Bnp increasing

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aneftp

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What’s everyone opinion about bnp? I know it’s not a 100% full proof predictor of chf. It has a lot of variables.

But had this 91 year old lady this morning Transferred from Another local hospital last night Aka dumped on me for Sunday case.

Anyways. She’s on hospice. Dnr but patient family said go ahead with the surgery. Age 91. Afib. Had rvr yesterday but rate controlled
This morning. EF is like 25%. Down from 45% last admission last month. Femur fx. Usual train wreck. On eliqis.

Cards evaluated her. Says high risk but stable from cardiac. I saw bnp was 10k yesterday and it came back at 18k this morning.

So does almost doubling overnight worry about anyone? They got her on bumex. This patient just didn’t look right. Confused/obtunded. I’m moonlighting anyways at locums job. So i just punted it to the Monday morning team to figure it out.
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Is she mobile?

Sounds like she's on her way out to meet Jesus. That's a high BNP.

But we can't let her die without cutting on them now can we? We gotta give it the good old college try!!

@dhb, What would they do in your country?

I don't want to sound like I am inhumane, but I think this is when Hospice/Palliative care earns its money. Unless she's a spry 90 year old, which she ain't, based on your prescription.
 
So a confused 91yo in hospice who has a new cardiomyopathy and is anticoagulated for her atrial fib needs a somewhat elective (could just manage her pain). This whole situation just seems stupid, why even offer surgery?


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ericL said:
So a confused 91yo in hospice who has a new cardiomyopathy and is anticoagulated for her atrial fib needs a somewhat elective (could just manage her pain). This whole situation just seems stupid, why even offer surgery?


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cause its america.
i would cancel the case. doubling of BNP to 18k does sound bad.
 
While this patient is clearly acutely decompensated, I don't think repairing the femur is so out of the question, especially since it can be considered a palliative procedure.

Admit her to cards, put her on a diuretic infusion, control her afib (which should definitely improve with better diuresis), bridge her with heparin and do it under spinal. Or do it under general. Her operative mortality can go from 75-90% to <10% with pure optimization.

Definitely a good call not to proceed right now though.
 
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How is eliquis a hospice drug?
Are you saying this lady should be on hospice care or is on hospice care already?
HH
 
ericL said:
So a confused 91yo in hospice who has a new cardiomyopathy and is anticoagulated for her atrial fib needs a somewhat elective (could just manage her pain). This whole situation just seems stupid, why even offer surgery?
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A troch nail is a 15 minute procedure and it's palliative.

Surgery is absolutely reasonable. But it's sure not an emergency and this is a good patient to optimize for a day or two.

Well punted. 🙂
 
pgg said:
A troch nail is a 15 minute procedure and it's palliative.

Surgery is absolutely reasonable. But it's sure not an emergency and this is a good patient to optimize for a day or two.

Well punted. 🙂
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It’s not so much about speed or safety, I’m positive we could get her through it, it’s more a matter of why waste the resources. If she’s already in hospice then her life expectancy I imagine to be in the months rather than years. Why expend the money and resources as opposed to focusing on pain management?


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ericL said:
It’s not so much about speed or safety, I’m positive we could get her through it, it’s more a matter of why waste the resources. If she’s already in hospice then her life expectancy I imagine to be in the months rather than years. Why expend the money and resources as opposed to focusing on pain management?
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Immobilizing a fracture is pain management.

People getting Hospice care have a wide range of functional status. There are a lot of these old, sick, terminal patients who are at least a little mobile, and are better off getting a troch nail than being bedridden obtunded with fentanyl patches for the last few weeks or months of their lives.


algosdoc said:
She will be dead in one week with or without surgery.
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Possibly. Or she might linger for 3 months.
 
algosdoc said:
She will be dead in one week with or without surgery.
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debbie-downer-wah-wah.gif
 
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BNP isn’t a lab that’s meant to be trended. If the patient was a fib with RVR, that could likely be the cause.
 
chocomorsel said:
Is she mobile?

Sounds like she's on her way out to meet Jesus. That's a high BNP.

But we can't let her die without cutting on them now can we? We gotta give it the good old college try!!

@dhb, What would they do in your country?

I don't want to sound like I am inhumane, but I think this is when Hospice/Palliative care earns its money. Unless she's a spry 90 year old, which she ain't, based on your prescription.
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We get our share of these, most of these cases don't live more than a couple of days. Best thing to do is to delay for more work up/ med tuning and hope they die before they get to the OR
 
its a palliative procedure.
so - frank discussion with patient and family, and do the case ... gentle GA + FIB
I would only delay to treat heart failure if it was clinically necessary (florid), I wouldn't have checked the BNP.

I would tell the family that I expect she will get through the surgery, that the surgery will improve her pain, but that she is unlikely to survive to discharge from hospital.
 
anbuitachi said:
Why not? Is there evidence for not trending BNP? They do this all the time in medicine
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No. It’s kind of like trending ammonia in a cirrhotic. Some people do it, but it doesn’t make sense.

The test is meant to simply risk stratify whether someone’s dyspnea is related to HF or not. If it’s up on admission, then you have other better, more relevant markers to follow - oxygen requirement, I/Os, physical exam, ability to lay flat, creatinine, etc.
 
anbuitachi said:
Why not? Is there evidence for not trending BNP? They do this all the time in medicine
Click to expand...

What's the point? BNP is meant to help differentiate btw heart failure vs something else. Once you have a working diagnosis, you intervene to fix it. What is the point of another bnp? Better to get a bmp, look at electrolytes and renal markers, urine output, amount of edema, change in jvp, etc.

Our medicine docs don't trend bnp.
 
Surgery was done this at noon time. I checked with my old practice where I moonlight. 30 minutes. No complications. Bnp was down to 9000 this morning. Rate controlled

Oh well...I’d rather them do it Monday than Sunday.
 
aneftp said:
Surgery was done this at noon time. I checked with my old practice where I moonlight. 30 minutes. No complications. Bnp was down to 9000 this morning. Rate controlled

Oh well...I’d rather them do it Monday than Sunday.
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I'll be checking this thread in a month or so...
 
GlowInTheDark said:
This seems like a good time to brush up/learn about BNP & and nt-proBNP, here’s a neato little read:

Clinical applications of B-type natriuretic peptide (BNP) testing | European Heart Journal | Oxford Academic
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That's a 15 year-old paper. I don't even have to bother to look at anything else beyond the publication date. Back then, BNP was the next best thing since sliced bread.

Also, I don't remember the ACC/AHA guidelines speaking about (pro)BNP (or me ever checking it). Third, this was not BNP elevation due to CHF decompensation, this was BNP elevation due to AFib/RVR. I'm not saying she doesn't have CHF, just that the impact of RVR on atrial distention was much higher than of fluid overload and CHF. The fact that cardiology didn't care about the BNP, and declared her "stable", should have been a hint.

This case is pretty clear-cut. Urgent surgery for palliative pain control (hospice is NOT comfort care, for Gods' sake!). The only question is whether it's worth optimizing the patient some more, which should be based on the clinical exam, not on numbers. Given the recent AFib/RVR, I wouldn't have jumped into it either, but I probably would have done it today (like they did), if no further cardiac issues. GA-LMA, easy-peasy.

And regarding the (de)mental status: pain (and/or its opiate treatment) alters the mental status in elderly. So, yeah, a 91 year-old patient won't "look right".
 
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FFP said:
The only question is whether it's worth optimizing the patient some more, which should be based on the clinical exam, not on numbers.

And regarding the (de)mental status: pain (and/or its opiate treatment) alters the mental status in elderly. So, yeah, a 91 year-old patient won't "look right".
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I almost totally disagree.
Clinical exam in a 91 yo with a fractured hip is basically like trying to tell next week's weather in Ireland by looking out the window.
Personally I think my clinical exam is feriocously good and I trust it to the hilt but I only trust it for my own utility. I wouldn't dare use it to explain in court why this lady died if something went wrong for example.

To that end, numbers are the only thing that matters. Just bnp isn't one of them. The usual 8 numbers are... Hr, sodium, temp, k, uncontrolled chest sepsis.

And the last number that matters is 48 hours. My opinion is it's a criminal sin to let a human being lie in a bed with a broken hip for linger than 2 days. So do what you can for those 2 days then fix it imo. That's our job. Suck it up
 
Newtwo said:
...
Personally I think my clinical exam is feriocously good and I trust it to the hilt but I only trust it for my own utility. I wouldn't dare use it to explain in court why this lady died if something went wrong for example.

To that end, numbers are the only thing that matters. Just bnp isn't one of them. The usual 8 numbers are... Hr, sodium, temp, k, uncontrolled chest sepsis.
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How on earth are you going to end up in court if a 91yo with a fractured hip dies?
set the expectations with the family before doing the case, allow them to hear the same from a second opinion colleague if they want, tell them you'll do all you can -- and that the patient will be comfortable but may not survive.

then just do the case
 
JobsFan said:
How on earth are you going to end up in court if a 91yo with a fractured hip dies?
set the expectations with the family before doing the case, allow them to hear the same from a second opinion colleague if they want, tell them you'll do all you can -- and that the patient will be comfortable but may not survive.

then just do the case
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You could potentially still go to court, or at least blame yourself if something simple is missed like the things above I've mentioned.
I don't like anyone to die on table, or in hospital for that matter.
Also it's impossible to prognosticate on who will die and when. It could well be today but it could be 10 daysor longer. If a patient will live anything longer than a femoral nerve block will.last for ie about 2 days, I think we should do the case.

Would you like your mother lying in bed in her final days unable to even use the wash room? Do the case, and a block at the end.
 
Well. I stand by decision to postpone Sunday case. It was dump from another community hospital that has history of dumping (aka they are much more profitable hospital). It was sick 91 year old and surgery still done within 2 days.
 
JobsFan said:
How on earth are you going to end up in court if a 91yo with a fractured hip dies?
set the expectations with the family before doing the case, allow them to hear the same from a second opinion colleague if they want, tell them you'll do all you can -- and that the patient will be comfortable but may not survive.

then just do the case
Click to expand...
Our orthopods have learned to request cardiology “clearance” as soon as these patients are admitted. Luckily we have a few semiretired cardiologists on staff who will clear a corpse. Everybody wins. Patient gets the surgery and our asses are somewhat covered.
 
aneftp said:
Well. I stand by decision to postpone Sunday case. It was dump from another community hospital that has history of dumping (aka they are much more profitable hospital). It was sick 91 year old and surgery still done within 2 days.
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fair enough ... wasn't criticising you at all - need the patient in front of you to be able to make a judgement
 
Newtwo said:
I don't like anyone to die on table, or in hospital for that matter.
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I sometimes wonder what the daily probability of a nonogenarian dying is.
I mean, what's the chance a 91 yo makes it to 92? 5%??
so 95% of them die sometime that year for whatever reason
95/365 ??
 
JobsFan said:
I sometimes wonder what the daily probability of a nonogenarian dying is.
I mean, what's the chance a 91 yo makes it to 92? 5%??
so 95% of them die sometime that year for whatever reason
95/365 ??
Click to expand...

Wonder no longer: 82% for males, 86% for females.

Actuarial Life Table

Calculating the daily probability of death is left as an exercise to the reader.
 
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