Hip Case

[OB1🤙]

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So a slip gets dropped for a 75 yo lil ol lady for a hip hemiarthroplasty. She was pruning a rose bush in her garden when she tripped on a pot and fell.

It turns out she's been transferred from an OSH for higher level of care. OSH had forgot one of the laws of the House of God: "If you don't take a temperature, you can't find a fever." What I mean is: they had found it fit to echo her, which revealed PA pressures estimated at 90-95 systolic. Systemic pressures are about 160/90. She also had some AS, with an AVA of 1 cm^2. She denies any cardiac symptoms, history, or previous workup.

How do you proceed? Do these echo findings change your usual approach to such a case?

 

[NotAMD]

huh? it seems like they found the fever..no? here PAPs are EXTREMELY high.. i have never seen PAPs that high, and she has critical AS..so of course it would change management..

i would do a CSE - minimal meds on the spinal end (prob just 25 of fentanyl plus a cc of 0.25% reg bupi), slow titration of epidural monitoring abp with an aline.. i would also put in a 9f introducer (unless shes very HD stable and i can get a couple 16g pivs)

 

[dhb]

Avoid hypoxia, hypercarbia, anemia, tachycardia, hypotension. Cleared for spinal

I find it hard to believe she is asymptomatic with those PA pressures.
In this case i would want to minimize changes to her actual physiology so two options: LP block + sciatic block or spinal cath at L2-L3 dosed incrementally 0.5cc at a time

 

[dhb]

i have never seen PAPs that high, and she has critical AS..so of course it would change management..

Not that uncommon for the PA pressures and critical AS would be under 1cm2 especially if she's 5"2 90Lb

 

[sevoflurane]

Why do you want an introducer? Would you monitor PA pressures and risk rupture? Maybe trickle in some NTG and monitor it's response....?

Is a spinal or epidural a contraindication to someone who has a fever? How about someone with AS? Is 1cm2 considered critical?

Do the risks outweigh the benefits of the above?

How 'bout pent sux tube and avoid hypercarbia, pain, hypoxia, acidosis etc. + some NTG.

I think there are different ways to skin this cat. I bet that with PA pressures that high, most would put in an a-line.

 

[dhb]

Is a spinal or epidural a contraindication to someone who has a fever?

I thought the fever was metaphorical?

 

[sevoflurane]

Hmmm.... I think you might be right.

Just for kicks... would fever be a contraindication to a spinal or epidural?

 

[C.P.]

Avoid hypoxia, hypercarbia, anemia, tachycardia, hypotension. Cleared for spinal

I find it hard to believe she is asymptomatic with those PA pressures.
In this case i would want to minimize changes to her actual physiology so two options: LP block + sciatic block or spinal cath at L2-L3 dosed incrementally 0.5cc at a time

spinal caths aren't very common across US institutions now-a-days, but are perfect for this kind of case.
not knowing anything else about the patient, an option would be to place an a-line and throw in a spinal cath (if you're insitution has one).
good for post op and intraop pain control, allows her to maintain her own CO2 balance, allows for gentle titration of a one sided level if you get the baricity of your solution correct, and because of her age, post-dural puncture headache is least likely.

 

[nap$ter]

repeat the echo

 

[periopdoc]

slavin beat me to it

- pod

 

[OB1🤙]

huh? it seems like they found the fever..no?

Yeah, but did they follow ACC/AHA recommendations? She was asymptomatic. And yes to others- the "fever" here is metaphorical. http://www.urbandictionary.com/define.php?term=Laws of the House of God

i would do a CSE - minimal meds on the spinal end (prob just 25 of fentanyl plus a cc of 0.25% reg bupi), slow titration of epidural monitoring abp with an aline.. i would also put in a 9f introducer (unless shes very HD stable and i can get a couple 16g pivs)

Is the introducer for volume or for a swan? CSE at these doses seems reasonable, though if the spinal dose wears off, it sure would suck if the epidural was patchy.

 

[OB1🤙]

Avoid hypoxia, hypercarbia, anemia, tachycardia, hypotension. Cleared for spinal

I find it hard to believe she is asymptomatic with those PA pressures.
In this case i would want to minimize changes to her actual physiology so two options: LP block + sciatic block or spinal cath at L2-L3 dosed incrementally 0.5cc at a time

I thought it strange too, but she really was asymptomatic. She wasn't running marathons, but was living alone, doing all ADLs, and plodding around in her garden quite happily.

I like the LP block + sciatic, but it'd have to be a pretty high sciatic (ie parasacral), and we hadn't done this before and weren't gonna start now.

We do have quite a bit of experience with spinal catheters in these patients, and this is what we decided to do.

Repeat echo confirmed OSH's data, BTW.

 

[OB1🤙]

Why do you want an introducer? Would you monitor PA pressures and risk rupture? Maybe trickle in some NTG and monitor it's response....?

Is a spinal or epidural a contraindication to someone who has a fever? How about someone with AS? Is 1cm2 considered critical?

Do the risks outweigh the benefits of the above?

How 'bout pent sux tube and avoid hypercarbia, pain, hypoxia, acidosis etc. + some NTG.

I think there are different ways to skin this cat. I bet that with PA pressures that high, most would put in an a-line.

Definitely a-line. And yeah, we were much more concerned with the PA pressures than the AS. We considered have nitric in the room, but decided that if we didn't put in a swan, there wouldn't be much data to titrate the stuff with.

The fact that the systemic pressures were much higher than the PAPs and that she had been asymptomatic were (somewhat) reassuring to us.

 

[OB1🤙]

So we decide to proceed with a spinal catheter. Aline goes in, we position her lateral with much protestation, and give sprinkles of midaz. However, her back is a wall of bone. I try for about 30 min. My pain-fellowship-trained attending tries for about 45 min. Multiple levels, multiple directions, multiple failures. Limited views of spine we can see on hip films show awful arthritis everywhere and no open spaces identifiable. Orthos are waiting patiently and understand why we're doing this, but it's 8PM by now. It just ain't gonna happen.

So it's time for a GA. Ok to proceed with just the a-line? Do we need swan or TEE? What is your preferred induction for a patient like this?

 

[nap$ter]

there is a significant false positive rate with TTE for diagnosing pulmonary hypertension - no test is perfect in isolation, and the echo findings don't correlate with the functional status she gave. the truth is usually somewhere in the middle...

that being said, she ain't gonna get a right heart cath from me in the above situation.

no swan; aline is sufficient. i would keep her on her side, place a LP catheter, judicious stunning dose of propofol ie 30, breath a bit of volatile, LMA. keep her sbp around 140-160, use vasopressin if you want, but i bet based on her functional status she does fine.

 

[proman]

Chest wall echo estimates RVSP and PA pressures by the amount of tricuspid regurgiation + an estimate of CVP (usually based on IVC size in response to a sniff). Patients with significant TR because of tricuspid problem won't have elevated PA pressures, but the echo doesn't show that. I'd want to know what the RV size, amount of hypertrophy and function is. Agree completely with repeating the echo. A cardiologist's interpretation is only as good as the sonographer who did the study. I've found enough mistakes in TTEs that I'll read the study myself preop if it's available.

As for the AS, the 2009 ASE guidelines don't include a critical category. A valve area of 1 is moderate, less than 1 is severe, greater than 1.5 is mild. I consider symptomatic AS (angina, syncope, hypotension) to be more important than actual AVA. Of course, 0.5 is much different than 0.9. I don't think moderate AS is a contraindication to spinal anesthesic, although I would pick an epidural + sedation or LMA.

 

[OB1🤙]

Another look at the echo shows the likely reason for the problem- the pt has a PFO or ASD. Bubble study positive, and L->R shunting seen on color flow. The RA volume is 102. RV size reported as mildly enlarged with low normal function. There is no comment on the tricuspid annulus but the jet is called mild, with a velocity of 4.65.

slavin- I like your recipe there. A lumbar plexus block would have been a nice way to smooth out the GA for her, and would make an LMA a little easier to manage.

As it was we induced with etomidate, intubated, and used vaso to keep systolic pressures up as needed. She tolerated it fine, luckily enough. Given her functional status, I suppose we shouldn't have been surprised that she tolerated the anesthetic well.

 

[Laryngophed]

I thought the fever was metaphorical?

Do we know her age and BUN? And did you manage to catch the other provider's HR?

 

[Mista Suprane]

Do we know her age and BUN? And did you manage to catch the other provider's HR?

is there even a hip fracture? are we sure both the medical student and the radiologist BOTH didn't see it on xray?

 

[Laryngophed]

is there even a hip fracture? are we sure both the medical student and the radiologist BOTH didn't see it on xray?

👍

 

[Jeff05]

fascia iliaca block and catheter. a line. slow controlled induction. tube.

 

[proman]

Another look at the echo shows the likely reason for the problem- the pt has a PFO or ASD. Bubble study positive, and L->R shunting seen on color flow. The RA volume is 102. RV size reported as mildly enlarged with low normal function. There is no comment on the tricuspid annulus but the jet is called mild, with a velocity of 4.65.

Nice. The reading cardiologist should be informed of the error and the study should undergo QA review. That sonographer probably makes many other errors as well.

 

[Robert Loblaw]

hmm, interesting...fifteen or so replies in and no one wrote "pent, sux, tube," so i'll do it: fent/etom/roc/tube

i'd do a GA with an a-line no problem. she has good functional status and, as such, has a well-compensated valvulopathy. the pap's, though high, likely reflect the filling pressures needed to keep her massive, hypertrophied LV happy. i bet if they fell too much she'd get hypotensive and probably start sam'ing, too. i'd be far more worried if she had a dilated and hypofunctioning rv with paps in the 40s, elevated lfts and peripheral edema.

 

[jetproppilot]

So a slip gets dropped for a 75 yo lil ol lady for a hip hemiarthroplasty. She was pruning a rose bush in her garden when she tripped on a pot and fell.

It turns out she's been transferred from an OSH for higher level of care. OSH had forgot one of the laws of the House of God: "If you don't take a temperature, you can't find a fever." What I mean is: they had found it fit to echo her, which revealed PA pressures estimated at 90-95 systolic. Systemic pressures are about 160/90. She also had some AS, with an AVA of 1 cm^2. She denies any cardiac symptoms, history, or previous workup.

How do you proceed? Do these echo findings change your usual approach to such a case?

I dunno....

EASY FOR ME TO MONDAY NIGHT QUARTERBACK...

but...

Why try and make your life miserable with regional here?

I'm a regional advocate. I'll do regional any chance I see.

Someone with aortic stenosis and pulmonary artery pressures OFF THE CHART

is getting a general anesthetic in my book.

This is a

GREAT TEACHING CASE

where it seems sometimes us as anesthesiologists are trying to

PROVE A POINT...

the point being

REGIONAL IS SUPERIOR...

I agree with that statement with 99% of cases.

In the case of some dude with aortic stenosis and pulmonary artery pressures off the chart,

Do yourself a favor.

Put in an a-line in holding, then

PUT'EM TO SLEEP

in the OR.

Going against the grain on this thread. I'm comfortable with that.

Think you dudes advocating regional in this case have decided that

MAKING YOUR LIVE'S MISERABLE IS OK.

Sorry, dudes.

I'll take the easy route with this case:

.5) A line in holding
1) midazolam 2mg on the way back to the OR
2) in the OR, monitors on, fentanyl 100ug, preoxygenation
3) rocuronium 10mg, an appropriate dose of propofol (on the lower side), as soon as he/she loses consciousness, succinylcholine 140 mg
4) Insert plastic thru the chords
5)Now we have a hemodynamically stable patient where no matter what happens considering their preoperative aortic stenosis and pulmonary artery pressures higher than LINDSAY LOHAN,

I got it.

 

[Coastie]

aline
etomidate
sux
tube


next?

 

[periopdoc]

Another look at the echo shows the likely reason for the problem- the pt has a PFO or ASD. Bubble study positive, and L->R shunting seen on color flow. The RA volume is 102. RV size reported as mildly enlarged with low normal function. There is no comment on the tricuspid annulus but the jet is called mild, with a velocity of 4.65.

slavin- I like your recipe there. A lumbar plexus block would have been a nice way to smooth out the GA for her, and would make an LMA a little easier to manage.

As it was we induced with etomidate, intubated, and used vaso to keep systolic pressures up as needed. She tolerated it fine, luckily enough. Given her functional status, I suppose we shouldn't have been surprised that she tolerated the anesthetic well.

So we have a putative cause for the pHTN, but we still have pHTN on this study. Estimating a CVP of 10 mm hg gives us a PASP of 96 mmHg (4V^2 +10). The relatively minimal aortic stenosis is a secondary concern.

She has arrived at this point slowly (over 75 years) as evidenced by her tolerance of these pressures during activity.

So I ask what is going to kill this patient? Assuming she still has reactive pulmonary vasculature, the answer is hypoxia, hypercarbia etc. 🙁

How are we going to avoid it in the OR? GA. If there was one major theme I took away from fellowship it is to control all the variables. Sedation can get you into a world of hurt with these folks and GA is usually safer than MAC.

How are we going to avoid it post-op? Minimize opiates, and make sure a medicine service gets involved. She needs a cath with closure of her ASD/PFO.

My plan? A-line, prop, sux, tube and vaso for hypotension. If she is having a lot of pain in PACU, I might throw in a gentle block, but they seem to do pretty well with usual therapy so I don't want to sedate them for a probably unnecessary block. KISS.

- pod