Hip # for ORIF, manage.

[CodeBlu]

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You're on call and your next patient is an 80 year old female who has fractured her left hip, fall from own height. Mechanical. Has been admitted for 24 hours pending repair of hip. Seen by internal medicine.

PMHx: HTN, Gout, Dyslipidemia, Pulmonary HTN, CAD with remote MI, CLL on no active treatment, previous DVT, stopped anticoag 6 months ago, chronic renal failure with baseline creat of 1.8 likely from CLL.

Rx: All the good stuff for above.

Labs: INR 1.3, everything else is fine-ish. Cr at baseline.

Echo: LVEF 40%, Pulm HTN with PASP of 80mmHg.

On your assessment, the patient is confused, has a PICC line in situ, looks like an easy airway. You place an art line and standard monitors.

BP by cuff is 92/40, BP on art line is 75/30.

How do you proceed?

 

[anbuitachi]

You're on call and your next patient is an 80 year old female who has fractured her left hip, fall from own height. Mechanical. Has been admitted for 24 hours pending repair of hip. Seen by internal medicine.

PMHx: HTN, Gout, Dyslipidemia, Pulmonary HTN, CAD with remote MI, CLL on no active treatment, previous DVT, stopped anticoag 6 months ago, chronic renal failure with baseline creat of 1.8 likely from CLL.

Rx: All the good stuff for above.

Labs: INR 1.3, everything else is fine-ish. Cr at baseline.

Echo: LVEF 40%, Pulm HTN with PASP of 80mmHg.

On your assessment, the patient is confused, has a PICC line in situ, looks like an easy airway. You place an art line and standard monitors.

BP by cuff is 92/40, BP on art line is 75/30.

How do you proceed?

spinal with phenylephrine infusion. 2.5ml isobaric

also how is RV on echo?

 

[ChiDO]

Hip pinning/short nail in 10 minutes or hemi in 30 mins. Leave room, tell nurse not to drop patient on floor, thank anesthesialogist, go to Dr lounge 😘

 

[GassYous]

GOC discussion

 

[secretasianman]

Call the ER resident that is here to tube.

 

[abolt18]

Hip pinning/short nail in 10 minutes or hemi in 30 mins. Leave room, tell nurse not to drop patient on floor, thank anesthesialogist, go to Dr lounge

Yeah, I wish this was a reality here...

 

[ethilo]

I like a touch of ketamine sedation to sit patient upright for isobaric spinal then propofol sedation.

If anticioag is an issue preventing a spinal then a ss fascia iliaca and a light GA with LMA works great for these.

 

[deleted162650]

2.5ml isobaric

why such a massive dose for a short procedure in a sick old lady???

I do TKA/THAs with 1.5mL isobaric.

 

[GassYous]

why such a massive dose for a short procedure in a sick old lady???

I do TKA/THAs with 1.5mL isobaric.

i think iso doesn't affect the pressure as much. It does last longer. I use about 1.6 of hyperbaric but 3 cc of iso for redos. Used to do 3 cc of iso for everyone in residency lol

 

[fakin' the funk]

Art line, ketamine, baby dose spinal, phenylephrine, maybe vaso or NE if things get hairy.

An RV that generates those kinds of pressures chronically does better than you'd expect, as long as you maintain systemic pressure.

 

[Planktonmd]

50 mg Propofol with some Phenylephrine , insert LMA, give some vapor and a bit of fentanyl, let her breath spontaneously.
She will do great.

 

[anbuitachi]

why such a massive dose for a short procedure in a sick old lady???

I do TKA/THAs with 1.5mL isobaric.

bc thats how much i need to do a quick hip here. i dropped it from 3ml

 

[Arch Guillotti]

50 mg Propofol with some Phenylephrine , insert LMA, give some vapor and a bit of fentanyl, let her breath spontaneously.
She will do great.

Exactly. Keep it simple.

 

[dchz]

You're on call and your next patient is an 80 year old female who has fractured her left hip, fall from own height. Mechanical. Has been admitted for 24 hours pending repair of hip. Seen by internal medicine.

PMHx: HTN, Gout, Dyslipidemia, Pulmonary HTN, CAD with remote MI, CLL on no active treatment, previous DVT, stopped anticoag 6 months ago, chronic renal failure with baseline creat of 1.8 likely from CLL.

Rx: All the good stuff for above.

Labs: INR 1.3, everything else is fine-ish. Cr at baseline.

Echo: LVEF 40%, Pulm HTN with PASP of 80mmHg.

On your assessment, the patient is confused, has a PICC line in situ, looks like an easy airway. You place an art line and standard monitors.

BP by cuff is 92/40, BP on art line is 75/30.

How do you proceed?

What is her heart rate and RV function?

Vasopressin 0.4 units IV push would be my first answer given how things have played out in OP's scenario.

But if we get the rewrite the whole story I'd just write it so the patient didn't have any disease and she's a healthy 24 year old.

 

[Urzuz]

50 mg Propofol with some Phenylephrine , insert LMA, give some vapor and a bit of fentanyl, let her breath spontaneously.
She will do great.

I would do this plus a fascia iliaca block.

 

[osumd]

Yawn. Can’t remember the last hip fracture who was fully oriented and had a healthy heart. Agree with above- little bit of bit of prop, lma, vapor. FI block would be nice. +/- art line depending on on the weather

 

[deleted697127]

75/30 on an art line and you guys are proceeding? That’s going to be a no from me. What’s her volume status and lactate? Or you know, the rest of her echo. “EF isnt that bad” ignoring the rest of the echo is silly. I wouldn’t assume this is chronic pHTN. In fact, most severe pHTN I’ve seen gets a lot better with volume status optimization. This could definitely be an acute PE or fat embolism. I would want a VQ scan. I’m not touching her until someone at least gets her BP compatible with life.

What exactly are you gaining by proceeding in this state?

 

[secretasianman]

I wouldn’t have the legal balls to drop a spinal in with a pasp of 80 and systemic hypotension.

 

[chocomorsel]

I wouldn’t have the legal balls to drop a spinal in with a pasp of 80 and systemic hypotension.

An isobaric one? Load her up w 500cc and she should be fine w isobaric spinal. If not AC w Plavix or whatever.
Me, I don’t do spinal in broken hips, I just put them to sleep so the plan w a little prop and LMA sounds great.

 

[anbuitachi]

75/30 on an art line and you guys are proceeding? That’s going to be a no from me. What’s her volume status and lactate? Or you know, the rest of her echo. “EF isnt that bad” ignoring the rest of the echo is silly. I wouldn’t assume this is chronic pHTN. In fact, most severe pHTN I’ve seen gets a lot better with volume status optimization. This could definitely be an acute PE or fat embolism. I would want a VQ scan. I’m not touching her until someone at least gets her BP compatible with life.

What exactly are you gaining by proceeding in this state?

a VQ scan?? so what if she has a PE . what will you do? anticoagulate? if you anticoagulate, how am i going to do my spinal?! the fracture needs to be fixed!

 

[anbuitachi]

Yawn. Can’t remember the last hip fracture who was fully oriented and had a healthy heart. Agree with above- little bit of bit of prop, lma, vapor. FI block would be nice. +/- art line depending on on the weather

An isobaric one? Load her up w 500cc and she should be fine w isobaric spinal. If not AC w Plavix or whatever.
Me, I don’t do spinal in broken hips, I just put them to sleep so the plan w a little prop and LMA sounds great.

couple months ago, another attending had to intubate in the lateral position bc the LMA stopped working properly and couldnt be fixed with troubleshooting. im not a fan of lateral LMAs

 

[MirrorTodd]

We talking lil ole lady that's 5'0 and 85 lbs or midwest grandma that weighs 200 lbs?

 

[anbuitachi]

We talking lil ole lady that's 5'0 and 85 lbs or midwest grandma that weighs 200 lbs?

my guess is 200lbs. its america.

 

[chocomorsel]

couple months ago, another attending had to intubate in the lateral position bc the LMA stopped working properly and couldnt be fixed with troubleshooting. im not a fan of lateral LMAs

If lateral I tube. Good points. Not all hips are lateral. I would ask surgeon about positioning.

 

[chocomorsel]

We talking lil ole lady that's 5'0 and 85 lbs or midwest grandma that weighs 200 lbs?

Midwest Grandma! Lol. I don’t understand how they stay so fat in their 80s. So true, I think that is such a Midwest thing. And we aren’t small in TX!

 

[secretasianman]

An isobaric one? Load her up w 500cc and she should be fine w isobaric spinal. If not AC w Plavix or whatever.
Me, I don’t do spinal in broken hips, I just put them to sleep so the plan w a little prop and LMA sounds great.

I don’t either. Whiff of prop and lma. I am just legally averse I guess. If there is a bad outcome for whatever reason I don’t want to have to defend the spinal.

 

[Arch Guillotti]

Vasopressin 0.4 units IV push would be my first answer given how things have played out in OP's scenario.

Why .4? I typically give .5-1 unit depending on the case just to make dosing easier.

 

[Beeftenderloin]

Why is her pulmonary HTN that bad? What’s the etiology? Her suprasystemic PA pressures are a very poor prognostic sign. She needs a frank GOC discussion with POA. If everyone is dead set on proceeding knowing she has a sky high chance of dying on the table or tonight in the unit then it’s awake a-line and prop/sux/tube so I can aggressively manage her CO2. Start some Levo with vaso/epi on a hair trigger.

Putting in an LMA and shifting her CO2 response curve with volatile and narcotics seems like a good way to kill this patient.

 

[Arch Guillotti]

Putting in an LMA and shifting her CO2 response curve with volatile and narcotics seems like a good way to kill this patient.

Minimize narcotics. Make the pt. "earn" them. As long as tidal volumes are ok and hemodynamics are ok, I don't see a big issue with spontaneous ventilation.

 

[deleted697535]

the only thing that i would be interested in is her baseline systemic BP. Id be looking back thru the charts to see any baseline reading. If her baseline with years is systolic 100 id probably be thinking to carry on, just go a GA, no big deal

If shes baseline 180 then no go, put in a nerve block and send her back for echo/ctpe lactate etc etc
Did someone give her wrong dose of beta blocker or some such?

these cases are our bread and butter, sometimes i do 5 of these a weekend but not with a systolic of 75. theyre usually crocks but sbp 180
pulmonary hypertension based off pasp on some tte doesnt interest me in the slightest. we do pte's with pasp 140's under GA with a swan sometimes and they do fine

 

[Hork Bajir]

Unlikely that the systemic BP was as low during the TTE. Don’t forget that pulmonary pressures are related to flow, filling pressures, interventricular dependence, volume status, etc. It’s not a static number. PASP of 80 in a patient with SBP of 180 (and a CI of 2.5) is a very different thing than PASP of 80 in a patient with SPB or 75. Unlikely that this lady actually has suprasystemic PAP

 

[chocomorsel]

Unlikely that the systemic BP was as low during the TTE. Don’t forget that pulmonary pressures are related to flow, filling pressures, interventricular dependence, volume status, etc. It’s not a static number. PASP of 80 in a patient with SBP of 180 (and a CI of 2.5) is a very different thing than PASP of 80 in a patient with SPB or 75. Unlikely that this lady actually has suprasystemic PAP

Well is that compatible w life for very long?

 

[abolt18]

Why .4? I typically give .5-1 unit depending on the case just to make dosing easier.

I'm guessing because that's usually 2cc from a bag of vaso.

 

[Urzuz]

Why is her pulmonary HTN that bad? What’s the etiology? Her suprasystemic PA pressures are a very poor prognostic sign. She needs a frank GOC discussion with POA. If everyone is dead set on proceeding knowing she has a sky high chance of dying on the table or tonight in the unit then it’s awake a-line and prop/sux/tube so I can aggressively manage her CO2. Start some Levo with vaso/epi on a hair trigger.

Putting in an LMA and shifting her CO2 response curve with volatile and narcotics seems like a good way to kill this patient.

melodramatic much? She would do fine in the periop period dude.

 

[dhb]

75 on the a line = code on induction
Most of the times these ladied come with 180 systolic and often end up at 80 on 1.2% of sevo.

 

[Beeftenderloin]

melodramatic much? She would do fine in the periop period dude.

Maybe I am being alarmist. But if I had to choose between respecting this patients physiology too much vs not enough I’d rather err on too much. If you make this lady out to be sick as **** (which she is) and you get her through, you look like a stud. If she dies, no ones pointing fingers at you. But if you make it out to be no big deal and she dies, you look like a fool.

Lots of people at varying levels of training read this stuff. Just trying to provide some balance against the people who say to just slide in an LMA.

 

[nimbus]

Hip pinning/short nail in 10 minutes or hemi in 30 mins. Leave room, tell nurse not to drop patient on floor, thank anesthesialogist, go to Dr lounge 😘

But how many minutes of positioning, reduction, and X-rays before the clock starts? I consider that procedural time even though it precedes incision. Somehow 10 minute cases often last an hour 😉

 

[nimbus]

Will be dispo issue if their bp is still 75/30 in PACU. Make sure there’s an empty ICU bed so you can take them there postop with pressor du jour.

 

[chocomorsel]

I'm guessing because that's usually 2cc from a bag of vaso.

What bag? Who has expensive as bags of Vaso just hanging around? One of the most overpriced pressors out there is Vaso.
Nope, the vial comes in 20u, you dilute in a a 20cc syringe and push doses are easy peasy.

 

[chocomorsel]

Maybe I am being alarmist. But if I had to choose between respecting this patients physiology too much vs not enough I’d rather err on too much. If you make this lady out to be sick as **** (which she is) and you get her through, you look like a stud. If she dies, no ones pointing fingers at you. But if you make it out to be no big deal and she dies, you look like a fool.

Lots of people at varying levels of training read this stuff. Just trying to provide some balance against the people who say to just slide in an LMA.

I do CMV through an LMA. Just gotta be careful at the end and during wake up when trying I get them breathing to make sure they don’t get acidotic is all. Lite narcotics, ketamine and we are golden.

 

[Iso4ane]

We talking lil ole lady that's 5'0 and 85 lbs or midwest grandma that weighs 200 lbs?

200lbs?!!! Where are you finding patients that small?

 

[D P356]

Aortic Valve? Mitral valve?
Is Pulm htn from COPD/Hpv, chf, left heat failure, MI, LVH or severe AS? Etc.

Lma first choice.
If AS is present, NPO yet horrendous airway with chili breath...a slowly, really slowly titrated epidural with no sedation, maybe

Or you could to that fancy PENG block and a 2 or 3 handed DL....using your forehead to advance the ETT.

 

[Urzuz]

Or you could to that fancy PENG block and a 2 or 3 handed DL....using your forehead to advance the ETT.

if you’re using your third hand to perform DL in the patient’s mouth you may get written up by the nursing staff

 

[dhb]

if you’re using your third hand to perform DL in the patient’s mouth you may get written up by the nursing staff

Third hand is ok it's the third leg that gets you in trouble.

 

[deleted875186]

I don’t understand why people would place an LMA.

GA with tube, keep her lighter but paralyzed for the case, control ventilation for the pHTN, set it and forget it. Don’t need to worry about LMA stopping working while the patient is way up in the air at orthopedic height or worse lateral positioning.

 

[Arch Guillotti]

I'm guessing because that's usually 2cc from a bag of vaso.

got it. I am used to just getting the small vial and diluting it.

 

[abolt18]

got it. I am used to just getting the small vial and diluting it.

Me to. I was just figuring, when we have bags for a drip, it's 0.2/ml. I was just guessing.

 

[ChiDO]

But how many minutes of positioning, reduction, and X-rays before the clock starts? I consider that procedural time even though it precedes incision. Somehow 10 minute cases often last an hour 😉

Agreeeee unfortunately. I had the OR manager look up my times out of curiosity.

Hip nail:
Room time avg 47mins
Procedure time avg 23 mins (incision to closure)

Hemi:
Room 87 mins
Procedure 42 mins

Gotta get my PAs to close faster 🤣

I always board nails for 1 hour and hemis for 1:30. So I'm pretty good at guessing my historical times. It's funny that the OR asks how long you need, because apparently they computer will automatically book you for your historical average.

 

[Ronin786]

Agreeeee unfortunately. I had the OR manager look up my times out of curiosity.

Hip nail:
Room time avg 47mins
Procedure time avg 23 mins (incision to closure)

Hemi:
Room 87 mins
Procedure 42 mins

Gotta get my PAs to close faster 🤣

I always board nails for 1 hour and hemis for 1:30. So I'm pretty good at guessing my historical times. It's funny that the OR asks how long you need, because apparently they computer will automatically book you for your historical average.

**** me. Is your anesthesia group hiring?

 

[GassYous]

Agreeeee unfortunately. I had the OR manager look up my times out of curiosity.

Hip nail:
Room time avg 47mins
Procedure time avg 23 mins (incision to closure)

Hemi:
Room 87 mins
Procedure 42 mins

Gotta get my PAs to close faster 🤣

I always board nails for 1 hour and hemis for 1:30. So I'm pretty good at guessing my historical times. It's funny that the OR asks how long you need, because apparently they computer will automatically book you for your historical average.

You need an anesthesiologist? Some of my surgeons take 42 minutes just to drape.