hip in VERY recent MI

[Dhanwanthari]

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Reminds me of my first few months out of training :

"dont worry sexy nurses.. I'm a gonna give her some Ketamine, roll her onto her side, get the spinal in 2 seconds and then I will have time to make love to all of you."

So I have 2 of versed, like 10 of ketamine, roll her over and get in nice and close so I can smell the crack of her butt and the next thing I hear:

"I DONT KNOW WHATS HAPPENING SOMEBODY HELP CALL THE POLICE I DONT LIKE THIS AAAAAHHHH AAAAAAAHHHHH EEEEEEKKK EEEEEEEEKK HEEEEEELLLLLPPPPP"

Must have given that poor old bird the scare of her lifetime with the unexpected K trip. No nurses were made love to that night and I piled on a bit more humility.

Laughing my ***** off.

 

[OB1🤙]

Not adding much here, but I think this is exactly the kind of patient that gets a lot of benefit from an intrathecal catheter and continuous spinal.

 

[foxtrot]

Agree with Jet. This is the type of thing that is bankrupting American medicine.

You should do the case, you have no leg to stand on to refuse.

Last guy I took care of like this (although he was mentally competent) flew through (a-line, prop, sux, tube, TEE) and was doing fine on Friday, 2d postop. I came back on Monday to find he had a big MI over the weekend and was not resuscitatable. Family was happy.

In a twisted sense, if you precipitate her death, you may be doing her and her family a favor by saving them from future suffering.

- pod

Agree with you both. You can't reign in healthcare costs when we are in the business of doing everything for the demented 85 year old nursing home patient. When you get these kinds of cases, you just have to suck it up and make sure you communicate a very bleak picture to the family. If pt not anticoagulated, then get CRNA to give a little propofol up front, turn pt on their side, CSE in lateral position. Propofol gtt for the rest of the case if BP will tolerate, if not just a little versed for relaxation. If anticoagulated, pre-op art line, a couple of IV's, GA with etomidate, neo gtt ready, and blood available for coronary perfusion if H/H drops. Giddyup.

 

[sevoflurane]

How about an Esophogeal doppler (CardioQ)? We have been using these and they are way cool - tons of really useful information, including real time fluid responsiveness.

I like the cardioQ. Very noninvasive and has quite a bit of information to give you once you align your probe right.

Have you checked this guy out?

I was playing with it last week and found it to be an anesthesiologists dream. Even more noninvasive than the CardioQ.

What it measures:

B.P./Map (Beat to Beat)
SVR
Stroke Volume
dP/dT (Contractility)...... yes! 🙂
CCO/CI
HR
Spo2
and......
Hgb (if equiped with the right probe)....continuous....👍

This all fits on your Finger....! 😱

I played with one for about 6 hours last week. I compared it to B.P. and a-line in the other extremity. Very close.

This device is made in Holland and can be found in their OR's and EP labs.

The analytical algorithms are the same ones used on the Vigileo.

Here are a couple pictures I took. I didn't have the Hgb probe on it.... but it is very simple to put on.

Unfortunately, it is dependent on perfusion to the extremity... so if you are maximally clamped down, I don't think it would be very reliable, which may defeat it's purpose in many of our patient populations (although the vendor may not admit it). CardioQ doesn't have this limitation.... but aligning the probe can be finicky from time to time.

It is first generation and I bet by the 2nd-3rd gen... it might be a pretty powerful tool with almost zero risk in regards to placement.

I wonder what we will be using 20 years from now.....🙄

 

[nap$ter]

How about an Esophogeal doppler (CardioQ)? We have been using these and they are way cool - tons of really useful information, including real time fluid responsiveness.

the cardioQ would be way cooler if the data were accurate or precise - but it's neither... an aline is more useful.

A comparison of CardioQ and thermodilution cardiac output during off-pump coronary artery surgery.
Hullett B, Gibbs N, Weightman W, Thackray M, Newman M.
J Cardiothorac Vasc Anesth. 2003 Dec;17(6):728-32.

 

[proman]

the cardioQ would be way cooler if the data were accurate or precise - but it's neither... an aline is more useful.

A comparison of CardioQ and thermodilution cardiac output during off-pump coronary artery surgery.
Hullett B, Gibbs N, Weightman W, Thackray M, Newman M.
J Cardiothorac Vasc Anesth. 2003 Dec;17(6):728-32.

The biggest problem with the esophageal doppler is that it assumes the size of the descending aorta based on a nomogram of height. Aortic diameter is a major factor in the equation, even 2D TEE underestimates the size when compared to 3D TEE reconstructions or CT reconstructions. Yet people use it.

 

[fabfive5]

I apologize if this was already said...I tried to read everything before posting.

I had a few of these types come in a row. Not a very recent MI, but both had MI's in the not-to-distant past and one was dimented (though surgery got consent from her!!).

I did Etomidate/Vec/50mcg Fentanyl - assured stability, then did a femoral nerve block (with resident) spreading the Ropiv cephalad, then did a selective Lat Fem Cut nerve block. Both got a total of 50-100 mcg of fentanyl and were both comfortable (and extubated in the OR). The demented one was a bit crazy afterwards though...I think it's b/c someone gave 1mg total of Versed.

I did not do sciatics....should I have?