Different case

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waterbottle10

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How would you do this case and what is your reasoning?

82 year old female comes to the Emergency department after fall and broke her hip, with history of HTN, DM, A fib on noac, Heart failure
Can slowly walk around prior to fall. Sleeps with multiple pillows at night

Procedure: hip replacement (per surgeon, case would take around 5 hours of surgical time)

EKG: A fib with PVCs, bundle branch block
TTE: RV dysfunction with severe dilation, severe TR with complete non coaptation of TR (2.2cm gap between anterior and septal leaflet), LV EF 55%, moderate AR, mild MR, moderate pericardial effusion. Positive Bubble Study

How would you proceed? Any more workup? Induction methods? If off anticoagulation for 5 days, spinal and if so what dosage?
 
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The longer I do this the more I believe you can “prop (carefully titrated), sux, tube” your way through almost anything. Almost. And its hard to kill someone with preserved LV function.

if she doesn’t appear decompensated, she’s probably as good as she is ever going to get. preop Aline, carefully titrated induction of choice. Augment blood pressure intraop.

No spinal for me.

If patient and family want surgery hip has to get fixed at some point. I wouldn’t push for more testing.
 
GA with ionotrope ready for support. Probably would not do a spinal even if off anticoagulation. Discuss staying intubated and to ICU after surgery. Not sure what her volume status is from exam, but probably in active heart failure, will be difficult to resuscitate if there’s significant bleeding and extubate her in the OR after. Would probably have a low threshold to start giving blood, limit the IVF, have ionotropes running on induction and for the case, let her rest on the vent overnight and the ICU can extubate when ready.
 
waterbottle10 said:
How would you do this case and what is your reasoning?

82 year old female comes to the Emergency department after fall and broke her hip, with history of HTN, DM, A fib on noac, Heart failure
Can slowly walk around prior to fall. Sleeps with multiple pillows at night

Procedure: hip replacement (per surgeon, case would take around 5 hours of surgical time)

EKG: A fib with PVCs, bundle branch block
TTE: RV dysfunction with severe dilation, severe TR with complete non coaptation of TR (2.2cm gap between anterior and septal leaflet), LV EF 55%, moderate AR, mild MR, moderate pericardial effusion

How would you proceed? Any more workup? Induction methods? If off anticoagulation for 5 days, spinal and if so what dosage?
Click to expand...

very common type of patient and comorbidities. not common is the 5 hours...why so long? LMA/ETT with titrated propofol, roc and narcotics. give blood if needed. extubate at end of case.
 
jeesapeesa said:
very common type of patient and comorbidities. not common is the 5 hours...why so long? LMA/ETT with titrated propofol, roc and narcotics. give blood if needed. extubate at end of case.
Click to expand...

It's common to see a 2.2cm gap in Tricuspid?
Why are so many people against spinal? Is it mainly due to surgical length? What if they can finish in 3 hours?

The surgeons here are very slow unfortunately.

DocMcCoy said:
The longer I do this the more I believe you can “prop (carefully titrated), sux, tube” your way through almost anything. Almost. And its hard to kill someone with preserved LV function.

if she doesn’t appear decompensated, she’s probably as good as she is ever going to get. preop Aline, carefully titrated induction of choice. Augment blood pressure intraop.

No spinal for me.

If patient and family want surgery hip has to get fixed at some point. I wouldn’t push for more testing.
Click to expand...


I'm more concerned with her right side, specifically poor RV + barely a tricuspid valve + atrial fib + positive ventilation, The LV can be pumping barely anything once PPV starts
 
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waterbottle10 said:
It's common to see a 2.2cm gap in Tricuspid?
Why are so many people against spinal? Is it mainly due to surgical length? What if they can finish in 3 hours?

The surgeons here are very slow unfortunately.




I'm more concerned with her right side, specifically poor RV + barely a tricuspid valve + atrial fib + positive ventilation, The LV can be pumping barely anything once PPV starts
Click to expand...


Its a lot harder to carefully titrate a spinal.

only partially joking. I haven’t put a spinal catheter in since residency, never for this procedure, and wouldn’t want to poke a big hole in someone on chronic anticoagulation even if they’ve been off it for 5 days.
 
anyone ever use isobaric bupi in spinals and have had bad results? that stuff is great
it works pretty slowly , way slower than a induction unless you slow your induction by like 50x. also nicer to the heart than propofol induction
 
Our surgeons push for 24 hours fixation of hip fractures. If a patient comes in on NOAC like this case, no chance I’m doing a spinal especially since long term data comparing to GA both have comparatively poor outcomes. And if something happens (particularly if you place spinal catheter, bleh), you’ll be on the hook. Carefully-titrated GA and do what you can to keep PA pressures down - 100% FiO2, avoid acidosis/HyperCarbia, Vasodilators (if tolerated)
 
anbuitachi said:
anyone ever use isobaric bupi in spinals and have had bad results? that stuff is great
it works pretty slowly , way slower than a induction unless you slow your induction by like 50x. also nicer to the heart than propofol induction
Click to expand...

Serious question. I don’t use it a lot. Would you be comfortable pushing a dose necessary for a >3 hr case single shot spinal in this patient?
 
AdmiralChz said:
Our surgeons push for 24 hours fixation of hip fractures. If a patient comes in on NOAC like this case, no chance I’m doing a spinal especially since long term data comparing to GA both have comparatively poor outcomes. And if something happens (particularly if you place spinal catheter, bleh), you’ll be on the hook. Carefully-titrated GA and do what you can to keep PA pressures down - 100% FiO2, avoid acidosis/HyperCarbia, Vasodilators (if tolerated)
Click to expand...

oh i meant without noac, assuming if they waited 5 days or something
i'd do GA if still on noac; i would use etomidate instead of propofol though, who has the patience to slowly tirate prop?
 
According to Openanesthesia,

"The choice between GA and regional is up to the anesthesiologist – Rodgers et al. conducted a metaanalysis of 141 trials including 9559 patients, which showed that neuraxial analgesia reduced overall mortality by about a third (OR=0.70, 95% CI 0.54 to 0.90, p=0.006). Neuraxial blockade reduced the odds of DVT by 44%, PE by 55%, transfusion by 50%, pneumonia by 39%, and respiratory depression by 59% (all p<0.001) [Rodgers A et al. BMJ 321: 1493, 2000]. Some authors suggest that at 2 months there is no significant difference in mortality."

Those are impressive numbers.

Would anyone wait 3 days for Eliquis to wear off and do a spinal as well as reduce bleeding?
 
"Total hip replacement (THR) is associated with three potentially life-threatening complications: profuse hemorrhage, VTE (most commonly during insertion of the femoral prosthesis), and bone cement implantation syndrome "

I am also concerned regarding bone cementing since this patient is very old and already has a poor RV with positive bubbles. r
 
dipriMAN said:
GA with ionotrope ready for support. Probably would not do a spinal even if off anticoagulation. Discuss staying intubated and to ICU after surgery. Not sure what her volume status is from exam, but probably in active heart failure, will be difficult to resuscitate if there’s significant bleeding and extubate her in the OR after. Would probably have a low threshold to start giving blood, limit the IVF, have ionotropes running on induction and for the case, let her rest on the vent overnight and the ICU can extubate when ready.
Click to expand...
*inotropes*
 
waterbottle10 said:
How would you do this case and what is your reasoning?

82 year old female comes to the Emergency department after fall and broke her hip, with history of HTN, DM, A fib on noac, Heart failure
Can slowly walk around prior to fall. Sleeps with multiple pillows at night

Procedure: hip replacement (per surgeon, case would take around 5 hours of surgical time)

EKG: A fib with PVCs, bundle branch block
TTE: RV dysfunction with severe dilation, severe TR with complete non coaptation of TR (2.2cm gap between anterior and septal leaflet), LV EF 55%, moderate AR, mild MR, moderate pericardial effusion. Positive Bubble Study

How would you proceed? Any more workup? Induction methods? If off anticoagulation for 5 days, spinal and if so what dosage?
Click to expand...

I wouldn't be comfortable doing a spinal for 5 hour (possibly longer) case.

I'm more concerned with her right side, specifically poor RV + barely a tricuspid valve + atrial fib + positive ventilation, The LV can be pumping barely anything once PPV starts
Click to expand...

An overly zealous spinal dose can also tank the preload. You cannot say that spinal is clearly better in this situation.
 
eikenhein said:
An overly zealous spinal dose can also tank the preload. You cannot say that spinal is clearly better in this situation.
Click to expand...

It can but isobaric bupi almost never does. Inject slowly, give phenylephrine, put an art line in if you are really worried.
 
Arch Guillotti said:
It can but isobaric bupi almost never does. Inject slowly, give phenylephrine, put an art line in if you are really worried.
Click to expand...

for a regular sized elderly patient without cardiac comorbidities, i've seen 12.5 mg isobaric bupi in a 70 kg pt drop SBP from 140 to 90's.

if you intend to have a spinal consistently last for 5 hours, you'll probably need more bupi than that.

not something that might be well tolerated in this situation with a bad right heart.

why do you suggest single shot spinal vs more titratable epidural?

do you do your neuraxials lateral or sitting up? it may not be the easiest to "slowly dose" a spinal either way.

IMO discussion with surgeon that patient is higher risk due to comorbidities. Agree w concerns about cementing. Maybe have the new residents take a step back on this one if it will make the case faster. This is not the type of case for a medical student or surgical intern to take an hour closing skin.



I did a case similar to this about 1.5 years ago. Very anxious, elderly, severe RV dysfunction and severe PH for hip replacement. Optimized fluid status prior to surgery. Did CSE with low dose isobaric bupivicaine ~8-10 mg, placed art line, phenylephrine gtt (also had levo and epi gtt available in room), checked levels and titrated epidural bupivicaine to effect, gave some versed and ran some precedex.
 
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She’s old and has pretty limited function to begin with. Wonder what the data would say about a cementless option for this lady given the positive bubble study? Also, wonder what the Ortho literature shows about the risks of waiting a few days to fix this (for the sake of argument, if you thought spinal was definitively the way to go, how long one could reasonably wait). Regardless those are both surgical decisions...

Prop, roc, tube. Cycle the cuff every minute during induction and only put in an art line if she proves that she needs it
 
Why do ppl keep saying 5 days for neuraxial? She’s probably on eliquis and OP didn’t mention renal dysfunction....so 48-72 hrs.

I would do GA anyway, but it seems like some y’all not taking the 3 pillow orthopnea/ active RHF / no atrial kick / severe TR....aka “pt on the edge of barely having any forward flow” very seriously..
 
Hork Bajir said:
She’s old and has pretty limited function to begin with. Wonder what the data would say about a cementless option for this lady given the positive bubble study? Also, wonder what the Ortho literature shows about the risks of waiting a few days to fix this (for the sake of argument, if you thought spinal was definitively the way to go, how long one could reasonably wait). Regardless those are both surgical decisions...

Prop, roc, tube. Cycle the cuff every minute during induction and only put in an art line if she proves that she needs it
Click to expand...

how does she prove to need it? after things go south? i have low threshold to put in arterial line because they are pretty quick and useful. the problem with the cuff is that if there are major changes with blood pressure low or high, it cycles forever before getting a number.

vector2 said:
Why do ppl keep saying 5 days for neuraxial? She’s probably on eliquis and OP didn’t mention renal dysfunction....so 48-72 hrs.

I would do GA anyway, but it seems like some y’all not taking the 3 pillow orthopnea/ active RHF very seriously..
Click to expand...

iso spinal with arterial line isn't taking it seriously? i'm avoiding PPV and systemic organ depression
 
5 hours means 8 hours. I wish I could tell the family find another surgeon who can do it faster. She doesn't need a perfect hip replacement to spend that many hours. I've had an in-house hip fracture patient see the surgeon in pre-op for the first time, and after seeing him, refused to have surgery done by him because he was so old and couldn't even walk straight.

I'd opt for pre-induction a-line and GA with a tube, put a BIS and run her light, BIS monitor.
 
eikenhein said:
for a regular sized elderly patient without cardiac comorbidities, i've seen 12.5 mg isobaric bupi in a 70 kg pt drop SBP from 140 to 90's.

if you intend to have a spinal consistently last for 5 hours, you'll probably need more bupi than that.

not something that might be well tolerated in this situation with a bad right heart.

why do you suggest single shot spinal vs more titratable epidural?

do you do your neuraxials lateral or sitting up? it may not be the easiest to "slowly dose" a spinal either way.

IMO discussion with surgeon that patient is higher risk due to comorbidities. Agree w concerns about cementing. Maybe have the new residents take a step back on this one if it will make the case faster. This is not the type of case for a medical student or surgical intern to take an hour closing skin.



I did a case similar to this about 1.5 years ago. Very anxious, elderly, severe RV dysfunction and severe PH for hip replacement. Optimized fluid status prior to surgery. Did CSE with low dose isobaric bupivicaine ~8-10 mg, placed art line, phenylephrine gtt (also had levo and epi gtt available in room), checked levels and titrated epidural bupivicaine to effect, gave some versed and ran some precedex.
Click to expand...

What was the spinal for that tanked the patient? Was it for fracture? One thing is their systolic probably will go down a little simply by taking away the pain of the fracture once spinal kicks in.

i do them lateral. a lot of them are old and have trouble sitting up, especially with broken hip

How did your case go? How long was the case? was 10 mg not enough to cover hip area, it sounds like you activated epidural before incision.
 
eikenhein said:
I did a case similar to this about 1.5 years ago. Very anxious, elderly, severe RV dysfunction and severe PH for hip replacement. Optimized fluid status prior to surgery. Did CSE with low dose isobaric bupivicaine ~8-10 mg, placed art line, phenylephrine gtt (also had levo and epi gtt available in room), checked levels and titrated epidural bupivicaine to effect, gave some versed and ran some precedex.
Click to expand...

absolutely agree with this. CSE with very small spinal dose and epidural titration. Avoid excessive bradycardia and tachy. You can also use low dose neo gtt OR vasopressin gtt to keep her BP rock stable. Would not run precedex though. Versed and low dose prop gtt

prop + phenylephrine = etomidate - adrenal suppression, so etomidate is a no for me ( not only in this case)

Also NoAc do not need 5 days to be held. 24-48 hours are sufficient.

aline...sure
 
Great discussion. One thing that has always interested me is the extreme variability I see with spinals (regarding blood pressure).

I did two today (with hyperbaric bupivicaine) and neither of them had a change in systolic BP at all. Sometimes people tank a surprising amount.
 
epidural man said:
Great discussion. One thing that has always interested me is the extreme variability I see with spinals (regarding blood pressure).

I did two today (with hyperbaric bupivicaine) and neither of them had a change in systolic BP at all. Sometimes people tank a surprising amount.
Click to expand...

I do think i have more variability with hyperbaric bupivicaines.

Lidolover said:
absolutely agree with this. CSE with very small spinal dose and epidural titration. Avoid excessive bradycardia and tachy. You can also use low dose neo gtt OR vasopressin gtt to keep her BP rock stable. Would not run precedex though. Versed and low dose prop gtt

prop + phenylephrine = etomidate - adrenal suppression, so etomidate is a no for me ( not only in this case)

Also NoAc do not need 5 days to be held. 24-48 hours are sufficient.

aline...sure
Click to expand...

wouldnt use precedex for this patient. though his patient was different, severe pHTN instead of severe TR
 
eikenhein said:
for a regular sized elderly patient without cardiac comorbidities, i've seen 12.5 mg isobaric bupi in a 70 kg pt drop SBP from 140 to 90's.
Click to expand...

Sure, but it’s a slow/gradual drop. Nothing like what happens with heavy bup. You’ve got plenty of time to correct/support the BP as the spinal sets up.

I think a CSE for a case like this is playing with fire. You underdose the spinal then cross your fingers that the epidural is solid. If it’s not, now you’re stuck having to snow them or induce them under the drapes (possibly lateral) in less than ideal conditions with some degree of sympathectomy on board.
 
I dno... something like this:
  • Non-neuraxial block (PENG/femoral/FI) + art. line pre-induction.
  • Probably give a hit of lignocaine +/- MgSO4 pre-induction to make myself feel better about the PVCs and TR combo and reduce propofol load. Wouldn't bother with an infusion.
  • Trickle in some fent and prop and turn on the gas early. Chase with an ephedrine bolus +/- infusion of your choice.
  • Slip in LMA.
  • Borderline hyperventilate her with a decent FiO2 for a generous time period post-induction.
  • Pressure-demand vent. +/- PCV if the block is trash and she needs it.
  • Be generous with the FiO2 and vent. support during the case.
Keep her rate and rhythm controlled as best you can and minimise pulm. afterload and negative inotropy. Put some pacing pads on her intra-op if you're super worried. Take out the LMA in recovery.

I dno...? Does something bad happen?

I wouldn't neuraxial. The heart would whinge.
 
waterbottle10 said:
How would you do this case and what is your reasoning?

82 year old female comes to the Emergency department after fall and broke her hip, with history of HTN, DM, A fib on noac, Heart failure
Can slowly walk around prior to fall. Sleeps with multiple pillows at night

Procedure: hip replacement (per surgeon, case would take around 5 hours of surgical time)

EKG: A fib with PVCs, bundle branch block
TTE: RV dysfunction with severe dilation, severe TR with complete non coaptation of TR (2.2cm gap between anterior and septal leaflet), LV EF 55%, moderate AR, mild MR, moderate pericardial effusion. Positive Bubble Study

How would you proceed? Any more workup? Induction methods? If off anticoagulation for 5 days, spinal and if so what dosage?
Click to expand...

Couple questions I'd ask the surgeon:

1) why THR over hemiarthroplasty or TFN in lady who isn't going to run marathons ever again? Is it fracture location or am I thinking of this wrong?
2) 5 HRS?????????????????????? Seriously what in Christ's name will you do for 4 of those hours? Is there prior hardware that needs to be removed? A prior TFN? A femoral rod?

Well, since you said 5 hours and appeared serious here'd be my plan:

1) GA
2) aline because a 5 hour hip is going to lose blood and I will want to follow labs. Hell a 1 hour hip loses blood but it typically reveals itself more post-operatively.
3) 1gm TXA IV pre incision
4) I'd type and cross for a couple units

- I'd never delay hip replacement in the elderly to wait for a spinal because there's no data for it. The evidence, per my orthos, is that morbidity and likely mortality increases significantly the longer you wait. We go to the OR and do GA.

- I guess there are specific situations where I could be convinced to do a spinal for a planned 5 hour surgery, but this is not one of them. That's GA all the way.
 
Southpaw said:
Couple questions I'd ask the surgeon:

1) why THR over hemiarthroplasty or TFN in lady who isn't going to run marathons ever again? Is it fracture location or am I thinking of this wrong?
2) 5 HRS?????????????????????? Seriously what in Christ's name will you do for 4 of those hours? Is there prior hardware that needs to be removed? A prior TFN? A femoral rod?

Well, since you said 5 hours and appeared serious here'd be my plan:

1) GA
2) aline because a 5 hour hip is going to lose blood and I will want to follow labs. Hell a 1 hour hip loses blood but it typically reveals itself more post-operatively.
3) 1gm TXA IV pre incision
4) I'd type and cross for a couple units

- I'd never delay hip replacement in the elderly to wait for a spinal because there's no data for it. The evidence, per my orthos, is that morbidity and likely mortality increases significantly the longer you wait. We go to the OR and do GA.

- I guess there are specific situations where I could be convinced to do a spinal for a planned 5 hour surgery, but this is not one of them. That's GA all the way.
Click to expand...

he asked a followup about if it only took 3 hrs which started spinal discussion
 
anbuitachi said:
so basically you would do spinal if the surgeon said 3 hours
Click to expand...

Its tough for me to say definitively in this patient. Scenarios on here are always tough for me because a lot of my plan is heavily dependent on my clinical assessment and interview with the patient. Based on just the numbers I’d go into the interview and consent process thinking GA, Aline.
 
anbuitachi said:
have the patient breathe..? also patient has severe TR and non co aptation. may not have severe pHTN

the patient is 82, a touch of ketamine will zone him out.
Click to expand...

Having a massively enlarged RV, large TV coaptation defect, reduced RV function, and increased left heart pressures from afib/AI/MR essentially guarantees her PVR is significantly increased and that her RV is under strain even if the nominal PA pressure number is now normal.
 
Last edited:
Discussion with surgeon was done about the high risk of the case and decision was made to do Hemi.
Patient received a arterial line, block, then spinal 2.7 ml of bupivicaine, with 10 mcg of fentanyl, with epinephrine. Pressure remained stable, with occasional dips 15 minutes later but quickly treated.

Thank you everyone
 
waterbottle10 said:
Discussion with surgeon was done about the high risk of the case and decision was made to do Hemi.
Patient received a arterial line, block, then spinal 2.7 ml of bupivicaine, with 10 mcg of fentanyl, with epinephrine. Pressure remained stable, with occasional dips 15 minutes later but quickly treated.

Thank you everyone
Click to expand...

How long did it end up taking?

I ask because that’s a gargantuan spinal dose. Not that a smaller dose would change much clinically. Just curious.
 
nimbus said:
For those who would do a spinal, how would you keep this patient still for 3 hours while optimizing PVR?
Click to expand...

I've treated an almost identical patient previously, with the exception of known severe pulm. HTN and a bedside TTE showing the RV trying to crush the LV.
We did a spinal. I wouldn't do it again in future.

Weekend case. In holding bay the woman was "demented" (in hindsight CO2 narced, and likely had been for a few days, hence the fall and peri-prosthetic femoral destruction from hip to knee)
She had that lovely grey-blue look. Short, ****ty, tachypnoeic breaths.
Super morbidly obese + in traction.
Etc, etc.

1 hour discussion with surgeons + family. Decision to proceed ~palliatively (with surgery), but given the extent of the prior metalwork --> was still going to be ~3 hours.

Non-neuraxial block + lick of ketamine to roll.
Art. line.
Spinal (usual dose bupiv., but opioid free).
Metaraminol infusion.

She immediately pinked up post-spinal. Breathing normalised. Vitals stabilised (although needing considerable metarminol infusion). She looked a million dollars.
Looking amazing ~ 1 hour into the case with extremely finicky pressor Mx. But just starting to get a bit grey-looking again. Go to do an ABG.
Art. line dislodged by nurse. New one needed.
BP dropping a bit (extremely tight fluid/Hb/pressor line we were walking). Can't easily get art. line due to body habitus and low BP. But still looking okay, maybe bit more grey again.
Pressor is micro-bolussed (bad idea) to help get art. line --> 1 minute later arrests (resuscitated and tubed).

Art. line was in at this point and bloods drawn immediately prior to arrest showed a massively elevated PaCO2.
She'd progressively been hypoventilating with the Hudson mask for some time and 1 hour in it got too much.

If the ABG had been taken, if the pressor hadn't been bolussed, if we had a more accurate ETCO2, if we'd done a repeat ABG earlier... maybe we would have seen it and tubed before it was too late... But that's a few big if's in a patient who was already quite a handful.

In retrospect, I'd be extremely cautious about neuraxial in these patients because if you need to treat the SVR, be aware you may also be affecting the PVR and that might just tip them over the edge. Also, you NEED to keep their PVR low and sometimes this is best achieved with high FiO2 and PPV.

Just my anecdote and thoughts.
 
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