Case discussion - a good day to wear brown underwear

[DrOwnage]

some of these procedures are palliative so the patient does not die in excruciating pain

And he will still die in excruciating postoperative and chronic pain. Who will want to give this man any form of opioid postoperatively? Maybe ketamine and tylenol is his only chance.

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[woopedazz]

Good points from everyone. All were brought up by our department. As stated earlier the decision was to proceed with a palliative Girdlestone procedure after all other parties decided surgical intervention was the only viable definitive analgesic option.

Partial alpha blockade was pursued pre-op with 48 hours of prazosin.
Fascia iliaca catheter loaded with a relatively high concentration/volume of Ropivacaine immediately prior to transfer from the ward - then removed to not get in way of surgery.
THRIVE (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange) + facemask --> SpO2 100%
Awake art. line.
Baby boluses of ketamine --> rolled fracture side down.
Homoeopathic vasopressin infusion commenced.
Intrathecal catheter inserted.
Micro-doses of Heavy Bupivacaine 0.5%
Total dose = 2mL over 30 minutes.
Traintrack vitals (200/105 since entering operating theatre).
Rolled onto back --> momentary HD instability --> straight leg raise --> improvement --> 200mL fluid bolus --> rallied.
Shifted to operating table + rolled fracture side up --> momentary HD instability --> vassopressin increased slightly --> rallied.
Senior surgeon present.
Skin to skin time = 15 minutes. Total blood loss = ~50mL.
Moved to recovery.
Vasopressin ceased.
Femoral nerve catheter re-inserted.
THRIVE ceased --> SpO2 immediately 50% despite 15L non-rebreather --> THRIVE re-initiated.
SpO2 ~85% on THRIVE overnight.
Downtitrated next morning.
Post-op pain controlled with femoral nerve catheter and low dose PRN opioids + simple analgesia.
At baseline 24 hours later: SpO2 80% on 8L.
Discharged home with pain improving and catheter removed.

Discussion:
Although everything went exactly as planned and the patient got an excellent result; this was unexpected. The outcome did nothing to sway the divided opinions within our department or other departments. In the end the patient received a purely palliative procedure and everything went right for them. Had they passed on would this have been appropriate? I doubt anybody's mind would have been changed regardless of the outcome.

What is key to note is this is what the patient and family wanted; this is what was offered by orthopaedic surgeons; and they will most likely go on to live a few more months in relative comfort in the place they wish to be. Palliation should focus on comfort, respect and autonomy. For that reason I am in the "exclude all other analgesic modalities and then proceed with definitive palliative surgery" camp. I'm sure many disagree.

 

[fakin' the funk]

The situation:
70+
#NOF for a hemiarthroplasty.
Mechanism of injury; rolled out of bed.
Patient at baseline health.

Baseline:
Palliated several months ago and discharged to high level of care nursing home. Prognosis at that time - days to weeks.
Made NFR, not for I+V, not for ICU/HDU, not for admission to hospital unless symptom control unable to be handled in high level of care nursing home.
Reason for palliation: End-stage COPD.
Baseline SpO2 75-80% on 10L hudson mask 24/7 since discharge to nursing home.
Severe pulm. HTN. mPAP 85mmHg.
Medically managed, actively secreting pheochromocytoma - blockade ceased when medications were rationalised several months prior during palliation process.
Neurofibromatosis type 1 (severe).

Action:
Over to you guys.

(During the planning phase the patient was happy to be talked about for education, but will still keep it relatively vague).

This thread is bonkers.

There is only one humane and appropriate medical care plan here and it does not involve orthopedic surgery.

 

[deleted697535]

If only there were other ways to ensure the patient doesn't die in excruciating pain...

A hemi on this patient is bordering on malpractice. Nail or bust. Or nail and, bust anyway.

What % of patients will need opioids after the spinal wears off? If acetaminophen and ketorolac can't control the pain, you're looking at narcotics, anyway. In which case you're at the same outcome as no surgery, but you've just chunked a 5 figure procedure onto the system unnecessarily. Do you do an epidural instead and keep it running for a few days? Hell, why not just tunnel an epidural and let them die with it? That might be the best option.

Just not sure what the goal is here with surgery. You're not going the "maximum number of days" route, because they're not going to the ICU and you're not going balls to the wall on resuscitation. You're not going the "as comfortable as possible" route, because there are cheaper and faster ways to achieve that without surgery.

Femoral nerve catheter man! Of fasci iliaca etc

 

[Mman]

If only there were other ways to ensure the patient doesn't die in excruciating pain...

A hemi on this patient is bordering on malpractice. Nail or bust. Or nail and, bust anyway.

What % of patients will need opioids after the spinal wears off? If acetaminophen and ketorolac can't control the pain, you're looking at narcotics, anyway. In which case you're at the same outcome as no surgery, but you've just chunked a 5 figure procedure onto the system unnecessarily. Do you do an epidural instead and keep it running for a few days? Hell, why not just tunnel an epidural and let them die with it? That might be the best option.

Just not sure what the goal is here with surgery. You're not going the "maximum number of days" route, because they're not going to the ICU and you're not going balls to the wall on resuscitation. You're not going the "as comfortable as possible" route, because there are cheaper and faster ways to achieve that without surgery.

Most of these old gomers get essentially no opioids postop. Give them a single shot fascia iliaca block and some tylenol and they will be fine. In fact, the majority of these patients actually get discharged from the hospital.

 

[deleted697535]

Good points from everyone. All were brought up by our department. As stated earlier the decision was to proceed with a palliative Girdlestone procedure after all other parties decided surgical intervention was the only viable definitive analgesic option.

Partial alpha blockade was pursued pre-op with 48 hours of prazosin.
Fascia iliaca catheter loaded with a relatively high concentration/volume of Ropivacaine immediately prior to transfer from the ward - then removed to not get in way of surgery.
THRIVE (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange) + facemask --> SpO2 100%
Awake art. line.
Baby boluses of ketamine --> rolled fracture side down.
Homoeopathic vasopressin infusion commenced.
Intrathecal catheter inserted.
Micro-doses of Heavy Bupivacaine 0.5%
Total dose = 2mL over 30 minutes.
Traintrack vitals (200/105 since entering operating theatre).
Rolled onto back --> momentary HD instability --> straight leg raise --> improvement --> 200mL fluid bolus --> rallied.
Shifted to operating table + rolled fracture side up --> momentary HD instability --> vassopressin increased slightly --> rallied.
Senior surgeon present.
Skin to skin time = 15 minutes. Total blood loss = ~50mL.
Moved to recovery.
Vasopressin ceased.
Femoral nerve catheter re-inserted.
THRIVE ceased --> SpO2 immediately 50% despite 15L non-rebreather --> THRIVE re-initiated.
SpO2 ~85% on THRIVE overnight.
Downtitrated next morning.
Post-op pain controlled with femoral nerve catheter and low dose PRN opioids + simple analgesia.
At baseline 24 hours later: SpO2 80% on 8L.
Discharged home with pain improving and catheter removed.

Discussion:
Although everything went exactly as planned and the patient got an excellent result; this was unexpected. The outcome did nothing to sway the divided opinions within our department or other departments. In the end the patient received a purely palliative procedure and everything went right for them. Had they passed on would this have been appropriate? I doubt anybody's mind would have been changed regardless of the outcome.

What is key to note is this is what the patient and family wanted; this is what was offered by orthopaedic surgeons; and they will most likely go on to live a few more months in relative comfort in the place they wish to be. Palliation should focus on comfort, respect and autonomy. For that reason I am in the "exclude all other analgesic modalities and then proceed with definitive palliative surgery" camp. I'm sure many disagree.

Well done. Exactly how I would've done it. 'only a coward cancels a hip'

You guys in the states are already the most expensive health care system on the planet with poor outcomes fkr all that money and there's ppl here that wouldn't do this case! Omg

 

[Arch Guillotti]

And he will still die in excruciating postoperative and chronic pain. Who will want to give this man any form of opioid postoperatively? Maybe ketamine and tylenol is his only chance.

???

The patient will feel better after he is patched up!

 

[10KHertz]

Consider combined epidural-spinal anesthesia like a high risk OB case. Enter epidural space, insert spinal needle, give low dose IT bupiv/fent combo. Don’t push the spinal level to high. Use epidural catheter as a back up if case goes to long. Supplement epicath as needed , lido 2% boluses . Use epidural pcea for post op pain and mobilization ...
MAC as needed, many suggestions provided above.

 

[pgg]

Consider combined epidural-spinal anesthesia like a high risk OB case. Enter epidural space, insert spinal needle, give low dose IT bupiv/fent combo. Don’t push the spinal level to high. Use epidural catheter as a back up if case goes to long. Supplement epicath as needed , lido 2% boluses . Use epidural pcea for post op pain and mobilization ...
MAC as needed, many suggestions provided above.

"MAC" in this patient is very likely to be an execution ...

End-stage COPD. Baseline SpO2 75-80% on 10L hudson mask 24/7 since discharge to nursing home. Severe pulm. HTN. mPAP 85mmHg.

IMO you've got to either control ventilation completely or you've got to leave it alone. Flirting with sedation is inviting a death spiral of hypoxia, hypercarbia, worsened PHTN, cardiovascular collapse.

 

[MoMoGesiologist]

Mask induction (+/- prop/etomidate/ketamine, whatever depending on vitals), slip in an LMA. Uppers and downers available for the pheo. Why all the enthusiasm for neuraxial and regional?

 

[Mman]

Mask induction (+/- prop/etomidate/ketamine, whatever depending on vitals), slip in an LMA. Uppers and downers available for the pheo. Why all the enthusiasm for neuraxial and regional?

you prefer a GA on pulmonary cripples?

 

[MoMoGesiologist]

N

you prefer a GA on pulmonary cripples?

No, you are right about that, GA isn’t ideal. I was thinking with the pHTN I’d want to take over oxygenation/ventilation. I think MAC has higher risk.

 

[IlDestriero]

I’d try to put it off for a few of days for a total spine MRI to eval NF, new echo, cards consult to optimize for good measure. The patient will likely have expired by that time.

 

[10KHertz]

"MAC" in this patient is very likely to be an execution ...



IMO you've got to either control ventilation completely or you've got to leave it alone. Flirting with sedation is inviting a death spiral of hypoxia, hypercarbia, worsened PHTN, cardiovascular collapse.

Not if you use combined epidural-spinal technique with MAC dexemetomidine ...

 

[nimbus]

Not if you use combined epidural-spinal technique with MAC dexemetomidine ...

Do most people consider dex safe in this patient? I would have concerns using it in the setting of a pheo and life threatening pulm htn.

 

[deleted697535]

I wish you guys would stop saying Mac. It means nothing.

 

[coffeebythelake]

N

No, you are right about that, GA isn’t ideal. I was thinking with the pHTN I’d want to take over oxygenation/ventilation. I think MAC has higher risk.

Why even use Mac if you have neuraxial block.

 

[ChiDO]

Clarification from Ortho.

If the patient needs a hemi, there is a displaced femoral neck fracture and screws or nail are not standard of care. A simple cemented hemi takes 25 mins + closing.

If this patient is this sick, palliative care and they'll have a 90% mortality rate within 3 months, which may be the same as fixing it or they could live for years.

 

[MoMoGesiologist]

Why even use Mac if you have neuraxial block.

Some people can’t sit still for a procedure even with block, especially If dementia. Or to cover an inadequate block lol

 

[deleted162650]

If the patient needs a hemi, there is a displaced femoral neck fracture and screws or nail are not standard of care.

Yes, I understand that point.

However, given this procedure is purely for pain control/palliation and not to restore function does that change things?

Would you consider screws for this particular scenario even though it's not the standard under more normal circumstances?

Thank you for your presence and input on this forum. It's nice to have perspective from the other side of the drapes around here.

 

[vector2]

Clarification from Ortho.

If the patient needs a hemi, there is a displaced femoral neck fracture and screws or nail are not standard of care. A simple cemented hemi takes 25 mins + closing.

If this patient is this sick, palliative care and they'll have a 90% mortality rate within 3 months, which may be the same as fixing it or they could live for years.

If the head of the femur is OK, is the the repair on the left sufficient for a bedbound patient?

 

[woopedazz]

Clarification from Ortho.

If the patient needs a hemi, there is a displaced femoral neck fracture and screws or nail are not standard of care. A simple cemented hemi takes 25 mins + closing.

If this patient is this sick, palliative care and they'll have a 90% mortality rate within 3 months, which may be the same as fixing it or they could live for years.

Yep. We went ahead and Girdlestone'd them due to the above. The cement exposure was what irked us so much about the hemi option.

 

[ChiDO]

If the head of the femur is OK, is the the repair on the left sufficient for a bedbound patient?

The first femoral neck fracture shown above is typically a subcapital (below the head) and usually nondisplaced, so you can fix with screws. A hemi is used for a completely displaced fracture due to blood supply being damaged. You could fix it with screws, but high chance the head dies and they have pain.

Google Image Result for https://musculoskeletalkey.com/wp-content/uploads/2016/11/f34-01.jpg

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Yep. We went ahead and Girdlestone'd them due to the above. The cement exposure was what irked us so much about the hemi option.

Good option to reduce or time and risks of cementing.

 

[ChiDO]

Yes, I understand that point.

However, given this procedure is purely for pain control/palliation and not to restore function does that change things?

Would you consider screws for this particular scenario even though it's not the standard under more normal circumstances?

Thank you for your presence and input on this forum. It's nice to have perspective from the other side of the drapes around here.

Surgical options would be a hemi or girdlestone as fixing it with screws would have a high chance for AVN of the head and then increased pain. Other option is hospice.

 

[deleted162650]

Surgical options would be a hemi or girdlestone as fixing it with screws would have a high chance for AVN of the head and then increased pain. Other option is hospice.

Why does the head not necrose with a Girdlestone, but would after screws?

Thanks for educating me.

 

[ChiDO]

Why does the head not necrose with a Girdlestone, but would after screws?

Thanks for educating me.

The femoral head and neck are removed in a Girdlestone procedure.

 

[deleted162650]

The femoral head and neck are removed in a Girdlestone procedure.

OK gotcha. Didn't realize the head was fully removed in a Girdlestone.

 

[nimbus]

OK gotcha. Didn't realize the head was fully removed in a Girdlestone.

I knew a German shepherd who had one. Unbelievable how well he moved without a femoral head.

 

[Mikkel]

I knew a German shepherd who had one. Unbelievable how well he moved without a femoral head.

Dogs do pretty well with an amputated leg too.

 

[pgg]

Dogs do pretty well with an amputated leg too.

Dogs seem pretty happy no matter what with just some attention from the people they love. People could learn something from them.

 

[ChiDO]

I'm always amazed of hearing from mission trips or overseas physicians about pain meds. You think we're doing cruel and unusual punishment when we don't prescribe opiods, yet total joint surgery in India you get Tylenol only.

Mission trips Tylenol and nsaids for all surgeries. And these people are so happy and thrilled to get care.

 

[dchz]

Do most people consider dex safe in this patient? I would have concerns using it in the setting of a pheo and life threatening pulm htn.

As long as you do'nt bolus it! really bad time for someone to clinically learn about the alpha 1 overflow of dexmedetomidine.

 

[deleted171991]

As long as you do'nt bolus it! really bad time for someone to clinically learn about the alpha 1 overflow of dexmedetomidine.

That's such a bad drug for anything more than some minor sedation (e.g. awake intubation) in the OR. It's unpredictable and has bad hemodynamic effects. There are better drugs around.

 

[10KHertz]

Do most people consider dex safe in this patient? I would have concerns using it in the setting of a pheo and life threatening pulm htn.

Dex (low dose infusion) is a reasonable option, with some acceptable risks, but not necessarily contraindicated with rare dual PHT and pheo indications... there isn’t a perfect option.

Dexmedetomidine: review, update, and future considerations of paediatric perioperative and periprocedural applications and limitations

Abstract. Despite lack of paediatric labelling, contributions to the literature on paediatric applications of dexmedetomidine have increased over recent years.

academic.oup.com

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