Hip # for ORIF, manage.

[DarkHorizon]

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

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.

Pretty much my time as well. Occasionally takes longer if I’m cementing a hemi or dropping down a long nail. Rate limiting step is usually Anaesthesia (a lot of times due to positioning concerns), unfortunately.

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[nimbus]

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

It takes our guys 10minutes to get the booties on for the ProFX table.

 

[Radetzky]

Do whatever preserves the most dignity in a patient who has reached the end of her life and will most likely not make it out of hospital.

 

[chocomorsel]

Do whatever preserves the most dignity in a patient who has reached the end of her life and will most likely not make it out of hospital.

Dude you practice outside the US. Lucky you. Over here we like to “do everything!” and the kitchen sink. Best believe everyone is gonna try and make sure she doesn’t die in the hospital. Who cares if she dies in the Rehab facility as soon as they drop her off after doping her up for the transport! Win win for everyone. Gotta have those stats and get paid!!

 

[anbuitachi]

what about total hips?!

Dude you practice outside the US. Lucky you. Over here we like to “do everything!” and the kitchen sink. Best believe everyone is gonna try and make sure she doesn’t die in the hospital. Who cares if she dies in the Rehab facility as soon as they drop her off after doping her up for the transport! Win win for everyone. Gotta have those stats and get paid!!

it definitely is about the stats. it reminds me of how so many studies look at 30 day mortalities. so easy to keep someone alive to 31 days and all of a sudden its not captured in the study anymore.

 

[nimbus]

what about total hips?!


it definitely is about the stats. it reminds me of how so many studies look at 30 day mortalities. so easy to keep someone alive to 31 days and all of a sudden its not captured in the study anymore.

Like this?



“Anything on Darryl Young?” asked cardiologist Dr. Darko Vucicevic, according to a recording of the meeting obtained by ProPublica.
“Need to keep him alive till June 30 at a minimum,” responded Dr. Mark Zucker, director of the hospital’s heart and lung transplant programs.”

“It’s Very Unethical”: Audio Shows Hospital Kept Vegetative Patient on Life Support to Boost Survival Rates

Darryl Young suffered brain damage during a heart transplant at Newark Beth Israel and never woke up. But, hardly consulting his family, doctors kept him alive for a year to avoid federal scrutiny.

www.propublica.org

 

[Fajardo04]

1) Frank discussion with patient’s family. She will certainly die within a couple weeks without surgery, but there is a very good chance she will die with surgery as well. The prognosis is not good regardless of decision made. Document this discussion extensively. Proceed with case if family wishes.
2) Propofol, sux, tube. A-line depending on the surgeon. She will likely code if you place a spinal with that preop pulmonary to systemic pressure ratio. She may also code with an LMA and spontaneous breathing if you let her CO2 climb too high. I have seen this several times in little old ladies with pulm HTN. Doesn’t mean she won’t code with GETA but odds are better.
3) Have plenty of vasopressin available and use plenty of it.
4) Light gas for the case. Minimize narcs. As awake as possible for emergence.

 

[Hoya11]

1) Frank discussion with patient’s family. She will certainly die within a couple weeks without surgery, but there is a very good chance she will die with surgery as well. The prognosis is not good regardless of decision made. Document this discussion extensively. Proceed with case if family wishes.
2) Propofol, sux, tube. A-line depending on the surgeon. She will likely code if you place a spinal with that preop pulmonary to systemic pressure ratio. She may also code with an LMA and spontaneous breathing if you let her CO2 climb too high. I have seen this several times in little old ladies with pulm HTN. Doesn’t mean she won’t code with GETA but odds are better.
3) Have plenty of vasopressin available and use plenty of it.
4) Light gas for the case. Minimize narcs. As awake as possible for emergence.

I just don't buy that having a ETCO2 of 50 will be harmful to this patient.
I have never had a patient spontaneously breath themselves into a code.
LMA is nice and gentle. No PPV. No reactive airway. No Paralysis. No apnea. KISS
You can keep the gas light without paralyzing, this is an elderly grandma. Less is more.
I'm definitely in the LMA camp. GETA IMO is more likely to buy you a trip to the unit with pressors and remaining intubated.
LMA highly likely to come out at the end, breathing uninhibited by what i've done, pain controlled with a very small dose of fentanyl.

 

[JoelJoel84]

There is the oral boards answer of pre-induction A-Line, slowly titrated induction with pressors, GETA, likely post op intubation and sedation etc.

But agree with most of you, in real life this is a simple LMA case of which we have 3-4 lined up every Saturday morning; done all of them by noon and they’re snoozing in PACU.

This is my first year as a solo PP attending and it’s remarkable what you learn in residency (both by the books and how your institution practices ) vs out in the world and your partners can teach you. KISS is the mantra that really works best most often.

 

[DrOwnage]

Not doing a pre-induction a line in this case is basically malpractice in my opinion. 1000 bucks says after you induce the bp cuff says "weak pulsation" or just cannot detect at all. If you do enough of these old people cases in people with a lines on induction you see they all drop from 160's into 70s with 100 of prop without comorbidities.

 

[Hork Bajir]

Not doing a pre-induction a line in this case is basically malpractice in my opinion. 1000 bucks says after you induce the bp cuff says "weak pulsation" or just cannot detect at all. If you do enough of these old people cases in people with a lines on induction you see they all drop from 160's into 70s with 100 of prop without comorbidities.

I’m not saying it’s wrong to do an A-line line but... why are you giving 100 of prop?

 

[Planktonmd]

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.

Because based on the law # 13 of the house of God: The delivery of medical care is to do as much nothing as possible. So, an LMA is basically an oral airway, it's as close to nothing as possible, you can give minimal anesthesia to insert it and to maintain it, and then hopefully you will let the patient breath on her own and avoid the temptation to do things you were taught you must do to fix her PHTN.

 

[DrOwnage]

It was an example in a healthy old person which is a perfectly fine dose for an ETT induction. I don't give 100 of prop to all my old and sick people, I usually give it slow, but even 50 of prop in this lady will tank her.

Edit: If it was me I would probably breathe this lady down with sevo, and take over ventilation when she let me, paralyze, then give 10-20 of prop and intubate.

 

[deleted875186]

Because based on the law # 13 of the house of God: The delivery of medical care is to do as much nothing as possible. So, an LMA is basically an oral airway, it's as close to nothing as possible, you can give minimal anesthesia to insert it and to maintain it, and then hopefully you will let the patient breath on her own and avoid the temptation to do things you were taught you must do to fix her PHTN.

I disagree with the assumption that using some muscle relaxant and putting an ETT will somehow harm her.

She has bad pulmonary HTN. The things that are likely to harm her are too much anesthesia, hypercarbia, hypoxia, etc. all more likely with an LMA. I can put in an ETT, keep her paralyzed, lighter plane of anesthesia. I don’t need to give more anesthesia to intubate her, just wait for the muscle relaxant to work.

 

[nimbus]

It was an example in a healthy old person which is a perfectly fine dose for an ETT induction. I don't give 100 of prop to all my old and sick people, I usually give it slow, but even 50 of prop in this lady will tank her.

Edit: If it was me I would probably breathe this lady down with sevo, and take over ventilation when she let me, paralyze, then give 10-20 of prop and intubate.

Inhalation induction/roc/tube is a reasonable plan but I don’t think the 10-20 of prop is doing anything for you.

 

[anbuitachi]

Pretty much my time as well. Occasionally takes longer if I’m cementing a hemi or dropping down a long nail. Rate limiting step is usually Anaesthesia (a lot of times due to positioning concerns), unfortunately.

question is why is only anesthesia team concerned with positioning... isnt that everyones issue

i click my 'anesthesia ready' after my tube goes in, not after the patient gets positioned

 

[DrOwnage]

Inhalation induction/roc/tube is a reasonable plan but I don’t think the 10-20 of prop is doing anything for you.

I usually do a little prop adjunct because can't reliably know if the patient is completely unaware with a slow volatile induction, especially with a sudden stimulating thing like a DL.

 

[GassYous]

I usually do a little prop adjunct because can't reliably know if the patient is completely unaware with a slow volatile induction, especially with a sudden stimulating thing like a DL.

I care more about them staying alive than if they remember dl. 80 yo with all those comorbidities? How long will they even be around to remember?

 

[Urzuz]

I usually do a little prop adjunct because can't reliably know if the patient is completely unaware with a slow volatile induction, especially with a sudden stimulating thing like a DL.

Patients like this are usually completely unaware 99% of time during their daily lives. Your 10-20 mg of propofol is doing more to relax your brain than it is to anesthetize hers.

 

[DarkHorizon]

question is why is only anesthesia team concerned with positioning... isnt that everyones issue

i click my 'anesthesia ready' after my tube goes in, not after the patient gets positioned

Fair enough, the integrity of the airway is of supreme concern, ortho can fix the hip pretty quickly. Most of us anyway.

 

[deleted697535]

Not doing a pre-induction a line in this case is basically malpractice in my opinion. 1000 bucks says after you induce the bp cuff says "weak pulsation" or just cannot detect at all. If you do enough of these old people cases in people with a lines on induction you see they all drop from 160's into 70s with 100 of prop without comorbidities.