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?
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?