Case from yesterday

[Urzuz]

Hey all, had a case yesterday that I want to hear from you all about.

75 year old male marine Vet, h/o severe COPD on home oxygen and several meds (albuterol neb 4x/day, symbicort, spiriva, daliresp, a few weeks ago started on prednisone taper down to 5 mg/day), h/o MI and severe PVD, h/o PE on Xarelto (last taken a little less than 2.5 days prior), IDDM, a hint of dementia and anxiety, comes in for a hip fracture after falling. You see him on oxygen, sitting in bed, speaking in somewhat complete but short sentences, doesn't seem too labored. Clearly has junk in his throat/lungs that he coughs up pretty regularly and interferes with what he is saying, which family says is normal for him. Satting 89-93% on 4L NC. Apparently his lungs are at his baseline, which by all accounts is terrible (>50 year smoker).

Labs show Cr 1.6, INR 1.4 (had been 3.0 on arrival), Plt 211. CXR showing stable emphysematous changes and changes consistent with COPD, no acute processes.

Surgeon in general is fairly fast, probably going to be a 45 min - 1 hour case. Minimal blood loss.

Family says that the last time he had a procedure (EBUS to biopsy a pulmonary nodule which was most likely lung CA), patient's lungs took beating (developed pneumonia why he is on the prednisone now) and he was quite delirious afterwards for a couple days.

Obviously there are multiple ways to approach this case, but I want to hear what your approach would be. Usually for hip fractures I do a fascia iliaca block, slide in an LMA and run them on a bit of gas, but I was reluctant to put this guy to sleep given his terrible pulmonary status. A spinal would be my next go to, but he had been on Xarelto, his renal function isn't optimal, and he had been off of it for slightly over 48 hours. Risks with both approaches here.

What would be your approach and why?

 

[PainDrain]

I am writing this on my iPhone so I will be brief. I would ask the surgeon to delay the case 24 hours to see if his INR came down and to give that xarelto more time to wear off. I would go with a spinal at that point and sedate with propofol or precedex. Could do the block for post op pain control and then keep narcotics to a minimum; no benzos during the case. His overall status is lousy at baseline but it seems he is at his baseline.

 

[urge]

Pent Sux Tube

 

[pgg]

ASRA says 3 days for Xarelto, so maybe the best answer is a spinal tomorrow.

If GA today, I actually prefer intubating these patients instead of LMAs. Yes it's a little more irritating to the airways. But it's so much easier to just control their ventilation and not deal with spontaneous (hypo)ventilation and CO2 retention. If I did use a LMA then I'd put him on the vent and not play with spontaneous vent at all until wakeup time. Maybe not pent-sux-tube but rather prop-tube-fascia-iliaca-block.

 

[anes121508]

ASRA says 3 days for Xarelto, so maybe the best answer is a spinal tomorrow.

If GA today, I actually prefer intubating these patients instead of LMAs. Yes it's a little more irritating to the airways. But it's so much easier to just control their ventilation and not deal with spontaneous (hypo)ventilation and CO2 retention. If I did use a LMA then I'd put him on the vent and not play with spontaneous vent at all until wakeup time. Maybe not pent-sux-tube but rather prop-tube-fascia-iliaca-block.

The asra app is great, I use it all the time.

Wait <24 hrs then spinal.

Id also be interested to see what they did for the EBUS and know exactly what happened afterwards if I could get the records.

 

[JobsFan]

spinal + fascia iliaca tomorrow

what about analgesia for now ? this guy is going to get worse fast laying flat and not moving.

 

[cleansocks]

Assuming xarelto halflife prolonged 2x, still 3-4 halflives cleared at 48-60 hours. Theres also a risk to being off xarelto for too long especially in hip fx. Moderate evidence for increased risk of PNA with general esp in him. Retrospective evidence for increased DVT's with general as well. So I think spinal today is what I would do.

Hey all, had a case yesterday that I want to hear from you all about.

75 year old male marine Vet, h/o severe COPD on home oxygen and several meds (albuterol neb 4x/day, symbicort, spiriva, daliresp, a few weeks ago started on prednisone taper down to 5 mg/day), h/o MI and severe PVD, h/o PE on Xarelto (last taken a little less than 2.5 days prior), IDDM, a hint of dementia and anxiety, comes in for a hip fracture after falling. You see him on oxygen, sitting in bed, speaking in somewhat complete but short sentences, doesn't seem too labored. Clearly has junk in his throat/lungs that he coughs up pretty regularly and interferes with what he is saying, which family says is normal for him. Satting 89-93% on 4L NC. Apparently his lungs are at his baseline, which by all accounts is terrible (>50 year smoker).

Labs show Cr 1.6, INR 1.4 (had been 3.0 on arrival), Plt 211. CXR showing stable emphysematous changes and changes consistent with COPD, no acute processes.

Surgeon in general is fairly fast, probably going to be a 45 min - 1 hour case. Minimal blood loss.

Family says that the last time he had a procedure (EBUS to biopsy a pulmonary nodule which was most likely lung CA), patient's lungs took beating (developed pneumonia why he is on the prednisone now) and he was quite delirious afterwards for a couple days.

Obviously there are multiple ways to approach this case, but I want to hear what your approach would be. Usually for hip fractures I do a fascia iliaca block, slide in an LMA and run them on a bit of gas, but I was reluctant to put this guy to sleep given his terrible pulmonary status. A spinal would be my next go to, but he had been on Xarelto, his renal function isn't optimal, and he had been off of it for slightly over 48 hours. Risks with both approaches here.

What would be your approach and why?

 

[vector2]

Start precedex, awake a-line no matter how good surgeon is or how little he says blood loss will be. Whiff of fentanyl, prop, sux, LTA, tube. Asleep femoral or FI block. Limit narcotics, continue low-dose precedex and use decadron, IV tylenol, ketamine etc. Give 20 puffs albuterol near end of case. Extubate wide awake, use NIPPV if required.

 

[Ezekiel2517]

Spinal. I wouldn't delay case to do it.

 

[Ronin786]

Start precedex, awake a-line no matter how good surgeon is or how little he says blood loss will be. Whiff of fentanyl, prop, sux, LTA, tube. Asleep femoral or FI block. Limit narcotics, continue low-dose precedex and use decadron, IV tylenol, ketamine etc. Give 20 puffs albuterol near end of case. Extubate wide awake, use NIPPV if required.

Whats the precedex doing for you in this situation?

 

[vector2]

Whats the precedex doing for you in this situation?

OP says the guy is anxious and has some dementia. Using pre-induction allows benzo sparing, intraop is opioid sparing, and continuing a low-dose infusion in the PACU will help smooth out the delirium issues the guy had previously with the EBUS.

 

[GravelRider]

OP says the guy is anxious and has some dementia. Using pre-induction allows benzo sparing, intraop is opioid sparing, and continuing a low-dose infusion in the PACU will help smooth out the delirium issues the guy had previously with the EBUS.

This guy has a 100% chance of post-op delirium. The best way to try to avoid delirium is minimize all meds. If you must put an awake a-line then try verbal reassurance and some local. I don't disagree with the a-line, but why do the a-line awake?

Overall, I would prefer postponing to at least give me the option of a spinal. I'm not opposed to doing a GA with an intubation if the case is better off happening now. However, I would make sure the patient and family are prepared for the possibility of a prolonged ICU stay. I would plan on extubating in the OR with a possible NIPPV bridge so long as the case was reasonably quick and there were no major complications. Other than a block as mentioned and a possible a-line, I probably wouldn't do anything else too fancy. I like to keep things simple when I have a complicated patient.

 

[Hoya11]

Hey all, had a case yesterday that I want to hear from you all about.

75 year old male marine Vet, h/o severe COPD on home oxygen and several meds (albuterol neb 4x/day, symbicort, spiriva, daliresp, a few weeks ago started on prednisone taper down to 5 mg/day), h/o MI and severe PVD, h/o PE on Xarelto (last taken a little less than 2.5 days prior), IDDM, a hint of dementia and anxiety, comes in for a hip fracture after falling. You see him on oxygen, sitting in bed, speaking in somewhat complete but short sentences, doesn't seem too labored. Clearly has junk in his throat/lungs that he coughs up pretty regularly and interferes with what he is saying, which family says is normal for him. Satting 89-93% on 4L NC. Apparently his lungs are at his baseline, which by all accounts is terrible (>50 year smoker).

Labs show Cr 1.6, INR 1.4 (had been 3.0 on arrival), Plt 211. CXR showing stable emphysematous changes and changes consistent with COPD, no acute processes.

Surgeon in general is fairly fast, probably going to be a 45 min - 1 hour case. Minimal blood loss.

Family says that the last time he had a procedure (EBUS to biopsy a pulmonary nodule which was most likely lung CA), patient's lungs took beating (developed pneumonia why he is on the prednisone now) and he was quite delirious afterwards for a couple days.

Obviously there are multiple ways to approach this case, but I want to hear what your approach would be. Usually for hip fractures I do a fascia iliaca block, slide in an LMA and run them on a bit of gas, but I was reluctant to put this guy to sleep given his terrible pulmonary status. A spinal would be my next go to, but he had been on Xarelto, his renal function isn't optimal, and he had been off of it for slightly over 48 hours. Risks with both approaches here.

What would be your approach and why?

Id do the case now under GA.
Place mask on patient.
Turn sevo to 8%. Let him breath himself asleep. (spontaneuously)
When deep enough (after 3-5 mins or so but before bottoms out), slide in LMA while breathing spontaneously.
Watch him breath through the LMA as you place it.
Never lose SV. Titate in a little narcotic.
At the end of the case take LMA out and place on FM with nebs in it PRN.

No block, - these are rarely that painful anyhow, id rather just give 100 of fent
No aline unless pressure unstable or hes going back intubated for some reason.

This approach I have had great success with. It is gentle on the heart and the lungs, and ensures you dont have a guy up on the fracture table who is going to freak out/be a problem if awake and spinalized. Especially this Vet with dementia.

I do think a spinal now or waiting for a spinal is also a reasonable approach, but again id worry about having to sedate him midway through due to him causing a problem and defeating the purpose of my spinal.

 

[Laryngophed]

OP says the guy is anxious and has some dementia. Using pre-induction allows benzo sparing, intraop is opioid sparing, and continuing a low-dose infusion in the PACU will help smooth out the delirium issues the guy had previously with the EBUS.

I love Precedex. I think that stuff ought to be in the water.

 

[Laryngophed]

spinal + fascia iliaca tomorrow

what about analgesia for now ? this guy is going to get worse fast laying flat and not moving.

Why not do a fascia today for analgesia, put him on the add on list for tomorrow and redo fascia with a spinal.

 

[GravelRider]

I think a "goals of care" discussion should also be had by a primary physician prior to this case. This guy has pretty lousy pulmonary reserve, CKD, cardiac disease, and multiple other comorbidities. I still think the surgery is necessary, but often times these falls and fractures become the sentinel event that starts the long and drawn out dying process. A frank discussion with the patient and family regarding what possibly lies ahead is really imperative here. The family needs to be prepared that although he may have been on the golf course last week, he likely will never be on one again. I'm not sure that is our domain as the anesthesiologist meeting the patient for the first time, but getting a primary care doctor involved early is important.

 

[Arch Guillotti]

awake a-line

Why?

 

[Arch Guillotti]

I think that whatever you decide to do, the most important thing about the case is seeing the patient ahead of time so that you don't get caught right before the case trying to figure out what to do. If you want to delay it for whatever reason, it goes over a whole lot better with the surgeon if you have things thought out well in advance rather than at the last minute when everyone is set up and ready to go.

 

[DrN2O]

I don't know what happens in PP land, but too often I see these geriatric hips languish on the add-on board day after day here at the "mothership". I think most professional societies recommend repair within 24 - 48 hours. What we do is a small part, the quality of care and management before and AFTER the surgery is much more important.

I think a "goals of care" discussion should also be had by a primary physician prior to this case. This guy has pretty lousy pulmonary reserve, CKD, cardiac disease, and multiple other comorbidities. I still think the surgery is necessary, but often times these falls and fractures become the sentinel event that starts the long and drawn out dying process. A frank discussion with the patient and family regarding what possibly lies ahead is really imperative here. The family needs to be prepared that although he may have been on the golf course last week, he likely will never be on one again. I'm not sure that is our domain as the anesthesiologist meeting the patient for the first time, but getting a primary care doctor involved early is important.

 

[partydoc]

Id do the case now under GA.
Place mask on patient.
Turn sevo to 8%. Let him breath himself asleep. (spontaneuously)
When deep enough (after 3-5 mins or so but before bottoms out), slide in LMA while breathing spontaneously.
Watch him breath through the LMA as you place it.
Never lose SV. Titate in a little narcotic.
At the end of the case take LMA out and place on FM with nebs in it PRN.

No block, - these are rarely that painful anyhow, id rather just give 100 of fent
No aline unless pressure unstable or hes going back intubated for some reason.

This approach I have had great success with. It is gentle on the heart and the lungs, and ensures you dont have a guy up on the fracture table who is going to freak out/be a problem if awake and spinalized. Especially this Vet with dementia.

I do think a spinal now or waiting for a spinal is also a reasonable approach, but again id worry about having to sedate him midway through due to him causing a problem and defeating the purpose of my spinal.

I like

 

[PainDrain]

Id do the case now under GA.
Place mask on patient.
Turn sevo to 8%. Let him breath himself asleep. (spontaneuously)
When deep enough (after 3-5 mins or so but before bottoms out), slide in LMA while breathing spontaneously.
Watch him breath through the LMA as you place it.
Never lose SV. Titate in a little narcotic.
At the end of the case take LMA out and place on FM with nebs in it PRN.

No block, - these are rarely that painful anyhow, id rather just give 100 of fent
No aline unless pressure unstable or hes going back intubated for some reason.

This approach I have had great success with. It is gentle on the heart and the lungs, and ensures you dont have a guy up on the fracture table who is going to freak out/be a problem if awake and spinalized. Especially this Vet with dementia.

I do think a spinal now or waiting for a spinal is also a reasonable approach, but again id worry about having to sedate him midway through due to him causing a problem and defeating the purpose of my spinal.

I don't understand the rationale for an inhalation induction? Call me crazy but this guy isn't cardiac cripple who can't tolerate a little hypotension. Why not just titrate in the appropriate dose of meds and then throw in an LMA if that is your plan. To often I see people titrate meds based on some arbitrary dose in a textbook rather than looking at the patient and slowly titrating them in. Nothing smoother than giving just the right amount of propofol and then throwing the LMA in and letting the patient start breathing on their own. V

 

[Robotic Wis-Hipple]

Id do the case now under GA.
Place mask on patient.
Turn sevo to 8%. Let him breath himself asleep. (spontaneuously)
When deep enough (after 3-5 mins or so but before bottoms out), slide in LMA while breathing spontaneously.
Watch him breath through the LMA as you place it.
Never lose SV. Titate in a little narcotic.
At the end of the case take LMA out and place on FM with nebs in it PRN.

No block, - these are rarely that painful anyhow, id rather just give 100 of fent
No aline unless pressure unstable or hes going back intubated for some reason.

This approach I have had great success with. It is gentle on the heart and the lungs, and ensures you dont have a guy up on the fracture table who is going to freak out/be a problem if awake and spinalized. Especially this Vet with dementia.

I do think a spinal now or waiting for a spinal is also a reasonable approach, but again id worry about having to sedate him midway through due to him causing a problem and defeating the purpose of my spinal.

This sounds good to me as well if the guy would tolerate the smaller TV's of spontaneously breathing GA, which I'm not sure he would and you're ok with an unsecured airway in what is essentially a trauma/non-NPO scenario. Not 100% sure I care that much about avoiding a carefully titrated IV induction but I don't see the issue with an inhaled induction either (well, again, unless I'm thinking he should be considered full stomach). My only question is what do you do if your surgeon requests relaxation? I haven't gone out into PP world yet but I can't recall a case I've done with ortho in the Ivory's where they didn't want complete relaxation, either GA + NMB or GA/MAC + spinal.

So with all that said, I think I've talked myself into KISS; prop, sux, tube.

 

[CriTICAL]

Im not familiar with the data supporting ASRA recc holding Xarelto 72hrs prior to neuraxial, would be curious to see evidence supporting this recc
I understand his renal function isnt great but hes not in complete renal failure
drug manufacturer reccs are 24 to 48hrs prior to surgery/procedure which I feel should be adequate and safe time to proceed with spinal
Coags are unreliable and variable in assessing NOAC activity, Coags designed only to measure Coumadin acitivity, that being said his iNR is near normal,
Anyway I would go ahead and place spinal
If u feel his blleeding risk > thrombotic risk than would go ahead and give reversal agent for extra-measure ie; Kcentra or feiba
anyway i think proceeding with spinal would be best and risk of pulm complications outweighs low risk of spinal hematoma in this guy
i like precedex during case for sedation, will likley need freq suctioning as well

otherwise would go ahead and prop/sux/tube
would not feel comfortable LMA in this guy with bad COPD and excessive scretions, high risk of aspiration PNA and mucous plugging as well as would like to have more control of ventilation in a guy with marginal oxygenation and likley Co2 retainer to avoid potential trouble

after case can do fascia block asleep if GETA or while spinal still working

 

[Noyac]

OP says the guy is anxious and has some dementia. Using pre-induction allows benzo sparing, intraop is opioid sparing, and continuing a low-dose infusion in the PACU will help smooth out the delirium issues the guy had previously with the EBUS.

Is there solid data on this?

 

[Noyac]

Im not familiar with the data supporting ASRA recc holding Xarelto 72hrs prior to neuraxial, would be curious to see evidence supporting this recc
I understand his renal function isnt great but hes not in complete renal failure
drug manufacturer reccs are 24 to 48hrs prior to surgery/procedure which I feel should be adequate and safe time to proceed with spinal
Coags are unreliable and variable in assessing NOAC activity, Coags designed only to measure Coumadin acitivity, that being said his iNR is near normal,
Anyway I would go ahead and place spinal
If u feel his blleeding risk > thrombotic risk than would go ahead and give reversal agent for extra-measure ie; Kcentra or feiba
anyway i think proceeding with spinal would be best and risk of pulm complications outweighs low risk of spinal hematoma in this guy
i like precedex during case for sedation, will likley need freq suctioning as well

otherwise would go ahead and prop/sux/tube
would not feel comfortable LMA in this guy with bad COPD and excessive scretions, high risk of aspiration PNA and mucous plugging as well as would like to have more control of ventilation in a guy with marginal oxygenation and likley Co2 retainer to avoid potential trouble

after case can do fascia block asleep if GETA or while spinal still working

https://www.asra.com/advisory-guidelines/article/1/anticoagulation-3rd-edition
So when there is a practice advisory it's probably not a good idea to go against it unless you have a really good reason. This may be one of those reasons, IDK.

 

[Noyac]

Personally, if the surgeon felt it was best to do this case today then I would do a fascia iliacus block and place an LMA.
NO A-line for this pt whatsoever, but if someone were to,place one then that's fine. But you won't gain anything from it.
If I had any serious concerns of the surgeons ability or the pts ability to spontaneously breath then I'd place an ETT after a real good LTA spraying.
I'd give a small dose of propofol and turn on some gas. Little bits of fentanyl and ask the surgeon to place local. Postoperative Cognitive dysfunction is more likely when the nurses give narcs, bentos, antihistamines, etc in the postoperative course. In the OR we give what is necessary but in small doses.
I also like the inhalation induction but I tend to do it differently. A small dose of propofol (like 5cc) then turn on some gas and mask him deeper whi,e we move him to the OR table and start to position him. Slip in the LMA and off to the charting.

 

[pgg]

He's a vasculopath but the history doesn't paint the picture of a cardiac cripple so I don't know if he really needs an a-line. But it's easy / low risk and takes 3 minutes (unless it takes 20 ) so I might put one in, depending on how he looked in person. Certainly wouldn't fault anyone who says they'd put one in.

He is a pulmonary mess and I think spontaneous (hypo)ventilation under GA is likely to be more of a problem than hypotension or BP lability. I would favor a tube. Not that you can't use PPV with an LMA but in this guy I think it'd be less likely to be easy.

He's not being intubated for respiratory failure, so extubating him 45 minutes later will be no problem if you go easy on the narcs. I'd do a FI block 2.5 days after Xarelto despite ASRA's (silly) guidelines equating PNBs to neuraxial, but I wouldn't do a spinal 2.5 days after Xarelto in this patient when GETA is a good option.

ASRA's evidence may be thin but I sure don't see a good reason to go against the guidelines in this patient.

 

[JobsFan]

Why not do a fascia today for analgesia, put him on the add on list for tomorrow and redo fascia with a spinal.

that's exactly what I was getting at.

 

[JobsFan]

I also like the inhalation induction but I tend to do it differently. A small dose of propofol (like 5cc) then turn on some gas and mask him deeper whi,e we move him to the OR table and start to position him. Slip in the LMA and off to the charting.

i do similar on fragile patients, but 50mg propofol could well be an IV induction in this guy

 

[SaltyDog]

I like UW's cheat sheet (available via Google) for anticoag references. Ideally spinal tomorrow as others already mentioned but if it needs to go today, I'll take the 1:>100k chance this guy develops an epidural hematoma over the 1:way more F'in likely chance this guy suffers lasting pulmonary pain in the assedness from a GETA.

 

[Hoya11]

I don't understand the rationale for an inhalation induction? Call me crazy but this guy isn't cardiac cripple who can't tolerate a little hypotension. Why not just titrate in the appropriate dose of meds and then throw in an LMA if that is your plan. To often I see people titrate meds based on some arbitrary dose in a textbook rather than looking at the patient and slowly titrating them in. Nothing smoother than giving just the right amount of propofol and then throwing the LMA in and letting the patient start breathing on their own. V

There is a difference between someone at 2-3% sevo breathing like a champ, and someone who you titrate just enough etomidate into slip in an LMA. Unless you dose the etom/prop perfectly, there will be some element of respiratory depression or under-anesthetization. Also the person breathing sevo is deeper, and breathing in a bronchodilator as they are going to sleep, not getting a med that can impair respiratory function. Also then you dont have to have a bounce back from the etom/prop before the gas comes on. I guess what Im saying is you can get them much deeper and still breathing well with sevo vs iv induction where eventually you are going to impair their breathing. Also the induction is smooth as silk breath to breath vs IV boluses. But its splitting hairs, both will work, I just prefer gas for the large margin of error to avoid apnea and have the patient deeper, sooner.

 

[CriTICAL]

https://www.asra.com/advisory-guidelines/article/1/anticoagulation-3rd-edition
So when there is a practice advisory it's probably not a good idea to go against it unless you have a really good reason. This may be one of those reasons, IDK.

thanks for the info,
Unfortunately looks like the practice advisory guidelines were made in 2010 before NOACS were even being used clinically so there wasnt any info to guide them and actually they make no specific reccomendation in that paper with respect to Xarelto since there was zero data at that time but only recommend to use "caution"
did a quick search and no real world cases found to date of spinal hematoma assoc with Xarelto to help guide decision -

But looks like the european and scandinavian societies seem to have updated their reccs based on the half life of the NOACS based on pt's thrombotic risk
so if high thrombotic risk 2 to 3 half lives which would be 24 to 36hrs for Xarelto
or if low thrombotic risk than 5 to 6 half lives which would be 72hrs maximum for Xarelto

so Im guessing thats where the 72hr reccomendation comes from since that seems to be the safest period to wait but looks like 48hrs is an acceptable time frame in select cases like this dude

 

[vector2]

Why?

As far as a-line, I'm not sure why everyone is assuming he's not a cardiac cripple when we have every reason to believe he is. Even though there's no echo mentioned in the OP, the guy has h/o of Mi, severe pvd, insulin dependent diabetes, renal insufficiency, smoking hx, 0 mets, and severe copd with almost certainly elevated pulmonary pressures. I wouldn't delay starting the case to do a-line awake if it was taking more than a couple minutes, but I'd want an a-line at some point to assess realtime hemodynamics, check abg prn, and follow hct if for some reason xarelto hasn't passed enough half lives and the suction canister starts filling up.

As for precedex, there is some evidence that it's superior for postoperative delirium after cardiac surgery, although I'm not sure of the strength of the evidence in this case. What we do have relatively strong evidence for is the assertion that dex is far and away the most effective medication to treat delirium and possibly to prevent delirium in geriatric ICU populations. Having any significant delirium in the ICU increases your mortality odds by 60% at 1yr out, even more so if you're frail and have a ton of comorbidities. The pt in the OP is the poster child for the cohort who should be getting perioperative dex for anxiolysis, opioid/anesthetic sparing, and delirium prevention.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4558278/#!po=44.7368

 

[Ronin786]

I'd run a thromboelastogram on the guy. If everything looks good, do a spinal.

 

[fakin' the funk]

I like UW's cheat sheet (available via Google) for anticoag references.

This.

Spinal tomorrow

 

[Noyac]

i do similar on fragile patients, but 50mg propofol could well be an IV induction in this guy

Thats the idea

 

[Noyac]

As for precedex, there is some evidence that it's superior for postoperative delirium after cardiac surgery, although I'm not sure of the strength of the evidence in this case. What we do have relatively strong evidence for is the assertion that dex is far and away the most effective medication to treat delirium and possibly to prevent delirium in geriatric ICU populations. Having any significant delirium in the ICU increases your mortality odds by 60% at 1yr out, even more so if you're frail and have a ton of comorbidities. The pt in the OP is the poster child for the cohort who should be getting perioperative dex for anxiolysis, opioid/anesthetic sparing, and delirium prevention.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4558278/#!po=44.7368

I believe the reason Dex is considered superior in the ICU is because it decreases Ativan usage. Therefore, the way I see it is that Ativan is the problem and avoiding it is better. This is just speculation on my part as I have not read any recent literature on this.
But as you mention, this guy has many issues. Preventing post op delirium may be lower down on the list of things he should worry about but still it is good to avoid it if possible. His 1yr mortality is probably >60% whether he gets POCD (post op cognitive dysfunction) or not.

 

[vector2]

I believe the reason Dex is considered superior in the ICU is because it decreases Ativan usage. Therefore, the way I see it is that Ativan is the problem and avoiding it is better. This is just speculation on my part as I have not read any recent literature on this.
But as you mention, this guy has many issues. Preventing post op delirium may be lower down on the list of things he should worry about but still it is good to avoid it if possible. His 1yr mortality is probably >60% whether he gets POCD (post op cognitive dysfunction) or not.

Dex has been put up head to head vs midaz in the ICU, and also head to head vs propofol. It's clearly superior to benzos for any prolonged sedation and I think everyone knows that. It's equivalent to propofol as far as duration of mechanical ventilation and overall mortality, but there does appear to be a relative risk reduction (0.40) in incidence of delirium and slight reduction in length of stay.

Agree that his 1yr mortality is extremely high regardless, but I can guarantee that in a situation where he was difficult to wean off the vent post-op, gets shipped to ICU, and then develops significant POCD... even if he gets off the vent he'll probably be severely debilitated/bedbound/dead in a couple weeks to couple months.

 

[anes121508]

Dex has been put up head to head vs midaz in the ICU, and also head to head vs propofol. It's clearly superior to benzos for any prolonged sedation and I think everyone knows that. It's equivalent to propofol as far as duration of mechanical ventilation and overall mortality, but there does appear to be a relative risk reduction (0.40) in incidence of delirium and slight reduction in length of stay.

Agree that his 1yr mortality is extremely high regardless, but I can guarantee that in a situation where he was difficult to wean off the vent post-op, gets shipped to ICU, and then develops significant POCD... even if he gets off the vent he'll probably be severely debilitated/bedbound/dead in a couple weeks to couple months.

The right amount of dex for spinals/epidurals in slightly agitated or demented patients with a laundry list of co-morbities has worked very well for me in the past. I'm a huge fan of it.

Whats the data say about the increase in morbidity/mortality per day or hours that you don't fix the hip? I've always been taught that hip fractures gotta go. But I'm not sure that the increased morbidity/mortality of waiting 18 hours or so for the xarelto to be within ASRA guidelines outweighs the risk of delirium and perioperative pulmonary complications of GA in this guy.

 

[Laryngophed]

I did a spinal recently on someone who I think would have had a setback with a general. My attending took some convincing to go with the spinal, but we did it. I wanted precedex based on what I had heard about the patients prior spinal anesthetic, and the attending nixed the bolus. I turned it on at 0.7mcg/kg/hr and the spinal. Sailed on through.

 

[IlDestriero]

Send him to the VA and let the CRNAs handle it.


--
Il Destriero

 

[Urzuz]

Thank you all for your input and the great discussion. As you all have noted this guy is a mess and the likelihood that he has some postoperative complication is not insignificant.

To be frank, it did not even cross my mind to delay the case. I am scratching my head as to why it did not, and I wish it had. But, again, for whatever reason it did not (this is why I like discussing cases and learning from you all!). Perhaps it is because subconsciously I know the surgeon and knew he would 100% say the case has to go now, perhaps it is because I thought I could get him through safely, perhaps it is because I work in a busy private practice where the cancellation of cases are a rarity, or perhaps it is because I had a brain fart. Not really sure. But again, in retrospect I wish I had at least entertained the idea of delaying the case.

Anyway, to get to what happened:

I found recommendations for doing a neuraxial anesthetic on patients taking Xarelto ranging anywhere from waiting 48-72 hours. Now if the guys kidney function had been fine I think I would have gone in a heartbeat. However, the fact that he was probably at ~60 hours since his last dose AND he had some renal insufficiency made me hesitate. But,

I'll take the 1:>100k chance this guy develops an epidural hematoma over the 1:way more F'in likely chance this guy suffers lasting pulmonary pain in the assedness from a GETA.

This was my thinking exactly. I figured that the risk of developing epidural/spinal bleeding, despite obviously being devastating, was WAY less than the risk of the guy developing a postoperative pulmonary complication like he did a few weeks earlier. Additionally, throw on top the risk of the guy getting totally delirious after a general anesthetic (which, as someone mentioned before, he will still get delirious with a spinal after he gets some intravenous pain medicine, but hopefully I would lessen the risk a bit?), I figured that I would proceed with the spinal. I had a long frank discussion with the family about my thinking and the risks/benefits, and documented the hell out of it (even though, again, in retrospect I wish I also had surgical documentation stating that the case had to go on that day).

Took him back into the OR, gave him probably 25 mg of ketamine, sat him up and popped in the spinal (redirected the spinal needle once, but otherwise was smooth as butter and fairly atraumtic), put a mask on him, and hit the accelerator. The ketamine gorked him pretty good for the majority of the case, but by the end he was totally awake, knew where he was and what was going on, and gave me a hug before we moved him over to the bed.

I saw him for several days after and gave both him and his family explicit instructions regarding the signs/symptoms of spinal/epidural hematoma. Also he happened to go to a neuro floor where they do q4 hour neuro checks on all patients, so all the better. Told the nurses what to be on the lookout for as well. He did great and was transferred out of the hospital on POD #3.

In retrospect, again, I wish I had entertained the idea of cancelling, as I think that would have been the safest option. In some ways I feel like I kinda dodged a bullet since I may not have had a leg to stand on if he had suffered a complication from the spinal.

 

[nimbus]

I did spinal for a turp on a relatively healthy 90 yo with a history of dementia. Sedation was propofol 30mcg/kg/min. Procedure was less than one hour. He was very clear headed in pacu but developed pocd/sundowned later that night. Never fully recovered, discharged to skilled nursing facility and died 3mos later. Anybody have an opinion as to whether dex would have been better?

 

[Ezekiel2517]

I did spinal for a turp on a relatively healthy 90 yo with a history of dementia. Sedation was propofol 30mcg/kg/min. Procedure was less than one hour. He was very clear headed in pacu but developed pocd/sundowned later that night. Never fully recovered, discharged to skilled nursing facility and died 3mos later. Anybody have an opinion as to whether dex would have been better?

The prop definitely killed him. Way to go, murderer.

 

[Arch Guillotti]

I did spinal for a turp on a relatively healthy 90 yo with a history of dementia. Sedation was propofol 30mcg/kg/min. Procedure was less than one hour. He was very clear headed in pacu but developed pocd/sundowned later that night. Never fully recovered, discharged to skilled nursing facility and died 3mos later. Anybody have an opinion as to whether dex would have been better?

I doubt it.

 

[IlDestriero]

It was probably the relative hypotension that your "colleague" ignored.



--
Il Destriero

 

[GravelRider]

I did spinal for a turp on a relatively healthy 90 yo with a history of dementia. Sedation was propofol 30mcg/kg/min. Procedure was less than one hour. He was very clear headed in pacu but developed pocd/sundowned later that night. Never fully recovered, discharged to skilled nursing facility and died 3mos later. Anybody have an opinion as to whether dex would have been better?

Anytime you are bringing an elderly patient to the OR with a serious comorbidity like this 90 year old with dementia, you are participating in the sentinel event that accelerates their dying process. The procedure may be necessary, but it doesn't change the fact that their 3-6 month morbidity and mortality is high. The family and patient should be aware of this, I don't care how spunky the patient was previously. I also highly doubt that using dex over propofol would have changed the outcome.