Different case

[MirrorTodd]

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.

What's the metaraminol?

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[anbuitachi]

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.

why do you think its the spinal? sounds like this happened because the nurse knocked out the art line . why was she retaining so much co2? what was your etco2? why was it so inaccurate?

 

[Arch Guillotti]

I ask because that’s a gargantuan spinal dose. Not that a smaller dose would change much clinically. Just curious.

The dose seems normal to me.

 

[deleted162650]

The dose seems normal to me.

For total hips and knees my group uses 1.5mLs of 0.5% bupi plain. We get a reliable 3-3.5 hour block from that.

I don’t think it was wrong to give what the OP gave - just seems like significant overkill especially in an old fogey.

 

[Arch Guillotti]

For total hips and knees my group uses 1.5mLs of 0.5% bupi plain. We get a reliable 3-3.5 hour block from that.

I don’t think it was wrong to give what the OP gave - just seems like significant overkill especially in an old fogey.

Three and a half hours of surgical block from 7.5 mg of plain Tupi. Wow. Ours must be sitting out in the sun or something.

 

[deleted162650]

Three and a half hours of surgical block from 7.5 mg of plain Tupi. Wow. Ours must be sitting out in the sun or something.

Ya I know - surprising, but that’s what we use and have been for a couple years now. We had surgeons complaining about prolonged motor blocks and inability to PT the afternoon of surgery. So we started gradually reducing our dose systematically until we settled on 7.5. Now everyone is happy.

 

[anbuitachi]

Ya I know - surprising, but that’s what we use and have been for a couple years now. We had surgeons complaining about prolonged motor blocks and inability to PT the afternoon of surgery. So we started gradually reducing our dose systematically until we settled on 7.5. Now everyone is happy.

definitely got some super bupi...

we use ~3ml regularly for ortho cases

 

[deleted162650]

definitely got some super bupi...

we use ~3ml regularly for ortho cases

We routinely have 2 different brands of bupi. Sometimes Hospira and sometimes it’s Fresenius. Same results with either.

 

[Arch Guillotti]

definitely got some super bupi...

we use ~3ml regularly for ortho cases

Same here

 

[deleted252565]

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.

Would you consider Andexanex to reverse factor Xa inhibitors?
I think there may be a value for reversal in this case to minimize transfusion and fluid shift given her HF status.
Also it may be worthwhile to know the etiology of her RVF, her baseline RVSP and PVR to guide resuscitative decision (inhaled pulmonary dilators, inotropic choices Epi vs Dobu/Milrinone). Definitely needs an aline, EJ vs IJ for pressor/inotrope infusion (i don’t think it’s a good idea to infuse neo or levo peripherally over 5hrs..) and for transducing cvp.

 

[anbuitachi]

Would you consider Andexanex to reverse factor Xa inhibitors?
I think there may be a value for reversal in this case to minimize transfusion and fluid shift given her HF status.
Also it may be worthwhile to know the etiology of her RVF, her baseline RVSP and PVR to guide resuscitative decision (inhaled pulmonary dilators, inotropic choices Epi vs Dobu/Milrinone). Definitely needs an aline, EJ vs IJ for pressor/inotrope infusion (i don’t think it’s a good idea to infuse neo or levo peripherally over 5hrs..) and for transducing cvp.

you saying you would delay the case
?

 

[nimbus]

Would you consider Andexanex to reverse factor Xa inhibitors?
I think there may be a value for reversal in this case to minimize transfusion and fluid shift given her HF status.
Also it may be worthwhile to know the etiology of her RVF, her baseline RVSP and PVR to guide resuscitative decision (inhaled pulmonary dilators, inotropic choices Epi vs Dobu/Milrinone). Definitely needs an aline, EJ vs IJ for pressor/inotrope infusion (i don’t think it’s a good idea to infuse neo or levo peripherally over 5hrs..) and for transducing cvp.

Would not give ANDEXXA without a very good reason...ie patient is bleeding to death. I’d rather transfuse more and risk some CHF than risk a thrombotic complication.

I’ve never had an EJ that I liked. Isn’t an EJ a peripheral IV?

 

[vector2]

(i don’t think it’s a good idea to infuse neo ... peripherally over 5hrs..)

 

[Arch Guillotti]

Would not give ANDEXXA without a very good reason...ie patient is bleeding to death. I’d rather transfuse more and risk some CHF than risk a thrombotic complication.

I’ve never had an EJ that I liked. Isn’t an EJ a peripheral IV?

Try one using a long catheter. Works great.

 

[Hork Bajir]

EJs are almost always positional in my experience, even with the longer 18g catheters. Generally not worth the trouble unless you don’t have other options (arms tucked and need an IV under the drapes). Just put in a triple lumen, way more reliable and takes only a minute longer.

Also, I think it’s fairly commonplace to run peripheral neo for extended periods. Ideally with a reliable IV and at lower rates. Peripheral Levo is also totally safe provided you’re using dilute enough concentration. Overall my threshold to place a central line is fairly low, but some arbitrary rule like “more than 5 hours of pressor” doesn’t make much sense IMHO.

 

[deleted59964]

What's the metaraminol?

it's the first line drug australians use to treat hypotension due to vasodilation.
predominantly an alpha agonist, with a little B1 agonsim too.
phenylephrine is used rarely here because it doesnt come pre prepared and is more effort to dilute and draw up.

just a regional difference.

https://www.phebra.com/wp-content/uploads/2018/07/Metaraminol-Phebra-0.5-V02.pdf

 

[anbuitachi]

only norep

EJs are almost always positional in my experience, even with the longer 18g catheters. Generally not worth the trouble unless you don’t have other options (arms tucked and need an IV under the drapes). Just put in a triple lumen, way more reliable and takes only a minute longer.

Also, I think it’s fairly commonplace to run peripheral neo for extended periods. Ideally with a reliable IV and at lower rates. Peripheral Levo is also totally safe provided you’re using dilute enough concentration. Overall my threshold to place a central line is fairly low, but some arbitrary rule like “more than 5 hours of pressor” doesn’t make much sense IMHO.

only a minute longer for triple lumens? then you are scrubbing wrong

my threshold for putting in triple lumens is pretty high. ive seen plenty of things go wrong with central lines over the years (not me), from rupturing svc, arrythmias, infections, carotid dilations, blah blah. way more than peripheral vasopressors go wrong.

ive had ICU tell me when i bring them patient, to put in central lines if i think i'll be using pressors and i just give them a big No.

 

[deleted875186]

only norep


only a minute longer for triple lumens? then you are scrubbing wrong

my threshold for putting in triple lumens is pretty high. ive seen plenty of things go wrong with central lines over the years (not me), from rupturing svc, arrythmias, infections, carotid dilations, blah blah. way more than peripheral vasopressors go wrong.

ive had ICU tell me when i bring them patient, to put in central lines if i think i'll be using pressors and i just give them a big No.

I will say I’ve also heard many more complications from central line insertions rather than extravasation. If I were running high dose pressors though I would place a CVC.

 

[nimbus]

only norep


only a minute longer for triple lumens? then you are scrubbing wrong

my threshold for putting in triple lumens is pretty high. ive seen plenty of things go wrong with central lines over the years (not me), from rupturing svc, arrythmias, infections, carotid dilations, blah blah. way more than peripheral vasopressors go wrong.

ive had ICU tell me when i bring them patient, to put in central lines if i think i'll be using pressors and i just give them a big No.

Those complications are preventable. I have a low threshold to insert a central line. Never regretted putting one in.

 

[Arch Guillotti]

EJs are almost always positional in my experience, even with the longer 18g catheters. Generally not worth the trouble unless you don’t have other options (arms tucked and need an IV under the drapes). Just put in a triple lumen, way more reliable and takes only a minute longer

I am not going to all that trouble of putting a central line in under the drapes. I can do an EJ in a minute and put in a midline which is almost never positional and will never fall out if positioned properly.

 

[Velefunt]

• fascia iliaca block - 0.5% ropi cut with 1% lido/epi

• propofol & LMA