue. So, in light of what might now be a major clinical predictor, I'd stick.

Does anyone know the literature on valve replacement for sev/crit AS before elective surgery?
 
I agree, it seems like overkill.

I would probably do one of two things:

1) GA with an LMA(PS): slow propofol induction +/- some ketamine, both to spare propofol and its vasodilatory and cardiac depressant effects and to provide multimodal, pre-emptive anesthesia. I'd maintain with propofol, maybe ketamine or remifentanil. Would I do an a-line? It might be nice for instant hemodynamic data during induction, and with a RA SpO2 of 96%, she may have an underlying shunt lesion or V/Q mismatching that would worsen under GA. I'm on the fence.

2) Epidural with IV sedation: the CSE is nice to help identify alignment/the space, but you lose the opportunity to evaluate the effectiveness of your catheter, so once the spinal wears off, you might be left holding the bag, so to speak. Plus, the spinal is probably more likely than an epidural-only to cause refractory hypotension (although you might reduce the likelihood of this by doing a narcotic-only intrathecal dose). Obviously, the epidural has the potential added benefit of enhanced post-op pain control compared to the GA but, as Vent mentioned, given her recent MI, we'd need to know whether or not she was stented and is on anti-platelet therapy.

How would I choose between these two? I guess I'd let the patient and surgeon weigh in, since I think both are safe and reasonable plans.
 
The lady is 83. If she did not or is not scheduled for heart surgery or have any other interventions after her MI, she is not going to get it before a relatively minor procedure such as an ORIF of the hip. You have a note from her Cardiologist which does not mean much but at least she has been followed up. I disagree that this is a totally elective procedure. The mortality is huge for this age group with a hip fracture. This needs to be fixed. These old people that can't get out of bed don't live long. Try to get her old records from her previous surgery. Try to get an old echo so you know what you've got. If she has anything but the tightest AS, put her to sleep (she is probably on plavix) with a small amount of propofol and put in an LMA. Put in an a line pre induction. Except for the MI, she actually sounds better tuned up than most hips I see.
 
New onset post MI murmur gets pentathol, vec, and a tube off the bat?

If the murmur is documented and she has followed a cardiologist fine.

Dude, there is NO reason to not have a follow up echo after an MI. NONE.

If her stenting was recent and after the MI and it has been less than 3 months she is at risk (stent occlusion...). Tough $hit. She's at risk. My point is, if she was recently stented then there is nothing more they are gonna do for her. BB and Epidural/GA. Done deal. If the murmur was documented prior.

I'm not as confident as MMD. I'll have years to get there. For now I'll play it "safe" = "academic?"= wuss.
 
cchoukal said:
I'll bite:

Elderly patient with a history of CAD, DM, and HTN, no known major clinical predictors
Click to expand...

I disagree with NO Known major predictors.

According to the 2007 ACC/AHA guidelines on Perioperative CV exam published by Fleischer in Circulation the 5 clinical risk factors are MI > 1 month or q waves, compensated HF, DM, Renal insufficiency/failure, and Cerebral vascular disease; she has 2 at least but given other comorbidities wouldnt be suprised in EGFR was 60's or less.

So non academically, this is urgent surgery, she is not going to get better than this (ie no one is going to replace a heart valve or do a cath is someone without symptoms) put her to sleep keeping vitals as normal as possible.

then Academic way would be to go through the algorithm for periopertive eval.

Step 1. emergent surgery? --> no, go to step 2
Step 2. pt in active cardiac condition--> no, if yes would stop planned surgery for cardiac eval
Step 3. Surgery low risk --> no, proceed to step 4
Step 4. Pt able to tolerate greater than 4 mets without cardiopulmonary symptoms--> per hx of stair walking appear so---> proceed with surgery (If you dont believe she met this critieria proceed to step 5
Step 5. (heres were it gets more confusing) Consider the 5 clinical risk factors (above). IF major vascular surgery and 3+ risk factors--> cardiac eval. Our pt fits in here, If pt has >or = to 1 risk factor scheduled for intermediate risk surgery consider cardiac eval if it will change management or proceed with beta blockade. if 0 risk factors proceed with surgery

so either way proceed with surgery.

sorry for being verbose
 
Although this is an old slide...it seems to say that this lady only has INTERMEDIATE CLINICAL PREDICTORS...nothing major.

fig1na7.jpg
 
seinfeld said:
I disagree with NO Known major predictors.

According to the 2007 ACC/AHA guidelines on Perioperative CV exam published by Fleischer in Circulation the 5 clinical risk factors are MI > 1 month or q waves, compensated HF, DM, Renal insufficiency/failure, and Cerebral vascular disease; she has 2 at least but given other comorbidities wouldnt be suprised in EGFR was 60's or less.
Click to expand...

What you list here are intermediate, not major clinical predictors, the potentially severe AS notwithstanding.
 
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militarymd said:
Although this is an old slide...it seems to say that this lady only has INTERMEDIATE CLINICAL PREDICTORS...nothing major.

fig1na7.jpg
Click to expand...

Except for that "new" murmur = valvular dz? New onset? Recent MI? Sorry holmes, somebody bothered to do a physical exam. Now follow it up. Sucks. Thats why I don't routinely listen to heart and lungs.

Nevermind the fact she stands a greater chance for clotting up after a new stent placement with under 3 months of anticoagulation (tacro) or 6 months (pac)...new data suggests LIFE LONG ANTICOAGULATION. Bummer.

Pentathol, vec, tube, next one....

Good discussion none the less.
 
I'm still not convinced you guys have done an adequate preop in this pt (labs and results aside). What history would you try to elicit?

cchoukal said:
Her age and exam raise the possibility of aortic stenosis...
Click to expand...

Are you sure about that? Anyone cares to disagree? Where are murmurs form valve disease heard?
 
urge said:
I'm still not convinced you guys have done an adequate preop in this pt (labs and results aside). What history would you try to elicit?



Are you sure about that? Anyone cares to disagree? Where are murmurs form valve disease heard?
Click to expand...

I'm not sure I put as much faith in the specificity of the physical exam (location/characteristics of the murmur) to rule out severe disease as you do.
 
Barring no new onset of SOB/CP/Palpitations with activity (although I cannot comment on how active this individual is, but I'd be willing to bet its on the low side) I don't think the valve dz is severe.

But if the infarct took out some pappilary muscle and leads to incompetent valve it should be evaluated....no? Maybe it is some old murmur. If it is and there was a post MI echo, then you're done.

I trust my physical exam of heart sounds for $hit. There is either a bad murmur or no murmur. If there is a murmur = echo time.
 
militarymd said:
Put a 2 MHz surface ultrasound probe on the chest, figure out where the murmur is from...

put her to sleep.

done.
Click to expand...

urge said:
I'm still not convinced you guys have done an adequate preop in this pt (labs and results aside). What history would you try to elicit?



Are you sure about that? Anyone cares to disagree? Where are murmurs form valve disease heard?
Click to expand...

cchoukal said:
I'm not sure I put as much faith in the specificity of the physical exam (location/characteristics of the murmur) to rule out severe disease as you do.
Click to expand...

That's why I said to do a bedside echo and find out where that noise is coming from.

Aortic stenosis is the only one I really care about....the rest are kind of irrelevant for this case.
 
What if the murmur was confined to the appex and could not be heard on the second right intercostal space nor in the neck vessels?
Does that make more people willing to proceed?
:)
 
Planktonmd said:
The Cardiologist sent a note sying she is cleared for surgery and to avoid hypotension and hypoxia :)
She had a cardiac catheter but the results are not avilable.
The cardiologist office is not open yet.
Click to expand...

We'd wait for the cardiologist's office to open. ;)
 
I AM ENDING THE ACADEMIC DIARRHEA YOU GUYS ARE SPUEING.

:laugh:

WOW...academic diarrhea...thats some funny s h i t....

I'm gonna use common sense.

This old lady with a femoral neck fracture, if we don't operate on her, is gonna lay in bed, and whither and die if her hip isnt fixed.

She aint gonna have heart surgery so whatever you are trying to identify, deal with it in the hip surgery. Even if it is the granddaddy aortic stenosis. Don't aortic stenosis patients having surgery for their heart endure induction?

I'm sure she's got grandkids she wants to hang out with for a few more years.

Without the surgery she runs a high risk of DVT, fulminant PE, and a buncha other s h it a bedridden person has to worry about.

Her surgery carries risk whether it is done today, tomorrow, or next month.

And the longer she lays immobile in bed, the higher her risk of something else arising becomes.

Her pressure is low to begin with so I'd feel more comfortable putting her to sleep.

Which I would do.

Optimizing her perfusion, hemodynamics, volume status, HCT, and urine output to the best of my ability.

Right now.
 
jwk said:
We'd wait for the cardiologist's office to open. ;)
Click to expand...
It will open in 2 hours but the surgeon has a full day shedule in 2 other hospitals and if I delay the case he is going to be very unhappy and the patient will have to wait until the evening when he gets back.
Do I have a good enough reason to do that?
 
Severe valve dz (scary and does indeed take preference over a hip...however unlikely considering her symptoms. Signs on the otherhand...who knows).

Hypoactive regional wall segments (does she need an angioPLASTY, or is that stuff toast no matter what, or is it CABG worthy). Is it just stunned stuff from the prior MI that never fully recovered after the stent? If so, then thats the end of that.

Global hypokinesis----->Worsening EF compared to prior echo. Tune up time for grandma or blessing from cards. Yeah, I said it.

Thing is, the case is most likely going to go barring the first two scenerios. She's gotta broken hip. If I go to court though, I'm taken like, 3 other dudes down with me. Surgeon, medicine dude, and cardiologist.

If she's got a clean cath then none of this crap matters.

There.
 
The reason I posted this case is because this is a common situation in the real world: Urgent case, incomplete data, and every one will hate you if you cancel without real solid reasons.
My thought process was similar to what Jet had mentioned: the hip has to be fixed and the longer you wait the more likely you will hurt this old lady.
Here is what we know: Elderly lady, has CAD and had an MI post-op 3 months ago, she has a systolic murmur at the apex, she is on beta blockers, her cardiologist said go ahead although did not care to elaborate (very common situation), she has a decent exercises tolerance (close to 4 mets).
She has no symptoms suggesting severe valvular disease and specifically no symptoms suggesting severe aortic stenosis ( no angina and no syncope).
There are many things that we don't know like the exact findings of the cardiac catheter and if any other studies were done but we know that she is not on plavix (no stents placed?), and the EKG does not show any scarring which makes you think that this might have been a non st elevation MI.
With the clinical picture above I felt confident to proceed so here is what we did:
In holding area I did a fascia iliaca block which took her pain level down to zero.
Went to the OR induced gently with propofol and placed LMA and maintained anesthesia with Sevo + N2O and only 50 Mcg of Fentanyl total.
Surgery was uneventful and blood loss was 100 cc, it took 45 min.
She was hemodynamically rock solid.
She had zero pain in recovery.
Again this case is an everyday kind of case and as an anesthesiologist in private practice you will see similar situations frequently.
You have an obligation to your patients to do what's right but you also have an obligation to do all you can to keep the OR flowing and the surgeons happy.
 
Planktonmd said:
The reason I posted this case is because this is a common situation in the real world: Urgent case, incomplete data, and every one will hate you if you cancel without real solid reasons.
My thought process was similar to what Jet had mentioned: the hip has to be fixed and the longer you wait the more likely you will hurt this old lady.
Here is what we know: Elderly lady, has CAD and had an MI post-op 3 months ago, she has a systolic murmur at the apex, she is on beta blockers, her cardiologist said go ahead although did not care to elaborate (very common situation), she has a decent exercises tolerance (close to 4 mets).
She has no symptoms suggesting severe valvular disease and specifically no symptoms suggesting severe aortic stenosis ( no angina and no syncope).
There are many things that we don't know like the exact findings of the cardiac catheter and if any other studies were done but we know that she is not on plavix (no stents placed?), and the EKG does not show any scarring which makes you think that this might have been a non st elevation MI.
With the clinical picture above I felt confident to proceed so here is what we did:
In holding area I did a fascia iliaca block which took her pain level down to zero.
Went to the OR induced gently with propofol and placed LMA and maintained anesthesia with Sevo + N2O and only 50 Mcg of Fentanyl total.
Surgery was uneventful and blood loss was 100 cc, it took 45 min.
She was hemodynamically rock solid.
She had zero pain in recovery.
Again this case is an everyday kind of case and as an anesthesiologist in private practice you will see similar situations frequently.
You have an obligation to your patients to do what's right but you also have an obligation to do all you can to keep the OR flowing and the surgeons happy.
Click to expand...

Very important scenerio and very relevant since like Plank said, this is a very common situation.

Thanks, Plank. :thumbup:
 
Planktonmd said:
The reason I posted this case is because this is a common situation in the real world: Urgent case, incomplete data, and every one will hate you if you cancel without real solid reasons.
My thought process was similar to what Jet had mentioned: the hip has to be fixed and the longer you wait the more likely you will hurt this old lady.
Here is what we know: Elderly lady, has CAD and had an MI post-op 3 months ago, she has a systolic murmur at the apex, she is on beta blockers, her cardiologist said go ahead although did not care to elaborate (very common situation), she has a decent exercises tolerance (close to 4 mets).
She has no symptoms suggesting severe valvular disease and specifically no symptoms suggesting severe aortic stenosis ( no angina and no syncope).
There are many things that we don't know like the exact findings of the cardiac catheter and if any other studies were done but we know that she is not on plavix (no stents placed?), and the EKG does not show any scarring which makes you think that this might have been a non st elevation MI.
With the clinical picture above I felt confident to proceed so here is what we did:
In holding area I did a fascia iliaca block which took her pain level down to zero.
Went to the OR induced gently with propofol and placed LMA and maintained anesthesia with Sevo + N2O and only 50 Mcg of Fentanyl total.
Surgery was uneventful and blood loss was 100 cc, it took 45 min.
She was hemodynamically rock solid.
She had zero pain in recovery.
Again this case is an everyday kind of case and as an anesthesiologist in private practice you will see similar situations frequently.
You have an obligation to your patients to do what's right but you also have an obligation to do all you can to keep the OR flowing and the surgeons happy.
Click to expand...

Good stuff.

Now, I can finally celebrate New Years by havin a few Negra Modellas at home on the couch.

CHeers b!tches
 
Planktonmd said:
The reason I posted this case is because this is a common situation in the real world: Urgent case, incomplete data, and every one will hate you if you cancel without real solid reasons.
My thought process was similar to what Jet had mentioned: the hip has to be fixed and the longer you wait the more likely you will hurt this old lady.
Here is what we know: Elderly lady, has CAD and had an MI post-op 3 months ago, she has a systolic murmur at the apex, she is on beta blockers, her cardiologist said go ahead although did not care to elaborate (very common situation), she has a decent exercises tolerance (close to 4 mets).
She has no symptoms suggesting severe valvular disease and specifically no symptoms suggesting severe aortic stenosis ( no angina and no syncope).
There are many things that we don't know like the exact findings of the cardiac catheter and if any other studies were done but we know that she is not on plavix (no stents placed?), and the EKG does not show any scarring which makes you think that this might have been a non st elevation MI.
With the clinical picture above I felt confident to proceed so here is what we did:
In holding area I did a fascia iliaca block which took her pain level down to zero.
Went to the OR induced gently with propofol and placed LMA and maintained anesthesia with Sevo + N2O and only 50 Mcg of Fentanyl total.
Surgery was uneventful and blood loss was 100 cc, it took 45 min.
She was hemodynamically rock solid.
She had zero pain in recovery.
Again this case is an everyday kind of case and as an anesthesiologist in private practice you will see similar situations frequently.
You have an obligation to your patients to do what's right but you also have an obligation to do all you can to keep the OR flowing and the surgeons happy.
Click to expand...


What did you use for your block?
 
DrRobert said:
Just curious why you opted for the regional block + GA instead of an epidural with sedation.
Click to expand...
Positioning a patient with a hip fracture to do an epidural is painful and pain could be all this patient needs to have a second MI.
Sure you could give her heavy sedation (basically GA) and do it, but it's not very elegant IMHO to give GA in order to give regional anesthesia. :)
Also this patient was hypotensive initially and looked dehydrated.
 
jetproppilot said:
I AM ENDING THE ACADEMIC DIARRHEA YOU GUYS ARE SPUEING.
Click to expand...



i like that you managed to spell DIARRHEA correctly, but not SPEWING. reminds me of my friend who is a PhD in biophysics, picking apart cellular transmembrane channels, but can't spell his own name. just teasin' JPP ;)


but yeah, i was reading this thread thinking "well crap, this reminds me of um.. a ton of patients i've seen already as a CA-1". Are there really healthy patients out there? or do they all just come to West Virginia to decay and die? i guess i'll be ready for the healthy ones after seeing all these sickies.
 
Great case. It really just sums up every hip fracture patient that comes through my practice. Usually we have to add on a little to a lot of dementia too. They are usually barely surgical candidates because broken hip or not, they don't have a lot of time left. But if the hip isn't fixed, that little time will be bed-ridden and painful and so it usually is worth the risk.

The plan: General, LMA. Keep the HCT above 29 or so, optimize volume, try to keep vital signs stable (obviously). I occasionally do blocks, but often these people are demented. (though the block is a great idea!)

The truth is, this woman has been seen by a cardiologist within the year. So she has unlikely developed some crazy new valvular disease or other heart disease that required surgery before she broke her hip. So no matter what we see from any of the results, it isn't anything that we would fix before surgery. The other important thing to know is what this woman was up to before she broke her hip. Did she break her hip playing basketball, or was she bed ridden because she can't hobble to the bathroom with severe shortness of breath or chest pain.

It is true that delaying the case 3 hours to get results from an office, could cause the patient to be bumped until later that night of even the next day in the private world. And so having this woman laying in bed, staying NPO and in terrible pain for a day is probably more stressful to her heart and system than just doing the surgery as soon as possible.
 
DrRobert said:
Just curious why you opted for the regional block + GA instead of an epidural with sedation.
Click to expand...

I've done many, many of these with a spinal, Robert. 22" needle.

You'd think with a broken hip it'd be hard but not really.

Bring 'em in the room and stun them with whatever cocktail you want.....propofol 50mg works pretty good....or ketamine, or fentanyl/versed....once their eyes start to roll back in their head have a cuppla assistants sit them up on the bed they rolled in on, sit behind them, prep away, drive the 22", squirt the HB bupiv in, and you're done.

With this lady and her 90 systolic BP, though, I wouldda done GA like Plank did.
 
Been greeted with this exact case several times. Usually you know about it the night before and can see the pt the night before. But if it is an add-on, it still doesn't matter. If the patient has a cardiologist, then it behooves you to at least speak with him/her prior to going ahead. I tell the Ortho that he should know better before bringing the patient down without the cardiologist's blessing. It might not make an iota of difference in your management, but it still is the right thing to do.

Ever have a patient die on you? I have. It ain't pretty. Try explaining to the relatives why you couldn't wait for the cardiologist's office to open.

By the same token I've also taken some of these patients into the OR afterwards and gotten away with it. Sheeet, virtually all the time you get away with it. Doesn't mean that it was the right thing to do.

The excuse of the orthopedist that he can't come back until much later is horsesh*t. His schedule shouldn't affect your patient care. Can I cancel the case because my kid has a play in the afternoon? Didn't think so.

Wow, sorry for the venting .
 
numbmd said:
Been greeted with this exact case several times. Usually you know about it the night before and can see the pt the night before. But if it is an add-on, it still doesn't matter. If the patient has a cardiologist, then it behooves you to at least speak with him/her prior to going ahead. I tell the Ortho that he should know better before bringing the patient down without the cardiologist's blessing. It might not make an iota of difference in your management, but it still is the right thing to do.

Ever have a patient die on you? I have. It ain't pretty. Try explaining to the relatives why you couldn't wait for the cardiologist's office to open.

By the same token I've also taken some of these patients into the OR afterwards and gotten away with it. Sheeet, virtually all the time you get away with it. Doesn't mean that it was the right thing to do.

The excuse of the orthopedist that he can't come back until much later is horsesh*t. His schedule shouldn't affect your patient care. Can I cancel the case because my kid has a play in the afternoon? Didn't think so.

Wow, sorry for the venting .
Click to expand...

You've GOT to be kidding me.....What's a cardiologist's "blessing" got to do with ANYTHING.

You're a MD right?

Waiting for the blessing is just wasting time.

people die...whether you take care of them or not.

80 year old's with broken hips DEFINITELY die if you don't take care of them.

Cardiologists don't take care of 80 year olds with broken hips.

Orthopods and anesthesiologists do.

You don't need a cardiologist to rule out MI as a cause of fall....Interns (PGY-1s) do that.

You don't need a cardiologist to manage conduction abnormalities as a cause of falls....they may need a permanent pacemaker, but temporary onces work just fine.

Give me a break...just put them to sleep.

..OK off Rant mode.
 
numbmd said:
Been greeted with this exact case several times. Usually you know about it the night before and can see the pt the night before. But if it is an add-on, it still doesn't matter. If the patient has a cardiologist, then it behooves you to at least speak with him/her prior to going ahead. I tell the Ortho that he should know better before bringing the patient down without the cardiologist's blessing. It might not make an iota of difference in your management, but it still is the right thing to do.

Ever have a patient die on you? I have. It ain't pretty. Try explaining to the relatives why you couldn't wait for the cardiologist's office to open.

By the same token I've also taken some of these patients into the OR afterwards and gotten away with it. Sheeet, virtually all the time you get away with it. Doesn't mean that it was the right thing to do.

The excuse of the orthopedist that he can't come back until much later is horsesh*t. His schedule shouldn't affect your patient care. Can I cancel the case because my kid has a play in the afternoon? Didn't think so.

Wow, sorry for the venting .
Click to expand...
In the case we were discussing there was "a Cardiologist blessing" he sent a note saying proceed but avoid hypotension and hypoxia!
Do you need more blessing than that?
Maybe he should have sent some holy water too.
 
numbmd said:
Been greeted with this exact case several times. Usually you know about it the night before and can see the pt the night before. But if it is an add-on, it still doesn't matter. If the patient has a cardiologist, then it behooves you to at least speak with him/her prior to going ahead. I tell the Ortho that he should know better before bringing the patient down without the cardiologist's blessing. It might not make an iota of difference in your management, but it still is the right thing to do.

Ever have a patient die on you? I have. It ain't pretty. Try explaining to the relatives why you couldn't wait for the cardiologist's office to open.

By the same token I've also taken some of these patients into the OR afterwards and gotten away with it. Sheeet, virtually all the time you get away with it. Doesn't mean that it was the right thing to do.

The excuse of the orthopedist that he can't come back until much later is horsesh*t. His schedule shouldn't affect your patient care. Can I cancel the case because my kid has a play in the afternoon? Didn't think so.

Wow, sorry for the venting .
Click to expand...

I wish I could tell the orthos to come back and do the case when we want to. But the truth is, this isn't an emergency. The patient isn't bleeding out of the hip. Orthos usually have a full day at the office, or a bunch of scheduled cases elsewhere. So they come by to do an add-on, if we say we have to wait, they say they will be back after they finish their office or their cases at another hospital. Just reality. It's the surgeon's case. I can't make them come back and do it.
 
Is there any reason for not inducing with etomidate, as propofol would have greater potential to decrease BP?


Planktonmd said:
The reason I posted this case is because this is a common situation in the real world: Urgent case, incomplete data, and every one will hate you if you cancel without real solid reasons.
My thought process was similar to what Jet had mentioned: the hip has to be fixed and the longer you wait the more likely you will hurt this old lady.
Here is what we know: Elderly lady, has CAD and had an MI post-op 3 months ago, she has a systolic murmur at the apex, she is on beta blockers, her cardiologist said go ahead although did not care to elaborate (very common situation), she has a decent exercises tolerance (close to 4 mets).
She has no symptoms suggesting severe valvular disease and specifically no symptoms suggesting severe aortic stenosis ( no angina and no syncope).
There are many things that we don't know like the exact findings of the cardiac catheter and if any other studies were done but we know that she is not on plavix (no stents placed?), and the EKG does not show any scarring which makes you think that this might have been a non st elevation MI.
With the clinical picture above I felt confident to proceed so here is what we did:
In holding area I did a fascia iliaca block which took her pain level down to zero.
Went to the OR induced gently with propofol and placed LMA and maintained anesthesia with Sevo + N2O and only 50 Mcg of Fentanyl total.
Surgery was uneventful and blood loss was 100 cc, it took 45 min.
She was hemodynamically rock solid.
She had zero pain in recovery.
Again this case is an everyday kind of case and as an anesthesiologist in private practice you will see similar situations frequently.
You have an obligation to your patients to do what's right but you also have an obligation to do all you can to keep the OR flowing and the surgeons happy.
Click to expand...
 
Broken Ankles said:
Is there any reason for not inducing with etomidate, as propofol would have greater potential to decrease BP?
Click to expand...
Hey, Great name :)
Etomidate is rapidly falling out of favor because it appears to be related to increased mortality in critical patients, it's also a lousy induction agent.
I still use it in certain patients but not as frequently as I did before.
Whenever you are concerned about Propofol causing hypotension use less and add some pressor to your induction cocktail
 
Regarding the "cardiologist blessing" nonsense, just how much legal protection does this afford you? Supposing something did go wrong - say the patient DID have AS and crashed on induction, (you knew about it, because you were deft and took a quick look with a TTE probe), and now the family wants to sue you for not consulting with the patient's cardiologist regarding proper optimization. Maybe she really did deserve an AVR prior to ORIF? What is likely to happen in court?
 
powermd said:
Regarding the "cardiologist blessing" nonsense, just how much legal protection does this afford you? Supposing something did go wrong - say the patient DID have AS and crashed on induction, (you knew about it, because you were deft and took a quick look with a TTE probe), and now the family wants to sue you for not consulting with the patient's cardiologist regarding proper optimization. Maybe she really did deserve an AVR prior to ORIF? What is likely to happen in court?
Click to expand...
I don't understand what you are saying, are we supposed to call the cardiologist and ask him how to give anesthesia?
He obviously didn't think anything needed to be done before surgery because he "cleared" her!
Patients who have severe aortic stenosis have symptoms (Angina, Syncope, CHF...), they don't climb stairs and they are generally unhappy!
How many times have you seen a patient get AVR before fixing their broken hip?
 
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