Case Discussion

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DrOwnage

DrOwnage

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Hey guys just wondering about your input for this case.

90-year-old female with history of prior CVA, breast malignancy, hypertension, hypothyroidism, who came in after a fall at home. X-rays reveal a severely comminuted and displaced humerus fracture (fracture of both head and neck of the humerus) and right femoral neck fracture. CT of the head was unremarkable. This was 2 days ago.

Found to be in a fib with RVR, trops peak at 2. Started on amiodarone and heparin drip. Now in NSR. Trops downtrending sitting at 1 today. Obviously NSTEMI from demand ischemia. Echo done, LVEF 65-70%, Sclerotic aortic valve, PASP 45-50.

Patients hemoglobin is 10. Not really any other lab abnormalities.

Family wants both the Hip ORIF and total shoulder arthroplasty done in one surgery. Hip first then shoulder. Patient is DNR. Fast surgeon, probably would take 3 hours for both, hopefully.

Scheduled for tomorrow morning (Saturday), and I'm on.

Any thoughts on safety with known recent NSTEMI 2 days prior? Suck it up and do both fractures at the same time? Awaiting prop, sux, tube comments. Thanks.
 
Interscalene, femoral or fascia iliaca, arterial line for checking hematocrit, LMA if supine and head available but realistically etomidate, midaz, ETT

Demand ischemia isn’t really an NSTEMI. Are they on heparin for a fib or plaque rupture. Still not sure it changes my plan.
 
Yep ISB, i don't think any blocks are really good for hip but she's not ambulating the next day so you could do a femoral if so inclined.
A line,tube, transfuse 1-2 units and hope for the best.
 
Ketamine 10. Femoral block ropi 0.5 10 cc. Peng 20 cc. Interscalene 10 cc. +/- on a line depending on surgeon. Good iv access.

Even if she had nstemi her 30 day mortality is high as it is. Just do both at once and let the family know that her risk for badness is high.
 
Wish I knew how to do a PENG block. Don't see a way doing this with just regional. I'm sure she will be fine, but was wondering about studies/what people knew about mortality given the circumstances.
 
DrOwnage said:
Found to be in a fib with RVR, trops peak at 2. Started on amiodarone and heparin drip. Now in NSR. Trops downtrending sitting at 1 today. Obviously NSTEMI from demand ischemia. Echo done, LVEF 65-70%, Sclerotic aortic valve, PASP 45-50.

Any thoughts on safety with known recent NSTEMI 2 days prior? Suck it up and do both fractures at the same time?
Click to expand...

What makes you say this is "obvious" demand ischemia? Do you have a recent left heart cath or stress echo to prove it?

Regardless this takes priority over the CABG anyways so document your consent suspend the dnr and:

Phenylephrine prop roc tube.

DrOwnage said:
Wish I knew how to do a PENG block. Don't see a way doing this with just regional.
Click to expand...

Don't see any contraindications against a spinal and interscalene.
 
dchz said:
What makes you say this is "obvious" demand ischemia? Do you have a recent left heart cath or stress echo to prove it?

Regardless this takes priority over the CABG anyways so document your consent suspend the dnr and:

Phenylephrine prop roc tube.



Don't see any contraindications against a spinal and interscalene.
Click to expand...

You are braver than me to put a spinal in when a heparin drip is going
 
GassYous said:
You are braver than me to put a spinal in when a heparin drip is going
Click to expand...

The surgery is tomorrow. Stop the drip 8 hours before.

For the record I wouldn't want to talk to a healthy 90 year old for 3 hours so I would have voted for GA. Just responding to his denial of anyway to do this regional.
 
dchz said:
What makes you say this is "obvious" demand ischemia? Do you have a recent left heart cath or stress echo to prove it?

Regardless this takes priority over the CABG anyways so document your consent suspend the dnr and:

Phenylephrine prop roc tube
Click to expand...

Seems like demand ischemia is most likely explanation for trop elevation.
 
dchz said:
The surgery is tomorrow. Stop the drip 8 hours before.

For the record I wouldn't want to talk to a healthy 90 year old for 3 hours so I would have voted for GA. Just responding to his denial of anyway to do this regional.
Click to expand...
Would you be ok with putting spinal in then converting to beach chair shortly after? He's quick with the hip. I'm honestly asking because I've never done that before. Guess isobaric wouldn't be bad.
 
DrOwnage said:
Hey guys just wondering about your input for this case.

90-year-old female with history of prior CVA, breast malignancy, hypertension, hypothyroidism, who came in after a fall at home. X-rays reveal a severely comminuted and displaced humerus fracture (fracture of both head and neck of the humerus) and right femoral neck fracture. CT of the head was unremarkable. This was 2 days ago.

Found to be in a fib with RVR, trops peak at 2. Started on amiodarone and heparin drip. Now in NSR. Trops downtrending sitting at 1 today. Obviously NSTEMI from demand ischemia. Echo done, LVEF 65-70%, Sclerotic aortic valve, PASP 45-50.

Patients hemoglobin is 10. Not really any other lab abnormalities.

Family wants both the Hip ORIF and total shoulder arthroplasty done in one surgery. Hip first then shoulder. Patient is DNR. Fast surgeon, probably would take 3 hours for both, hopefully.

Scheduled for tomorrow morning (Saturday), and I'm on.

Any thoughts on safety with known recent NSTEMI 2 days prior? Suck it up and do both fractures at the same time? Awaiting prop, sux, tube comments. Thanks.
Click to expand...
ISB, GA LMA
 
coffeebythelake said:
Are you expecting the patient to lose a bunch of blood from this surgery? Hgb is 10.
There is some evidence that liberal transfusion strategies post MI have higher mortality rates.
Click to expand...
She's probably hemoconcentrated with dehydration and she's going to lose blood with the double surgery so 1 unit upfront and the 2nd depending on how the surgery goes seems reasonable and is better than playing catch up in PACU.
 
coffeebythelake said:
Are you expecting the patient to lose a bunch of blood from this surgery? Hgb is 10.
There is some evidence that liberal transfusion strategies post MI have higher mortality rates.
Click to expand...

You can easily lose a few hundred from a hip. I don't blame people for getting blood ready but unless the patient is consistently hypotensive with increasing pressor requirement I'm avoiding blood administration even in the setting of this trop leak.
 
dhb said:
She's probably hemoconcentrated with dehydration and she's going to lose blood with the double surgery so 1 unit upfront and the 2nd depending on how the surgery goes seems reasonable and is better than playing catch up in PACU.
Click to expand...

Agreed. If they’re 90 and frail enough to break 2 long bones at the same time they’re likely dehydrated, hemeconcentrated, and don’t have a lot of volume to lose.

A fractured head and neck of humerus is a bloody case. You likely can’t use a tourniquet. I would love ortho to prove me wrong that this won’t be bloody but I am very skeptical.

You only have one arm to work with intraop which more than likely will also have a BP cuff. Their veins are probably thoroughly shredded by lab draws before you ever get incolved.

...and they’re also on a heparin drip. Shutting off a heparin drip and subjecting a patient to surgery if this is a real NSTEMI with a troponin of 2 is not something i would do and would require the cardiologists blessing. I wouldn’t push for this if they tell you they are concerned enough to cath them after their surgery. But doing so, so you can attempt this under regional and spinal is dubious. You think a 90 year old is going to tolerate banging and drilling next to their ear with the occasional accidental sucker punch with their face draped and lateral for 2 hours? Plus add in dealing with obstruction, hypoxia, and hypercarbia.

It’s too many stars needing to align for me.

At the very least, do yourself a favor and place the arterial line for hemodynamic monitoring and blood draws so you don’t have to crawl under the drapes or risk your IVs.
 
anbuitachi said:
what blocks do you do to do this only under blocks? im curious. none of the blocks have a complete coverage i thought
Click to expand...
Ideally high sciatic and lumbar plexus.

GassYous said:
I've done hips with fascia iliaca minimal sedation no opioid and they do ok.
Click to expand...
How much is minimal? .5 mac of sevo? Fascia iliaca doesn't cover much of anything...
 
I have done cases like this one in my career. What is her weight 45 kg? Typically, 90 year old women don't weigh much. As for Regional I would be very careful with an ISB because at this age patients can become dyspneic after an ISB. I would likely do a reduced volume and reduce concentration ISB like 6-8 mls of 0.25% BUP. Similarly for the FICB I would be very careful about LAST here and reduce the concentration.

LMA is an excellent choice here but an ETT is also reasonable. I would place an arterial line due to the recent MI and the likelihood of hemodynamic instability during the case requiring pressors. 2 good functioning IV's like a 20G and an 18G. As for transfusing any PRBCs in advance I would make sure there are 2 units in the room but I wouldn't give any blood unless the EBL warranted it. My target Hgb on her is 8.5-9.0 and not 10.0.

I would avoid a spinal on her because I see no reason to do 2 anesthetics to cover her Humerus and her hip. KISS principle dictates GA. I assume she is not on any anticoagulants and her heparin drip was D/C'd 6-8 hours ago.
 
BLADEMDA said:
I have done cases like this one in my career. What is her weight 45 kg? Typically, 90 year old women don't weigh much. As for Regional I would be very careful with an ISB because at this age patients can become dyspneic after an ISB. I would likely do a reduced volume and reduce concentration ISB like 6-8 mls of 0.25% BUP. Similarly for the FICB I would be very careful about LAST here and reduce the concentration.

LMA is an excellent choice here but an ETT is also reasonable. I would place an arterial line due to the recent MI and the likelihood of hemodynamic instability during the case requiring pressors. 2 good functioning IV's like a 20G and an 18G. As for transfusing any PRBCs in advance I would make sure there are 2 units in the room but I wouldn't give any blood unless the EBL warranted it. My target Hgb on her is 8.5-9.0 and not 10.0.

I would avoid a spinal on her because I see no reason to do 2 anesthetics to cover her Humerus and her hip. KISS principle dictates GA. I assume she is not on any anticoagulants and her heparin drip was D/C'd 6-8 hours ago.
Click to expand...
Unless they are in the Midwest! Those old folks stay eating and stay fat. It’s so interesting.
Anyway, I would ISB, prop roc tube, A line, Blood ready and keep her VSS. Lol.
 
dhb said:
Ideally high sciatic and lumbar plexus.


How much is minimal? .5 mac of sevo? Fascia iliaca doesn't cover much of anything...
Click to expand...

Like 25-50 of prop or 0.3-.4 of sevo. These guys don't need much of anything before they start crashing
 
Anything's possible, but this was almost certainly demand ischemia and not a plaque rupture/ACS. No need for heparin in this patient. Evidence for anticoagulation in a true ACS is mostly unsupported anyway. They either need to go to hospice or the OR depending on the patient's frailty and their goals of care.
 
BLADEMDA said:
I have done cases like this one in my career. What is her weight 45 kg? Typically, 90 year old women don't weigh much. As for Regional I would be very careful with an ISB because at this age patients can become dyspneic after an ISB. I would likely do a reduced volume and reduce concentration ISB like 6-8 mls of 0.25% BUP. Similarly for the FICB I would be very careful about LAST here and reduce the concentration.

LMA is an excellent choice here but an ETT is also reasonable. I would place an arterial line due to the recent MI and the likelihood of hemodynamic instability during the case requiring pressors. 2 good functioning IV's like a 20G and an 18G. As for transfusing any PRBCs in advance I would make sure there are 2 units in the room but I wouldn't give any blood unless the EBL warranted it. My target Hgb on her is 8.5-9.0 and not 10.0.

I would avoid a spinal on her because I see no reason to do 2 anesthetics to cover her Humerus and her hip. KISS principle dictates GA. I assume she is not on any anticoagulants and her heparin drip was D/C'd 6-8 hours ago.
Click to expand...

Do a suprascapular block then I guess. I don't do them but shown to have noninferiority
 
leviathan said:
Anything's possible, but this was almost certainly demand ischemia and not a plaque rupture/ACS. No need for heparin in this patient. Evidence for anticoagulation in a true ACS is mostly unsupported anyway. They either need to go to hospice or the OR depending on the patient's frailty and their goals of care.
Click to expand...

Newtwo said:
Ive actually never looked into this... can u briefly summarise or link main trials?
Thank you


edit i found this Heparin for Acute Coronary Syndrome: an evidence review - First10EM

interesting note: Note: This discussion does not include or apply to STEMI patients.
Click to expand...

Something I took for granted and never questioned. Great stuff and news to me...thanks!
 
Wow, lots of stuff going on. Number one is obvious the cardiac issues folllowed by Pulm HTN.
I would have a conversation with family and patient about high risk of periop MI, CVA, death etc.
2nd, why bother with DNR if you going through surgery. Either you get rid of DNR and do the surgery or don’t do anything.
I’m leaving heavily towards GA with ETT. I like the control we get with control ventilation, depth of anesthesia and ability to paralyze patient. If it was just hip or just a humerus maybe LMA. Honestly there’s so much going on that I’m not a fan of the SV LMA.

How did the case go ?
 
PlayToWin said:
Wow, lots of stuff going on. Number one is obvious the cardiac issues folllowed by Pulm HTN.
I would have a conversation with family and patient about high risk of periop MI, CVA, death etc.
2nd, why bother with DNR if you going through surgery. Either you get rid of DNR and do the surgery or don’t do anything.
I’m leaving heavily towards GA with ETT. I like the control we get with control ventilation, depth of anesthesia and ability to paralyze patient. If it was just hip or just a humerus maybe LMA. Honestly there’s so much going on that I’m not a fan of the SV LMA.

How did the case go ?
Click to expand...

Most patients tell me they want to be resuscitated in the event of a reversible event. But not if there's little hope of meaningful survival. I think that's pretty reasonable and don't remove the dnr.
 
GassYous said:
Most patients tell me they want to be resuscitated in the event of a reversible event. But not if there's little hope of meaningful survival. I think that's pretty reasonable and don't remove the dnr.
Click to expand...

Who determines a reversible event? Are we going to go through every scenario and figure what the plan is. I usually write in DNR rescinded but family does not want ACLS or BLS, etc .
I hate going into a case knowing I’m essentially euthanizing the patient .
It’s a tough scenario that we deal with daily. Like let’s say grandma needs to be intubated , are we going to abandon the case because DNR/DNI. She goes into CHF and needs some PPV... too many scenarios besides just arrhythmias.
 
dhb said:
Ideally high sciatic and lumbar plexus.


How much is minimal? .5 mac of sevo? Fascia iliaca doesn't cover much of anything...
Click to expand...

I just did a case like this. LMA, fascia iliaca and peng. Zero pain postop and no prn pain meds taken 16 hours out.

PlayToWin said:
Who determines a reversible event? Are we going to go through every scenario and figure what the plan is. I usually write in DNR rescinded but family does not want ACLS or BLS, etc .
I hate going into a case knowing I’m essentially euthanizing the patient .
It’s a tough scenario that we deal with daily. Like let’s say grandma needs to be intubated , are we going to abandon the case because DNR/DNI. She goes into CHF and needs some PPV... too many scenarios besides just arrhythmias.
Click to expand...

A lot of gray but sometimes it's obvious.
 
As my colleagues know DNR doesn't demand DNI. In addition, stopping a DNR isn't mandated (by asa and American college of surgeons) but might be mandated by antiquated (imo) hospital rules. Personally, if a patient tells me they want to be resuscitated (when they had a pre-op DNR that In my value judgement/clinical expertise was reasonable) but not if they are going to be a "vegetable" I agree to this and say I am only going to do things that make sense (I've heard patients/families say this 100x) . I'm ok with this moral ambiguity because presumably I'm an expert. (And either I document this conversation and make sure surgeons and nursing is on board), nursing because I'm too good/lazy to do CPR.


 
Last edited:
dhb said:
The thing is maybe the pain would have been 0 without the blocks. In my hands i haven't found a reliable block for hip cases.
Click to expand...

True. I've tried QL and fascia iliaca alone and couldn't tell if there was a difference. But the point is that it's possible to do the hip case with regional alone as some of my partners do with the really sick patients.
 
GassYous said:
True. I've tried QL and fascia iliaca alone and couldn't tell if there was a difference. But the point is that it's possible to do the hip case with regional alone as some of my partners do with the really sick patients.
Click to expand...

Which block(s)? And don’t say spinal😉
 
GassYous said:
True. I've tried QL and fascia iliaca alone and couldn't tell if there was a difference. But the point is that it's possible to do the hip case with regional alone as some of my partners do with the really sick patients.
Click to expand...
What kind of hip case?
 
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