hip in VERY recent MI

[Gas you down]

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weekend case. lady in her 80s comes in for busted hip. troponins bumped, with septal ECG changes. Ortho declares it an emergency, you know the whole "she is a train wreck, but she HAS to have it fixed NOW", even though she just had an MI. Cardiologist consulted; says she is as at very high risk for surgery, but it is up to ortho, if they declare it an emergency, then go ahead, which they do...
she is very demented at baseline. family is completely on board. they understand the risk and want to proceed.
what do you do?

 

[dhb]

she is very demented at baseline. family is completely on board. they understand the risk and want to proceed.
what do you do?

Proceed, you're golden

 

[Dhanwanthari]

As long as the ortho team documents it as an emergeny, and her family is aware of the inc. cardiac risk as described by the cardiologist.

Arterial line then spinal....

I'm as worried about the weeks of post op cog dysfunction from a deep anesthetic plane as the postoperative risk of recurrent MI.

Full stomach? I'm waiting til she's appropriately npo and doing the above.

 

[jetproppilot]

weekend case. lady in her 80s comes in for busted hip. troponins bumped, with septal ECG changes. Ortho declares it an emergency, you know the whole "she is a train wreck, but she HAS to have it fixed NOW", even though she just had an MI. Cardiologist consulted; says she is as at very high risk for surgery, but it is up to ortho, if they declare it an emergency, then go ahead, which they do...
she is very demented at baseline. family is completely on board. they understand the risk and want to proceed.
what do you do?

Thanks for sharing.

Your predicament brings most of us back to the same exact scenario. Elderly patient who isn't even aware they are still on this planet because of dementia.

A family who wants US, The Doctors, to do

EVERYTHING THEY CAN TO SAVE THE LIFE OF THEIR MINDLESS RELATIVE.

Dude, from a medicine standpoint,

yeah man, we need to do the case. Old people sitting in beds with major fractures DIE from complications from sitting in said bed.

From that standpoint,

it's worth the risk.

LET's GO.

Ethically,

I'm not an ethical expert but man, we've all been put into this position, whether you're an orthopedist, an anesthesiologist, et al, it's

Bull s h I t.

There is no need for us to do our deeds on someone who is beyond help, someone who is not even aware that they still exist.

Yet we are still coerced by The Family.

Uhhhhhhhhh....

WE ARE DOCTORS.

The patient's FAMILY

Is not.

I think we've become too politically correct....afraid of the

RIGHT DECISIONS.

 

[Idiopathic]

well, ill leave out the shtick and tell you what i tell residents: we are not in the business of palliation or deciding who is "worth saving". We are consultants called upon to protect someone during a surgical procedure that will happen whether we are there or not. you are somewhat protected here, and you can focus on what is best for this patient during this procedure, and then you can have a metaphysical debate over what is best for the patient's soul and the medical health of the economy overall at another time...but never the paths shall cross.

 

[chocomorsel]

Thanks for sharing.

Your predicament brings most of us back to the same exact scenario. Elderly patient who isn't even aware they are still on this planet because of dementia.

A family who wants US, The Doctors, to do

EVERYTHING THEY CAN TO SAVE THE LIFE OF THEIR MINDLESS RELATIVE.

Dude, from a medicine standpoint,

yeah man, we need to do the case. Old people sitting in beds with major fractures DIE from complications from sitting in said bed.

From that standpoint,

it's worth the risk.

LET's GO.

Ethically,

I'm not an ethical expert but man, we've all been put into this position, whether you're an orthopedist, an anesthesiologist, et al, it's

Bull s h I t.

There is no need for us to do our deeds on someone who is beyond help, someone who is not even aware that they still exist.

Yet we are still coerced by The Family.

Uhhhhhhhhh....

WE ARE DOCTORS.

The patient's FAMILY

Is not.

I think we've become too politically correct....afraid of the

RIGHT DECISIONS.

Absolutely second this.

 

[periopdoc]

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

 

[GasEmDee]

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

Totally agree with you and Jet.

Had an 80+ year old man, totally non-verbal, mentally checked out, who developed ascending cholangitis. What a perfect opportunity to let this vegetable die. But the family insisted on an ERCP and prolonged ICU stay.

TOTAL WASTE OF HEALTHCARE DOLLARS.

And everyone thinks doctors are paid too much. I think someone must have been collecting a check for the care of this person.

 

[periopdoc]

Yes, the hospital. Those are essentially charity cases for most of us docs.

- pod

 

[Idiopathic]

As long as the ortho team documents it as an emergeny, and her family is aware of the inc. cardiac risk as described by the cardiologist.

Arterial line then spinal....

I'm as worried about the weeks of post op cog dysfunction from a deep anesthetic plane as the postoperative risk of recurrent MI.

Full stomach? I'm waiting til she's appropriately npo and doing the above.

not always appropriate. in fact id probably put this pt to sleep up front. gentle induction with art line, avoid hypotension, hypoxia, tachycardia, etc. this MI was of the demand type more than likely, and we have greater control over that aspect than we do over the supply.

 

[fakin' the funk]

Yet we are still coerced by The Family.

Uhhhhhhhhh....

WE ARE DOCTORS.

The patient's FAMILY

Is not.

I think we've become too politically correct....afraid of the

RIGHT DECISIONS.

As always Jet, a good point and lots of punctuation.

But when you say, "WE ARE DOCTORS" you have to remember that we are talking about orthopedic surgeons here

All joking aside, as much as we'd like to pretend that we are NOT paternalistic in medicine anymore, and that the patient/family are the decision-makers, they ultimately aren't freaking qualified to make those decisions, and we can usually "steer" them to whatever choice we would like them to make. So we have the ability, and IMO the imperative, to selectively offer interventions while still respecting patient autonomy.

In the cases of patients undergoing life-prolonging but not life-improving treatments/surgeries etc, the interventionalist person can CHOOSE not to offer whatever treatments. Not everyone needs to be offered dialysis, or hip surgery, or blood transfusions, etc.

In the end though, there's no money to be made in ethical decision-making and it is hard to tell the family something to the effect of "there's nothing we can do [to change this patient's outcome]."

 

[Gas you down]

So i did the case. preOP Artline and off to the OR.
HR was 110s, so titrated in some esmolol. gave fentanyl 100mcg (weighs maybe 50-55kg). so far so good. gave propofol 35mg. wait. pressure begins to drop, i give phenylephrine, sux, tube. BP still dropping.
more neo, obviously not working, i give epi 100mcg, flushing it in well.
bp is now ON THE FLOOR. huge ST depression. over next 15 minutes, we give epi 3mg, levo gtt maxed out, plus touches of vasopressin. bolused 3L NS. came close to doing compressions. but she slowly became stable. titrated all pressors down until none needed. spont ventilating nicely. followed commands.
that was a close one...

 

[seinfeld]

This is medicare debate no one really wants to have. Congress and the president talk about reigning in costs but still want to provide access to care to anyone who wants it. The funny thing is that congress does not need to limit access to care they need to provide liability reform. If more phyisicians felt comfortable saying NO then this whole thing would be moot. Of course the other side is that although medicare rates are low they are still better than no pay and if you dont do cases you dont get paid, some of these ortho surgeries border on fraud.

 

[Planktonmd]

So i did the case. preOP Artline and off to the OR.
HR was 110s, so titrated in some esmolol. gave fentanyl 100mcg (weighs maybe 50-55kg). so far so good. gave propofol 35mg. wait. pressure begins to drop, i give phenylephrine, sux, tube. BP still dropping.
more neo, obviously not working, i give epi 100mcg, flushing it in well.
bp is now ON THE FLOOR. huge ST depression. over next 15 minutes, we give epi 3mg, levo gtt maxed out, plus touches of vasopressin. bolused 3L NS. came close to doing compressions. but she slowly became stable. titrated all pressors down until none needed. spont ventilating nicely. followed commands.
that was a close one...

Although I don't like Etomidate but it would have been my induction agent of choice here.

 

[cchoukal]

we are not in the business of palliation or deciding who is "worth saving". ... you can focus on what is best for this patient during this procedure, and then you can have a metaphysical debate over what is best for the patient's soul and the medical health of the economy overall at another time...but never the paths shall cross.

I like the way you put this. I think it's hard to work simultaneously for the system AND the patient.

As an intensivist, I'm frequently confronted with pressure to perform care in seemingly futile scenarios, so I'm no stranger to these issues.

Still, if we decline to do the case, or talk the family and the surgeons out of it, what happens then? It's not like she's unstable and will die quickly with some basic palliative measures, or withdrawal of support (she's not on any). No, instead she goes back to the nursing home with an unstable leg, gets an infection or a DVT and comes back to the hospital a few times, and then dies a more grizzly death. I think it's worth sitting down with the family and the orthopods, though, and having the discussion about what will happen if you don't fix it. My guess is the orthopods will paint a pretty grim (and possibly accurate) picture, which might ease our collective conscience about doing the case.

 

[Dhanwanthari]

not always appropriate. in fact id probably put this pt to sleep up front. gentle induction with art line, avoid hypotension, hypoxia, tachycardia, etc. this MI was of the demand type more than likely, and we have greater control over that aspect than we do over the supply.

I feel that idio... definitely not always appropriate.

Also, beta blockers in this lady could be deleterious and exacerbate myocardial dysfunction (fresh MI) ... but its all i've got to keep the demand down.

Lack of pain control, anxiety control will also drive up her heart rate and exacerbate her ischemia.

This is a patient I would have to see before I said tube vs. spinal vs. epidural (slow titrated block).

If she's calm, narcotized and out of it...i'm going with epidural or spinal...These patients sometimes have that phenotype when they finally get to us from the ED.

I'm going to discuss with the patient's family about the potential days to weeks to months of worsened post op cog dysfunction. Regardless of my anesthetic approach, communication with the family of the complicated and high risk nature is one of my most important interventions for the day.

 

[Oggg]

1. If she's completely demented and old, she might not need any fentanyl at all. Sometimes the little bits of morphine they give on the floor are enough. Fentanyl is not supposed to drop your BP, but from clinical experience, it really does take away that sliver of sympathetic tone that is keeping these trainwrecks alive. If you do a brief, gentle laryngoscopy, you don't need that much fentanyl. I think esmolol and your dose of PPF 35mcg were appropriate, though I might have used etomidate.

2. There's a couple case reports of doing Fascia Iliaca Compartment Block with sedation in trainwreck patients. You could do a FICB and probably not need narcotic. And spare her the postop delirium from needing narcotics. If you were crazy you could do a lumbar plexus block, but I'm guessing her anticoagulation status is probably not favorable.

 

[jwk]

weekend case. lady in her 80s comes in for busted hip. troponins bumped, with septal ECG changes. Ortho declares it an emergency, you know the whole "she is a train wreck, but she HAS to have it fixed NOW", even though she just had an MI. Cardiologist consulted; says she is as at very high risk for surgery, but it is up to ortho, if they declare it an emergency, then go ahead, which they do...
she is very demented at baseline. family is completely on board. they understand the risk and want to proceed.
what do you do?

Thankfully we have more reasonable orthopedic surgeons. Fractured hips are not emergencies.

 

[Planktonmd]

Thankfully we have more reasonable orthopedic surgeons. Fractured hips are not emergencies.

They are not emergencies but delaying them is almost never in the patient's best interest.
The best thing you can do for an elderly patient with a broken hip is to fix the fracture as soon as possible and get them out of the hospital before they kill them.

 

[jwk]

They are not emergencies but delaying them is almost never in the patient's best interest.
The best thing you can do for an elderly patient with a broken hip is to fix the fracture as soon as possible and get them out of the hospital before they kill them.

No argument there - but it's more than a matter of the surgeon saying "jump" and the anesthesiologist asking "how high?"

So I'm still not clear from the OP - you say you "did the case" but was the procedure done? Considering your near-arrest after induction, I'm not at all sure we'd have continued with the procedure.

 

[Idiopathic]

I feel that idio... definitely not always appropriate.

Also, beta blockers in this lady could be deleterious and exacerbate myocardial dysfunction (fresh MI) ... but its all i've got to keep the demand down.

Lack of pain control, anxiety control will also drive up her heart rate and exacerbate her ischemia.

This is a patient I would have to see before I said tube vs. spinal vs. epidural (slow titrated block).

If she's calm, narcotized and out of it...i'm going with epidural or spinal...These patients sometimes have that phenotype when they finally get to us from the ED.

I'm going to discuss with the patient's family about the potential days to weeks to months of worsened post op cog dysfunction. Regardless of my anesthetic approach, communication with the family of the complicated and high risk nature is one of my most important interventions for the day.

i think i could have been swayed to place an epidural (or IT catheter). i agree that beta blockade is one way to keep demand down, but optimizing preload also important. if you think you are off the end of the starling curve then nitrates are beneficial...many things you can do. i think we can agree that the actual patient described here seems very dry and maxed on autologous catecholamines. a little judicious volume loading might have helped, but im not sure it would have been prudent without TEE...

regardless, you did the Rock Star thing and saved this ladys life. no doubt she was on the brink.

 

[Idiopathic]

No argument there - but it's more than a matter of the surgeon saying "jump" and the anesthesiologist asking "how high?"

So I'm still not clear from the OP - you say you "did the case" but was the procedure done? Considering your near-arrest after induction, I'm not at all sure we'd have continued with the procedure.

you do, and heres why. youve assumed the risk, youve had the heart to heart with the family, and if you cancel her now, no one else will ever do it. if you/they committed to giving her this shot, then you go through with it. my personal philosophy.

 

[Gas you down]

No argument there - but it's more than a matter of the surgeon saying "jump" and the anesthesiologist asking "how high?"

So I'm still not clear from the OP - you say you "did the case" but was the procedure done? Considering your near-arrest after induction, I'm not at all sure we'd have continued with the procedure.

sorry for not clarifying. after her near death experience, case canceled. i hear what idio was talking about, going ahead with the case, but that never entered my mind. i was just glad that she was not only alive, but also responsive.

in hindsight, yeah I would have given her fluids prior to starting. and maybe i would have attempted regional or neuraxial, but given her mental state and pain i thought a nice controlled induction would be easier (boy was i dreaming) and next time i will use etomidate, although i thought such a low dose of propofol was comparable.
thanks for the feedback.

 

[Idiopathic]

crazy...you got her through the challenging part of the case. did someone at least discuss w/the family the events before deciding to cancel? i know you gave 3 resuscitation doses of epi (!) and i certainly wasnt there, but did you think she wouldnt tolerate the rest of the surgery? or were you just shellshocked at the induction (been there).

 

[Gas you down]

crazy...you got her through the challenging part of the case. did someone at least discuss w/the family the events before deciding to cancel? i know you gave 3 resuscitation doses of epi (!) and i certainly wasnt there, but did you think she wouldnt tolerate the rest of the surgery? or were you just shellshocked at the induction (been there).

i never left the room. when the orthopod saw the crash cart and the way we were working, he went to the family. it wasn't until much later that i was able to wean her down to nothing. i honestly doubted that she would wake up. i guess now that i've had time to think about it, i see the pro of going ahead with the case. i wouldn't be suprised to see her on the schedule in a day or two. if so, i will be sure to be in on that case.

 

[fakin' the funk]

This is medicare debate no one really wants to have. Congress and the president talk about reigning in costs but still want to provide access to care to anyone who wants it. The funny thing is that congress does not need to limit access to care they need to provide liability reform. If more phyisicians felt comfortable saying NO then this whole thing would be moot. Of course the other side is that although medicare rates are low they are still better than no pay and if you dont do cases you dont get paid, some of these ortho surgeries border on fraud.

👍 👍 👍

 

[jetproppilot]

i think i could have been swayed to place an epidural (or IT catheter). i agree that beta blockade is one way to keep demand down, but optimizing preload also important. if you think you are off the end of the starling curve then nitrates are beneficial...many things you can do. i think we can agree that the actual patient described here seems very dry and maxed on autologous catecholamines. a little judicious volume loading might have helped, but im not sure it would have been prudent without TEE...

regardless, you did the Rock Star thing and saved this ladys life. no doubt she was on the brink.

General or neuraxial, I don't think it matters in a pt like this.

You're gonna have your hands full either way.

Agree with your ROKKSTAR reference.👍

Disagree with the TEE since pragmatically,

that's not a real world tool in orthopedic cases.

Not saying it's not useful, of course it is...but to say "a little judicious volume loading might have helped, but I'm not sure it would have been prudent without TEE.."

Idio I think you and maybe six other dudes in the United States...ok ok I'm being sarcastic....you and EIGHT other dudes in the US are dropping TEEs in hips to guide volume therapy.😕

You sold it like giving a volume challenge without TEE is not smart.

That's not a real world answer man.

Not even close.

 

[proman]

i never left the room. when the orthopod saw the crash cart and the way we were working, he went to the family. it wasn't until much later that i was able to wean her down to nothing. i honestly doubted that she would wake up. i guess now that i've had time to think about it, i see the pro of going ahead with the case. i wouldn't be suprised to see her on the schedule in a day or two. if so, i will be sure to be in on that case.

It's a tough position, no doubt. Things I would have considered, was this an ongoing infarction (had the troponins peaked or still going up?) Also, there's a big difference between a troponin of 0.9 and 9, both are positive but the degree of infarction is much different.

I probably would have done a gradual inhalation induction with sevoflurane. In my limited experience it's the most stable induction because there's no bolus of anything (except some fentanyl).

Finally, this patient needs some sort of evaluation of left ventricular function given the infarction. If a high quality TTE hadn't been done yet, I would have done an intraoperative TEE.

 

[Idiopathic]

yeah i know it was a hedge, maybe its because ive got orals coming up. in reality im giving a little volume in holding and some more in the OR. preinduction a line...i would have felt comfortable with the small dose of propofol you used, maybe i should reevaluate that?

 

[HalO'Thane]

Great thread guys. This is something I routinely saw on the oral boards but would find much more daunting in the real world. Sounds like it was handled well. I did a lit search on the efficacy of peripheral nerve blocks for hip surgeries in these train wreck elderly patients. There have been case reports of them being done with a combined lumbar plexus block and sciatic nerve block (glutuel region). Anyone have experience with this technique? We all know the pros and cons of GA vs. Neuraxial in a sick patient but I think a truly working peripheral nerve block(s) would pose the least dangerous side effects. Any thoughts?

 

[epidural man]

So i did the case. preOP Artline and off to the OR.
HR was 110s, so titrated in some esmolol. gave fentanyl 100mcg (weighs maybe 50-55kg). so far so good. gave propofol 35mg. wait. pressure begins to drop, i give phenylephrine, sux, tube. BP still dropping.
more neo, obviously not working, i give epi 100mcg, flushing it in well.
bp is now ON THE FLOOR. huge ST depression. over next 15 minutes, we give epi 3mg, levo gtt maxed out, plus touches of vasopressin. bolused 3L NS. came close to doing compressions. but she slowly became stable. titrated all pressors down until none needed. spont ventilating nicely. followed commands.
that was a close one...

Agree with Oggg - FI catheters in this setting can work as your sole anesthetic, I've seen it done.

If you are going to do general, how about 1mg versed, 1mg to 1.5mg Alfentanil, lidocaine, +/- magnesium and sux? Octogenerians are walking around already with a MAC of 0.5 at baseline - plus she is demented...how strong are the memories she is forming? Is there a case of recall in an old demented patient documented? I think the sux is the key to get good intubating conditions, the rest is fluff, or there to control sympathetic response (which can be done with the agents I mentioned).

Or use ketamine (blah blah blah about sympathetic response....show me a GOOD study that demonstrated this, I'll show you 10 that shows there is no change in sympathetic outflow with the doses we typically use). You may help the dementia with the ketamine - at least it has been shown to decrease post-op delirium after pump cases - and NMDA-r antogonists are used to treat dementia.

I think alfentanil is a way underused drug - but it's really great, very quick on, very quick off.

Any thought on using narcan if you think the fentanyl may be contributing to hypotension? I haven't ever done it, but I wonder if it makes sense.

Final point about propofol vs etomidate - There is a great article (can't find the reference, but will later) that shows that when intubating patients in extremis, hypotension is the same with propofol, etomidate, or nothing. It's a gem of an article to keep in the back pocket.

 

[epidural man]

Disagree with the TEE since pragmatically,

that's not a real world tool in orthopedic cases.

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.

 

[goldfinger]

with these types of cases you can do no wrong. you are dealing with a biological organism at that point, not a 'living' human being. you are actually practicing politics and law, not anesthesia. just make sure everyone is on the same page and do your thing.....

 

[jetproppilot]

yeah i know it was a hedge, maybe its because ive got orals coming up. in reality im giving a little volume in holding and some more in the OR. preinduction a line...i would have felt comfortable with the small dose of propofol you used, maybe i should reevaluate that?

No...board examiners are looking for knowledge and sound thought process...

35 mg propofol is a dramatically reduced dose (good thought process)

Reduced propofol dose (especially a low dose like this) verses etomidate..if asked you would spout how several studies have shown minimal clinically significant differences in etomidate vs (lower adjusted) propofol concerning hemodynamic alteration (good knowledge).

I'd go with the propofol 35mg.

Or maybe justa few milligrams of midazolam.

Btw if this lady crashed like she did with the OP's very gentle induction,

whaddya think woulda happened if you eliminated a significant percentage of her sympathetic tone with neuraxial blockade?

Probably the same thing.

Like I said in a previous post, dude wouldda had his hands full either way.

Concerning the orals,

you could elect to do this case either way. Most of you dudes on this board are sharp and knowledgable. Keep that in mind during the test.

You can do these kinda cases in your sleep, right? I mean you've been hit with these trainwrecks for years now.

During the test, remember:

You know what you're doing.

The orals is kinda like posting

here at SDN anesthesia....describing a case; explaining what you did and why.

You do it very well here where we all come under fire sometimes.

You can do it there.

Pretend the scenerios given to you during your oral exam are actually clinical cases on this website that you've responded to for years. Easily and freely.

It's a mind game man.

 

[Gasworks]

I don't know how it is in other practices, but I do at least 1 of these a week. Usually it takes a couple of days to get them "cleared" which is just enough time to dry them out, throw off their lytes and maybe even aspirate a few times. My question is just what kind of repairs are your surgeons doing? This sounds like a fracture table / rod / screw scenario which is 45-90 minutes for even the most minimally competent orthopod. Given this scenario, I'd start with 100mcg of fent, 50-100mg of dip, a good fitting LMA, as much nitrous as the pt will tolerate and dial in a little sevo as needed. IMO as long as you don't murder them with the induction (keep some ephedrine handy), maintain SV with negative intrathoracic pressures they'll go back to their rooms in better condition than they arrived in the OR.

 

[Planktonmd]

Agree with Jet that no matter what anesthetic technique you pick this is going to be a high risk procedure in a patient like the one presented.
As for Etomidate versus Propofol, for many years I thought that a small dose of Propofol is OK but I saw a couple of cases where the patient collapsed and could not be resuscitated following a very small dose of Propofol, and these cases where always patients with significant LV dysfunction.
So, this is anecdotal but I try to avoid Propofol if I suspect or know the patient has significant LV dysfunction, and a recent MI fits under this category.
As for Fascia iliaca blocks they are good for post op pain but I am not sure you could use them as the only anesthetic on an elderly demented patient as some one suggested.

 

[epidural man]

So, this is anecdotal but I try to avoid Propofol if I suspect or know the patient has significant LV dysfunction, and a recent MI fits under this category.
As for Fascia iliaca blocks they are good for post op pain but I am not sure you could use them as the only anesthetic on an elderly demented patient as some one suggested.

I would say the same thing would have happen with any induction agent, or no agent. Intubation itself can cause hypotension (damn...i got to find the reference.) You never know what would have happened had you used etomidate - my guess is the same thing.

FI Cath - agree, hard pill to swallow, but I've seen it done.

 

[fakin' the funk]

I don't know how it is in other practices, but I do at least 1 of these a week. Usually it takes a couple of days to get them "cleared" which is just enough time to dry them out, throw off their lytes and maybe even aspirate a few times..

So true

My question is just what kind of repairs are your surgeons doing? This sounds like a fracture table / rod / screw scenario which is 45-90 minutes for even the most minimally competent orthopod.

Did one recently which ended up 4 hours, 2L EBL, 3 big IV's and A-line, 7 units of product.

 

[jetproppilot]

.

 

[joshmir]

Would anyone ask for a balloon to be put in prior to the next induction? if not, when do you usually ask for a balloon?

 

[Idiopathic]

an aortic balloon? i dont think so, especially with the need for full heparinization.

its obviously indicated in cardiogenic shock, but i think the nature of the surgery precludes its use here.

 

[Ketafol20]

Couple thoughts. What was her lactate? Or her base deficit? Did she have AS?

I agree that no matter what form of induction agent (ie: etomidate, Midaz, prop, whatever) this would have happened since it happened with only 35 mg prop. I typically test the response to neo before induction on these pts.

Spinal or epidural would have done the same thing.

My personal induction would have been 1-2mg Midaz and if that wasn't enough 5 mg ketamine. But that is Monday morning QB on my part.

 

[Gasworks]

My personal induction would have been 1-2mg Midaz and if that wasn't enough 5 mg ketamine. But that is Monday morning QB on my part.

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.

 

[Ketafol20]

Funny story.

Yeah it's always wise to make sure you give the Midaz time to kick in.

 

[cchoukal]

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.

That is a spectacular story.

 

[Gas you down]

guess who was added on today for a bipolar hip? yep, so of course i volunteered for the case. only new info was that she was on heparin gtt until an hour before surgery. her recent echo showed severe TR w/ RV hypokinesis, mod-severe AR, mild-mod MR. EF 30-35%, the rest escapes me at the moment.
in holding she still looked dry, so gave 250cc albumin, and 500 crystalloid, and solucortef 100mg (a suggestion from one of the older cardiac guys).
in OR, 0.5mg versed. BP 160s/90s, HR high 90s
plenty of help in the room, gave ketamine 50mg. sux, tube.
BP dropped to 70/30, HR to 60. gave 10mg ephedrine, hovered at 70s for awhile. over 5 min, slowly picked up to 130/80. BP fairly stable after that. (tech working on getting the CVP working) abg looked good. operation started.
then i was relieved by cardiac guy...

 

[jetproppilot]

guess who was added on today for a bipolar hip? yep, so of course i volunteered for the case. only new info was that she was on heparin gtt until an hour before surgery. her recent echo showed severe TR w/ RV hypokinesis, mod-severe AR, mild-mod MR. EF 30-35%, the rest escapes me at the moment.
in holding she still looked dry, so gave 250cc albumin, and 500 crystalloid, and solucortef 100mg (a suggestion from one of the older cardiac guys).
in OR, 0.5mg versed. BP 160s/90s, HR high 90s
plenty of help in the room, gave ketamine 50mg. sux, tube.
BP dropped to 70/30, HR to 60. gave 10mg ephedrine, hovered at 70s for awhile. over 5 min, slowly picked up to 130/80. BP fairly stable after that. (tech working on getting the CVP working) abg looked good. operation started.
then i was relieved by cardiac guy...

👍

 

[jetproppilot]

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.

Dude are you ZIPPY?

If not,

this forum has a NEW ZIP!!!!👍

 

[Idiopathic]

guess who was added on today for a bipolar hip? yep, so of course i volunteered for the case. only new info was that she was on heparin gtt until an hour before surgery. her recent echo showed severe TR w/ RV hypokinesis, mod-severe AR, mild-mod MR. EF 30-35%, the rest escapes me at the moment.
in holding she still looked dry, so gave 250cc albumin, and 500 crystalloid, and solucortef 100mg (a suggestion from one of the older cardiac guys).
in OR, 0.5mg versed. BP 160s/90s, HR high 90s
plenty of help in the room, gave ketamine 50mg. sux, tube.
BP dropped to 70/30, HR to 60. gave 10mg ephedrine, hovered at 70s for awhile. over 5 min, slowly picked up to 130/80. BP fairly stable after that. (tech working on getting the CVP working) abg looked good. operation started.
then i was relieved by cardiac guy...

 

[BLADEMDA]

Great thread guys. This is something I routinely saw on the oral boards but would find much more daunting in the real world. Sounds like it was handled well. I did a lit search on the efficacy of peripheral nerve blocks for hip surgeries in these train wreck elderly patients. There have been case reports of them being done with a combined lumbar plexus block and sciatic nerve block (glutuel region). Anyone have experience with this technique? We all know the pros and cons of GA vs. Neuraxial in a sick patient but I think a truly working peripheral nerve block(s) would pose the least dangerous side effects. Any thoughts?

I have done a few. You still end up needing a propofol infusion for some additional coverage especially during manipulation of the hip. Lumbar Plexus blocks aren't to be taken lightly and may carry almost as much risk in an anticoagulated patient as a Neuraxial block.