Hip Case

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GassYous

GassYous

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  1. Attending Physician
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For students and residents

89 yo lady for elective total hip replacement. htn hld gerd ckd. Looks good in preop. Anything you want to know before you go to the OR?
 
GassYous said:
For students and residents

89 yo lady for elective total hip replacement. htn hld gerd ckd. Looks good in preop. Anything you want to know before you go to the OR?
Click to expand...
sure, I want to know what it was like to be a woman in her 20’s during the 1950’s, and to be a woman in her 30’s in the 1960’s. Where was she when she saw the moon landing?

there’s obviously a “gotcha”. However if she meets METS and, as you said, no other red flags beyond what you’ve mentioned, or red flags buried in the PMHx you mention (I’m assuming you have a med list and some labs, and that she’s been seen by an internist in the last year), then the obvious answer is no, we don’t routinely get any more information than what you’ve offered.

that said, I love a good case, so I’ll assume she has SAM and she missed her beta blocker and she is a fourth case start and has been NPO for 18 hours, or maybe she has Harrington rods, a frozen c-spine and hx of radiation to the neck.

anyway what’s the catch?
 
Had the other side done 20 years ago and did well.

psh: hysterectomy, colonoscopy, chole, cataracts

allergic to ace, amlodipine, hydralazine

Just on oxy, aspirin, nifedipine and takes nitro

5'1 55 kg bp 150s/80s

laying in bed nad, conversating normally. 2+ edema in the LE but otherwise ok. no murmur.

na 135 k 4 cl 101 bicarb 29 bun 16 cr 1.2 glucose 110. wbc 9 hgb 11 plt 240
inr 1 ptt 55

Medicine doc says she's good to go.

What's your plan?
 
GassYous said:
Had the other side done 20 years ago and did well.

psh: hysterectomy, colonoscopy, chole, cataracts

allergic to ace, amlodipine, hydralazine

Just on oxy, aspirin, nifedipine and takes nitro

5'1 55 kg bp 150s/80s

laying in bed nad, conversating normally. 2+ edema in the LE but otherwise ok. no murmur.

na 135 k 4 cl 101 bicarb 29 bun 16 cr 1.2 glucose 110. wbc 9 hgb 11 plt 240
inr 1 ptt 55

Medicine doc says she's good to go.

What's your plan?
Click to expand...

notably we still do not have METs provided which is what this case hinges on. that and her nitro hx.
 
Her hip hurts, she doesn't walk that much. She takes nitro for angina but very rarely.

She had a stress test and tte a year ago. They were done when she first started having chest pain. Stress test was ok, echo shows mild as and grade 2 diastolic dysfunction
 
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Spinal, prop, neo drip. But delay the case until the PM so you only have to start it and then get immediately relieved by your colleague on call before the oh fck here's the oral boards portion of the case arrives
 
Based on what you have stated so far she may have CHFpEF with volume overload as evidenced by the LE edema. AS can progress rapidly so maybe that is why. In PP the case is probably going forward as she is old and probably has no idea about the chronicity of her LE edema and was cleared by her PCP who follows her longitudinally.
 
Eh she's probably a little volume overloaded but it didn't bother me much. Lungs clear, patient not in any distress. I would just proceed with the case from that standpoint.

vector2 said:
Spinal, prop, neo drip. But delay the case until the PM so you only have to start it and then get immediately relieved by your colleague on call before the oh fck here's the oral boards portion of the case arrives
Click to expand...

Would you do the spinal with those labs though?
 
GassYous said:
Eh she's probably a little volume overloaded but it didn't bother me much. Lungs clear, patient not in any distress. I would just proceed with the case from that standpoint.



Would you do the spinal with those labs though?
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Not with that PTT of 55. A quick prop, roc, tube.
 
GassYous said:
Eh she's probably a little volume overloaded but it didn't bother me much. Lungs clear, patient not in any distress. I would just proceed with the case from that standpoint.



Would you do the spinal with those labs though?
Click to expand...
Woops didn't see that PTT. Why's it elevated?
 
abolt18 said:
Not with that PTT of 55. A quick prop, roc, tube.
Click to expand...

Would you proceed with the case or would you want to work that up first?

If you do proceed, why tube? Would an lma work?

Would you block this lady?
 
My first thought is it’s a spurious lab and repeat. Nurse drew the lab from an IV that was recently locked with heparinized saline. Liver disease, hemophilia, some weird DIC picture? FSP and ACT maybe to verify? No spinal until normal lab in my hot little hand. Would FI block her and do a general with a tube as my orthos always ask for relaxation
 
doubt she has APS or hemophilia as she hasn’t clotted or exsanguinated (respectively) with previous procedures. normal INR rules against liver disease. likely a bad lab, but now that you’ve got it, you gotta re-check it.
 
GassYous said:
Eh she's probably a little volume overloaded but it didn't bother me much. Lungs clear, patient not in any distress. I would just proceed with the case from that standpoint.



Would you do the spinal with those labs though?
Click to expand...
Does she take dietary supplements?
 
GassYous said:
Would you proceed with the case or would you want to work that up first?

If you do proceed, why tube? Would an lma work?

Would you block this lady?
Click to expand...

#1 rule... ELECTIVE surgery.

Time to optimize here. Sorry, but 89 years old... and hip surgery? I'm scared. Very very scared. (Hip # and old people = universal badness IMO)

Cancel case, consult cardiology, admit for work up. She most likely has antiphospholipid syndrome from her grade 2 diastolic dysfunction. Which is pseudonormal at rest, and probably way worse with any stress or tachycardia... her AS has likely progressed. So her thick beefy non compliant ventricle needs some TLC before we go anywhere.

Cath normal a year ago is great. But, I want a repeat TTE before doing anything to her.

She has GERD... I don't do LMAs with GERD. LMA's are a tougher anesthetic.

Edit: I saw the comment about a little volume overloaded... and no, I'm not doing a neuraxial technique with aPTT of 55. Yes, a spinal is the best thing for her pain/DVT risk etc etc etc. But, this could very easily be done with a GA and a fascia iliaca block. But, I'm not sticking a needle in her back.
 
Let's say we repeated the lab and it came back as 55 so it was real. When I look back, she has had a high ptt for about 10 years.

I think liver disease in someone with normal inr and other labs ok is unlikely. Also an outpatient who came in for an elective hip and nothing acutely wrong with them probably isn't having dic. Hemophilia is a good thought. Maybe some factor deficiency? 8,9,11,12? Unlikely to be 12 but maybe 8 or 9. I like the comment about aps and the diastolic dysfunction. Would you work up someone that's asymptomatic though?

Anyone wonder why someone with high blood pressure is on nifedipine? And what their allergic reactions are?
 
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GassYous said:
Let's say we repeated the lab and it came back as 55 so it was real. When I look back, she has had a high ptt for about 10 years.

I think liver disease in someone with normal inr and other labs ok is unlikely. Also an outpatient who came in for an elective hip and nothing acutely wrong with them probably isn't having dic. Hemophilia is a good thought. Maybe some factor deficiency? 8,9,11,12? Unlikely to be 12 but maybe 8 or 9. I like the comment about aps and the diastolic dysfunction. Would you work up someone that's asymptomatic though?

Anyone wonder why someone with high blood pressure is on nifedipine? And what their allergic reactions are?
Click to expand...

Drug induced APS? I dont know anything about this... But that is what you're hinting at I think. We dont work this kind of stuff up ourselves as anesthesiologists really... But a markedly abnormal lab prior to elective surgery warrants a work up. Maybe this has been worked up actually, but the pt is old and many old people have no clue what is going on.
 
CodeBlu said:
#1 rule... ELECTIVE surgery.

Time to optimize here. Sorry, but 89 years old... and hip surgery? I'm scared. Very very scared. (Hip # and old people = universal badness IMO)

Cancel case, consult cardiology, admit for work up. She most likely has antiphospholipid syndrome from her grade 2 diastolic dysfunction. Which is pseudonormal at rest, and probably way worse with any stress or tachycardia... her AS has likely progressed. So her thick beefy non compliant ventricle needs some TLC before we go anywhere.

Cath normal a year ago is great. But, I want a repeat TTE before doing anything to her.

She has GERD... I don't do LMAs with GERD. LMA's are a tougher anesthetic.

Edit: I saw the comment about a little volume overloaded... and no, I'm not doing a neuraxial technique with aPTT of 55. Yes, a spinal is the best thing for her pain/DVT risk etc etc etc. But, this could very easily be done with a GA and a fascia iliaca block. But, I'm not sticking a needle in her back.
Click to expand...

you have a bright future at your local academic center for mental masturbation and blocking patients from ever getting to the OR.

just kidding, good thoughts on the case. FWIW, ASRA recommends using the same guidelines for peripheral nerve blocks as you use for neuraxial, so if you are really risk averse and don’t want to needle the back, you may not want to needle their leg either unless it’s critical to the management of the patient. Traditionally the teaching was that you can compress the site of injection for a PNB so you can be a little looser with anticoagulants etc (and intuitively that makes sense), but from a strictly guideline/medicolegal perspective, the same standards apply.
 
Arch Guillotti said:
Which is not really realistic.
Click to expand...

since when have guidelines reflected reality?

as I said it intuitively makes sense why you would use a different standard between PNBs vs neuraxial, but our academic experts who write the guidelines which dictate what is ‘safe’ from a medicolegal perspective don’t see it that way.
 
Guillemot said:
Drug induced APS? I dont know anything about this... But that is what you're hinting at I think. We dont work this kind of stuff up ourselves as anesthesiologists really... But a markedly abnormal lab prior to elective surgery warrants a work up. Maybe this has been worked up actually, but the pt is old and many old people have no clue what is going on.
Click to expand...

Yep! So the patient was taken off ace for cough and amlodipine due to leg swelling. They tried hydralazine and it led to an increase in ptt. They measured all the factor levels, factor 8 was down to 30%. Positive lupus anticoagulant, positive ana, dsdna, reduced c3, c4. positive thyroid perox autoab. histone antibody positive as well pointing to drug induced.

So even though this patient has a high ptt, they are hypercoagulable. Do they need anticoagulation? I didn't think so especially because this case can have significant blood loss but it's a consideration.

I didn't do a nerve block but I did skip the spinal. I put in an lma and she did fine. I think as long as they don't have postural symptoms, lma is well tolerated even in lateral position. However, putting a fascia iliaca or even femoral nerve block in with a ptt of 57 is okay. Superficial, compressible site.

Props to blockit for pointing out the ptt early although he graciously removed his post so the trainees can look at the case first.
 
My question for you guys: is there a ptt or inr where you would delay surgery if it wasn't worked up? When would you proceed with surgery but skip neuraxial?
 
GassYous said:
Yep! So the patient was taken off ace for cough and amlodipine due to leg swelling. They tried hydralazine and it led to an increase in ptt. They measured all the factor levels, factor 8 was down to 30%. Positive lupus anticoagulant, positive ana, dsdna, reduced c3, c4. positive thyroid perox autoab. histone antibody positive as well pointing to drug induced.

So even though this patient has a high ptt, they are hypercoagulable. Do they need anticoagulation? I didn't think so especially because this case can have significant blood loss but it's a consideration.

I didn't do a nerve block but I did skip the spinal. I put in an lma and she did fine. I think as long as they don't have postural symptoms, lma is well tolerated even in lateral position. However, putting a fascia iliaca or even femoral nerve block in with a ptt of 57 is okay. Superficial, compressible site.

Props to blockit for pointing out the ptt early although he graciously removed his post so the trainees can look at the case first.
Click to expand...
Why not just do a spinal if she's off anticoagulation and the appropriate specialty like heme/onc has documented that her abnl ptt is from APS?
 
GassYous said:
My question for you guys: is there a ptt or inr where you would delay surgery if it wasn't worked up? When would you proceed with surgery but skip neuraxial?
Click to expand...
Should have been caught preoperatively, either by the doc who "cleared" the patient or the anesthesia preop labs (if they were taken before the DOS). I would have told the surgeon because I bet more than a few orthopods would cancel the case despite the cavalier attitude that many seem to have. I would have done the case without further workup, just not a spinal. Yes, the limits get pushed sometimes.
 
Urzuz said:
FWIW, ASRA recommends using the same guidelines for peripheral nerve blocks as you use for neuraxial
Click to expand...
I am not sure this is correct, can you elaborate? My ASRA app indicates a clear difference in approach, at least in regards to blood thinners.
 
CodeBlu said:
#1 rule... ELECTIVE surgery.

Time to optimize here. Sorry, but 89 years old... and hip surgery? I'm scared. Very very scared. (Hip # and old people = universal badness IMO)

Cancel case, consult cardiology, admit for work up. She most likely has antiphospholipid syndrome from her grade 2 diastolic dysfunction. Which is pseudonormal at rest, and probably way worse with any stress or tachycardia... her AS has likely progressed. So her thick beefy non compliant ventricle needs some TLC before we go anywhere.

Cath normal a year ago is great. But, I want a repeat TTE before doing anything to her.

She has GERD... I don't do LMAs with GERD. LMA's are a tougher anesthetic.

Edit: I saw the comment about a little volume overloaded... and no, I'm not doing a neuraxial technique with aPTT of 55. Yes, a spinal is the best thing for her pain/DVT risk etc etc etc. But, this could very easily be done with a GA and a fascia iliaca block. But, I'm not sticking a needle in her back.
Click to expand...

Let me take a wild guess and say you don't practice in the real world.
 
Arch Guillotti said:
Cancelling a case is one thing, consulting cardiology is another but admission is an alternate universe.
Click to expand...


How does one justify admitting a patient for a workup that can be done as an outpatient? Would Medicare/insurance companies pay for it even? What would the patient and family think/say? If it were me, I would be pissed off.
 
dchz said:
Correct my ignorance. Please tell me the mechanism behind this.
Click to expand...

Left ventricular diastolic abnormalities other than valvular heart disease in antiphospholipid syndrome: An echocardiographic study

Antiphospholipid syndrome (APS) can be primary or secondary to other autoimmune disorders. Besides valvular heart disease (VHD) and coronary artery disease (CAD), little is known about the impact of APS on left ventricular (LV) function.
www.internationaljournalofcardiology.com

Left ventricular diastolic abnormalities other than valvular heart disease in antiphospholipid syndrome: An echocardiographic study​



  • Diastolic dysfunction is detectable in APS patients, free of cardiac manifestations.
  • •
    Diastolic dysfunction is prominent in primary than in secondary APS.
  • •
    The degree of LV diastolic dysfunction is independently associated with LA positivity.
  • •
    Diastolic dysfunction should be searched in APS free of cardiac manifestations.
 
CodeBlu said:
Okay, not an admission... but at least a cardio consult/heme consult.
It's elective surgery. It can wait
Click to expand...
A cold hard truth of private practice- Nothing is totally elective in the eyes of administration and surgeons.

Insurance authorizations, NPO patient already in day surgery, 90 planned minutes of a surgeons block time. Hell these days our orthos have to work to wrestle a bed from a Covid border for post op admissions. In their eyes you didn’t save a patient from a near miss, you cost them thousands of dollars.

the worst thing you can do is cancel a case for a work up and the consult says NTD follow up in my clinic after surgery. (Been there).

You should still be thinking about how things will impact your anesthetic and patient outcome. But a 90 year old with no history of clotting or bleeding, asymptomatic with “medical clearance”, and hobbled in under her own power should probably go to the OR rather than chase zebras in preop.
 
Arch Guillotti said:
I am not sure this is correct, can you elaborate? My ASRA app indicates a clear difference in approach, at least in regards to blood thinners.
Click to expand...

www.nysora.com

Neuraxial Anesthesia and Peripheral Nerve Blocks in Patients on Anticoagulants - NYSORA

The decision to perform neuraxial anesthesia or peripheral nerve blocks in patients on anticoagulants, should be made on an individual basis, weighing the benefits of regional anesthesia against the risks. Intraspinal hematoma is a relatively rare condition resulting from a variety of causes...
www.nysora.com www.nysora.com

"If appropriate, peripheral nerve blocks can be performed in patients taking anticoagulants. In contrast to neuraxial procedures in the presence of anticoagulants, there have been no prospective studies on peripheral nerve blocks in the presence of anticoagulants. The ASRA recommends the same guidelines for peripheral nerve blocks as for neuraxial procedures. Cases of psoas and retroperitoneal hematomas have been reported after lumbar plexus nerve blocks and psoas compartment nerve blocks. These patients were either on enoxaparin, ticlopidine, or clopidogrel. In some cases, the hematoma occurred in spite of adherence to the ASRA guidelines."

It goes on to say:

"It is probably too restrictive to adapt the ASRA guidelines on neuraxial nerve blocks to patients undergoing peripheral nerve blocks. The European Society of Anaesthesiology has noted that the guidelines for neuraxial nerve block do not routinely apply to peripheral nerve blocks. The Austrian Society for Anesthesiology, Resuscitation and Intensive Care, on the other hand, has suggested that superficial nerve blocks can be safely performed in the presence of anticoagulants. Because of the possibility of retroperitoneal hematoma, lumbar plexus and paravertebral nerve blocks merit the same recommendations as for neuraxial injections. The same guidelines should also apply to visceral sympathetic nerve blocks. The ASRA guidelines may, therefore, be applicable to nerve blocks in vascular and noncompressible areas, such as celiac plexus nerve blocks, superior hypogastric plexus nerve blocks, and lumbar plexus nerve blocks. Clinicians should individualize their decision and discuss the risks and benefits of the nerve block with the patient and the surgeon. Most importantly, the clinician should follow the patient closely after the nerve block placement."

To reiterate, I agree that it's too stringent to apply the same guidelines for neuraxial procedures as you would for a peripheral nerve block in a compressible area. That being saying, as I was telling the guy I originally responded to, if you want to do everything by the book and follow the guidelines to the letter (which is what his post seemed to indicate given the number of studies he wanted to order on that patient), you should avoid a PNB if you are avoiding neuraxial for anticoagulation reasons.

EDIT: I went to the ASRA website itself and read the most recent article in the BMJ where they detail guidelines.


In 2018, it seems like they added a clause to superficial nerve blocks to make the ASRA guidelines more in line with common sense and the other societies' guidelines from around the globe.

"16.0 Anesthetic Management of the Patient Undergoing Plexus or Peripheral Block
16.1 For patients undergoing perineuraxial, deep plexus, or deep peripheral block, we recommend that guidelines regarding neuraxial techniques be similarly applied (grade 1C).
16.2 For patients undergoing other plexus or peripheral techniques, we suggest management (performance, catheter maintenance, and catheter removal) based on site compressibility, vascularity, and consequences of bleeding, should it occur (grade 2C). Remarks: This is a new recommendation."

So I guess they did revise it in the most recent iteration of the guidelines. Prior to 2018, this 16.2 clause didn't exist and they recommended all PNBs follow the same anticoagulation guidelines as neuraxial techniques. NYSORA should probably update their article as well!
 
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I’m still not getting why you guys wouldn’t do a spinal in someone whose PTT prolongation is documented APS, a hypercoagulable disorder.
 
Last edited:
I’m lucky if my patients show up with an old EKG, much less a full workup from a specialist.

Mets ok? No CP/SOB? Prop-Sux-Tube.
 
vector2 said:
I’m still not getting why you guys wouldn’t do a spinal in someone whose PTT prolongation is documented APS, a hypercoagulable disorder.
Click to expand...
I would but I don't think it was really presented that way.
 
Wow!
The asymptomatic high PTT in antiphospholipid syndrome is actually common and it's amazing how many people in anesthesia and surgery seem to know nothing about it.
Now how about we just give her a little bit of Propofol, place an LMA. and let her breath a little bit of anesthesia so they can do their surgery?
This technique by the way is the simple answer in most these cases that tend to be turned into a circus by the academic gurus.
 
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Arch Guillotti said:
I don’t get it either.
Click to expand...
It's a coincidence and I am amazed that someone wasted their time trying to prove it is not!
But that happens a lot when people are under pressure to publish something so they come up with these weird theories and try to prove them.
 
CodeBlu said:
#1 rule... ELECTIVE surgery.

Time to optimize here. Sorry, but 89 years old... and hip surgery? I'm scared. Very very scared. (Hip # and old people = universal badness IMO)

Cancel case, consult cardiology, admit for work up. She most likely has antiphospholipid syndrome from her grade 2 diastolic dysfunction. Which is pseudonormal at rest, and probably way worse with any stress or tachycardia... her AS has likely progressed. So her thick beefy non compliant ventricle needs some TLC before we go anywhere.

Cath normal a year ago is great. But, I want a repeat TTE before doing anything to her.

She has GERD... I don't do LMAs with GERD. LMA's are a tougher anesthetic.

Edit: I saw the comment about a little volume overloaded... and no, I'm not doing a neuraxial technique with aPTT of 55. Yes, a spinal is the best thing for her pain/DVT risk etc etc etc. But, this could very easily be done with a GA and a fascia iliaca block. But, I'm not sticking a needle in her back.
Click to expand...
Im scared too.

We should book her for a TAVI and myectomy to optimise her for hip fracture. It is part of the AHA preoptimisation guidelines for hip fractures
 
We had a guy for BKA one time in ICU who was in ICU cause of his DKA.

I told the orthopod i needed to delay a couple hours cause he was in DKA, before doing his BKA.

He got really confused

We just looked at each other for a solid 15 seconds, then both backed away
 
Newtwo said:
We had a guy for BKA one time in ICU who was in ICU cause of his DKA.

I told the orthopod i needed to delay a couple hours cause he was in DKA, before doing his BKA.

He got really confused

We just looked at each other for a solid 15 seconds, then both backed away
Click to expand...

No doubt the surgeon was trying to reach back deep to his medical school days to figure out what DKA meant
 
abolt18 said:
How loud is her systolic murmur?
Click to expand...
After doing TAVRs for the past 10 years these are the patients who I don't take a shortcut and not carefully listen to their hearts. I also auscultate every TAVR so my radar for low flow low cardiac output aortic stenosis is fully tuned in. I obviously put a lot of patients to sleep safely with critical AS for cardiac procedures but I don't want to do a spinal in a patient with an aortic valve area of 0.5 cm2.
 
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