Hip Fracture and Medical Optimization

[turnupthevapor]

I am hoping to kind of get a multi center consensus here:

Case: 94 yr old demented hip fracture, unable to obtain functional status due to dementia. EKG NSST changes (mild) HGB 9 bp 100/40 hr 60

What are you all doing with this patient. I am often tempted to postpone the procedure until I see an echo. I usually don't ask for a stress test.

I am not sure waiting for the echo is changing my management. Obviously if I see they have sever AS or low EF I am more delicate with them, maybe put in an aline but in reality I am wondering If I should just do these cases with out delay which probably has advantages for the patients


What are you all doing with these patients

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[coprolalia]

Any audible murmur? Was the patient ambulatory and otherwise asymptomatic beforehand? Are they going to do a perc-pinning or are they replacing the whole damn hip?

If the answers are "yes" and "no" and "not sure" (respectively), get an echo even if you don't have ECG voltage criteria for ventricular hypertrophy and have some blood ready.

Conversely, you could do as you say by putting in a pre-induction a-line, throwing in a lumbar epidural (if no contraindication) and topping it up very slowly, essentially doing this like a sedation case, and having a pressor in-line hanging and ready to go. Overall, guess it depends on how "urgent" it is to get this done.

Also, talk to Grandma's family and make sure they understand that this fall might become a "terminal" event. You won't lose this one if it goes to court... which it won't. Not saying you still shouldn't do what's right, though.

-copro

 

[Planktonmd]

I am hoping to kind of get a multi center consensus here:

Case: 94 yr old demented hip fracture, unable to obtain functional status due to dementia. EKG NSST changes (mild) HGB 9 bp 100/40 hr 60

What are you all doing with this patient. I am often tempted to postpone the procedure until I see an echo. I usually don't ask for a stress test.

I am not sure waiting for the echo is changing my management. Obviously if I see they have sever AS or low EF I am more delicate with them, maybe put in an aline but in reality I am wondering If I should just do these cases with out delay which probably has advantages for the patients
What are you all doing with these patients

Here is what I would do:
Go to the OR stick an LMA and fix the fracture under GA (I do all hip fractures under GA+ fascia iliaca block).
I am not sure why you feel you need an echo and what you intend to do with the results of that echo once you get them.
If your surgeon tends to lose a lot of blood during a hip ORIF then give some PRBC.
Every extra day this patient stays at the hospital makes it less likely for him to leave the hospital alive.

 

[Planktonmd]

Conversely, you could do as you say by putting in a pre-induction a-line, throwing in a lumbar epidural (if no contraindication) and topping it up very slowly, essentially doing this like a sedation case, and having a pressor in-line hanging and ready to go. Overall, guess it depends on how "urgent" it is to get this done.

-copro

😕😕😕
you are kidding aren't you??
You forgot to mention a PA catheter, a TEE and having the perfusionist on standby!

 

[dhb]

What are you all doing with these patients

We put them to sleep

 

[Dejavu]

This pt would get an aline, 2 IVs, and probably a GETA from most of my colleagues. She would get blood at the first sign of blood loss, but this is a teaching hospital with learners everywhere so things go slowly.

I doubt you could find a 94yo without NSST changes.

You could get clever and do a continuous spinal and slowly load up with small doses of bupiv.

Other places, faster surgeons, I used to use a spinal, some Ketamine for sedation, two IVs (or one nice one), no aline. However, this is with surgeons that get Done.

 

[dhb]

Dementia and spinals are not are great mix imho

 

[Planktonmd]

Dementia and spinals are not are great mix imho

Exactly!
When people insist on doing hip fractures under spinal they usually have to induce GA or get very close to it just to position the patient for the spinal then during the case they have to be very close to GA since most of these patients are elderly and disoriented.
So this is basically either dangerously deep sedation or GA with unprotected airway just to pretend that we are doing the case under regional.
The alternative is straight forward and safe GA if you know how.

 

[thegasman]

I am hoping to kind of get a multi center consensus here:

Case: 94 yr old demented hip fracture, unable to obtain functional status due to dementia. EKG NSST changes (mild) HGB 9 bp 100/40 hr 60

What are you all doing with this patient. I am often tempted to postpone the procedure until I see an echo. I usually don't ask for a stress test.

I am not sure waiting for the echo is changing my management. Obviously if I see they have sever AS or low EF I am more delicate with them, maybe put in an aline but in reality I am wondering If I should just do these cases with out delay which probably has advantages for the patients


What are you all doing with these patients

Prop sux tube (+neo) and at least type and screen. I would also consider lma or I work with one older crna who prefers to mask this case.

 

[Dejavu]

Dementia and spinals are not are great mix imho

And believe me, I recognize that a bunch of people share that opinion (and a bunch do not), but that doesn't mean it cannot safely be done.

 

[Dejavu]

Exactly!
When people insist on doing hip fractures under spinal they usually have to induce GA or get very close to it just to position the patient for the spinal then during the case they have to be very close to GA since most of these patients are elderly and disoriented.
So this is basically either dangerously deep sedation or GA with unprotected airway just to pretend that we are doing the case under regional.
The alternative is straight forward and safe GA if you know how.

I think Plank just took a shot at me, but I don't know for sure

 

[coprolalia]

.

 

[coprolalia]

😕😕😕
you are kidding aren't you??
You forgot to mention a PA catheter, a TEE and having the perfusionist on standby!

THIS WAS THE CONTEXT OF THE QUESTION, PLANK... (uggh, why do I bother)

Obviously if I see they have sever AS or low EF I am more delicate with them, maybe put in an aline but in reality I am wondering If I should just do these cases with out delay which probably has advantages for the patients


What are you all doing with these patients

Then, I asked...

Any audible murmur?

Any audible murmur? Any audible murmur? ANY AUDIBLE MURMUR?

If NO...

Go to the OR stick an LMA and fix the fracture under GA...

... NO DISAGREEMENT.

But, instead I said...

Conversely, you could do as you say by putting in a pre-induction a-line, throwing in a lumbar epidural (if no contraindication) and topping it up very slowly, essentially doing this like a sedation case, and having a pressor in-line hanging and ready to go. Overall, guess it depends on how "urgent" it is to get this done.

That better, sweetie?

🙂

-copro

 

[dhb]

And believe me, I recognize that a bunch of people share that opinion (and a bunch do not), but that doesn't mean it cannot safely be done.

Oh i've done it: 25mg of K to position patient from bed to OR table roll in the or and sit the patient up (no problem with the K aboard) do spinal proceed w surgery.

I'm just stating my preference: the babysitting part is very annoying.

 

[Planktonmd]

That better, sweetie?


-copro

Are you officially coming out of the closet?

 

[Planktonmd]

I think Plank just took a shot at me, but I don't know for sure

No, was not intended to be a shot at you. I just never understood the wisdom in inducing GA in order to do a pretend regional anesthetic.

 

[Planktonmd]

Any audible murmur? Any audible murmur? ANY AUDIBLE MURMUR?

If NO...



-copro[/QUOTE]

Every 94 Y/O has an audible murmur and they don't need an Echo, they need their hip fracture fixed.

 

[Robert Loblaw]

I am hoping to kind of get a multi center consensus here:

Case: 94 yr old demented hip fracture, unable to obtain functional status due to dementia. EKG NSST changes (mild) HGB 9 bp 100/40 hr 60

What are you all doing with this patient. I am often tempted to postpone the procedure until I see an echo. I usually don't ask for a stress test.

I am not sure waiting for the echo is changing my management. Obviously if I see they have sever AS or low EF I am more delicate with them, maybe put in an aline but in reality I am wondering If I should just do these cases with out delay which probably has advantages for the patients


What are you all doing with these patients

with due respect, i do not see the controversy here. if an orthopod says "we have to do this fracture." you say "when?" if he says, "we have to do it now," you say "okay." you then fairly and objectively document your discussion with the surgeon (not the throw-under-the-bus RN "md-aware" note), then proceed to the OR. if he says, "it's urgent, but it can wait until tomorrow," then tell the primary service what info you need to do the case safely--either they or you can find the relevant history, or they can order the relevant tests. either way, i'm sure the patient has a cxr (for heart size), an ekg, cardiac enzymes, and, of course, you can auscultate, as detailed above. if he's got a systolic murmer, it's most likely AS, though it could be MR. a patient with MR does not need an overly cautious induction, so just assume its AS and do a more careful induction or put an aline in if you want.

irrespective of the above, if you ask me to generally anesthetize any 94 year old, for any procedure, i don't care if he is jack friggin lalaine (who, ironically, upon checking wikipedia, is found to be 94 years old), he's gonna get 1 mg midazalam, 0.5-1mg/kg propofol injected over 1-2 minutes and titrated to specific effect, 50-100mcg of fentanyl, 0.25 - 0.5 MAC of agent, quite possibly 100mcg of neo, and an airway. maps will be kept in the 70's-80's regardless of surgical bickering.

 

[coprolalia]

with due respect, i do not see the controversy here. if an orthopod says "we have to do this fracture." you say "when?" if he says, "we have to do it now," you say "okay." you then fairly and objectively document your discussion with the surgeon (not the throw-under-the-bus RN "md-aware" note), then proceed to the OR. if he says, "it's urgent, but it can wait until tomorrow," then tell the primary service what info you need to do the case safely--either they or you can find the relevant history, or they can order the relevant tests. either way, i'm sure the patient has a cxr (for heart size), an ekg, cardiac enzymes, and, of course, you can auscultate, as detailed above. if he's got a systolic murmer, it's most likely AS, though it could be MR. a patient with MR does not need an overly cautious induction, so just assume its AS and do a more careful induction or put an aline in if you want.

irrespective of the above, if you ask me to generally anesthetize any 94 year old, for any procedure, i don't care if he is jack friggin lalaine (who, ironically, upon checking wikipedia, is found to be 94 years old), he's gonna get 1 mg midazalam, 0.5-1mg/kg propofol injected over 1-2 minutes and titrated to specific effect, 50-100mcg of fentanyl, 0.25 - 0.5 MAC of agent, quite possibly 100mcg of neo, and an airway. maps will be kept in the 70's-80's regardless of surgical bickering.

Excellent post. Glad to know this forum isn't all cowboys.

-copro

 

[ncdoc1974]

Our 94 y/o hip fx patients have usually been seen by a cardiologist and the cardiologist usually "clears" them with an EKG, CXR and negative TropI, typically no ECHO and states we should "proceed with urgent non-cardiac surgery"...not real helpful, but whatever....I usually take them to the OR, induce them on their hospital stretcher then move them to the OR table after intubation....I usually give them 2-4cc of fentanyl, then some etomidate....If they drop their BP, I intubate, recheck the BP, then neo if necessary...If they do not significantly drop their BP (usually the case with this combo, no other drugs on board) I'll use an LTA followed by intubation...I avoid muscle relaxants unless absolutely necessary for me or the surgeon...this avoids side effects of reversal agents etc...I occasionally slip an LMA in for TFNs, but I usually prefer a secure airway...Routinely no a-line...Trying to position a hip fx patient for a spinal in private practice at 10pm with limited staff sucks...Very rare that I will do a spinal on a case like this...Anyway this is what I typically do...I have found it to be a pretty smooth, safe, and simple technique with nice hemodynamics...