How about a case

[Beeftenderloin]

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87yo F s/p mechanical fall with right distal femur fracture. Ortho wants to take for ORIF.

Past medical hx of severe mitral stenosis, severe pulm HTN (RVSP 81 on echo, no right heart cath), LVEF preserved but RV is moderately dilated. Pulm HTN presumed to be from the valve. Also ESRD on HD and obesity. Hx of CAD s/p DES in LAD about 15 months ago.

Prior to fall was able to do household chores but couldn’t walk more than half a block without becoming dyspneic. Not on home O2.

Cards has seen the patient and says short of getting the mitral valve replaced there’s is no further optimization to be done. Patient got dialyzed yesterday and is at her baseline BP 90/50. Hgb 8.5.

AND has a new right popliteal DVT and is on a heparin gtt on floor.

Go...

 

[Hoya11]

87yo F s/p mechanical fall with right distal femur fracture. Ortho wants to take for ORIF.

Past medical hx of severe mitral stenosis, severe pulm HTN (RVSP 81 on echo, no right heart cath), LVEF preserved but RV is moderately dilated. Pulm HTN presumed to be from the valve. Also ESRD on HD and obesity. Hx of CAD s/p DES in LAD about 15 months ago.

Prior to fall was able to do household chores but couldn’t walk more than half a block without becoming dyspneic. Not on home O2.

Cards has seen the patient and says short of getting the mitral valve replaced there’s is no further optimization to be done. Patient got dialyzed yesterday and is at her baseline BP 90/50. Hgb 8.5.

AND has a new right popliteal DVT and is on a heparin gtt on floor.

Go...

LMA.

Neo gtt.

And I would talk to the service about an IVC filter while asleep.

 

[anbuitachi]

I would actually put an art line in this patient

 

[drmwvr]

I would actually put an art line in this patient

WTF?

 

[Hork Bajir]

She's definitely high-risk, but unless you fix the femur then she's looking at palliative care (and even then, fixing the femur could be considered palliative). LMA vs ETT doesn't matter much as long as you prevent any significant respiratory acidosis... A dilated RV w/ PA pressures >2/3 systemic is bad, but from the story she doesn't strike me as someone who would try to die as soon as she gets any positive pressure ventilation. Regional would be a nice addition; femoral nerve block, adductor canal, pick your poison... Would even be reasonable to consider a spinal catheter (yes I'm serious). Dose it SLOWLY, compensate with pressors/volume as needed. Obviously the heparin complicates this plan, but I wouldn't rule it out- everything is risk/benefit.

That's all fun academic masturbation, but in real life I'd probably give prop --> roc --> tube and get on with my day. Agree with art line, though.

 

[deleted697535]

Good case...

Why are they doing ORIF for distal femur#? Would it not be IM nail?

Pre-op
Id like to know a little more about her DVT, exactly where is it? Above/below knee. Sounds like it has to be treated though so continue Heparin and neuraxial is out

Id also like to see her ECG, CXR, Holter and echo myself. High risk for Afib. Prob huge LA.
Whats the code status?
Obvi check lytes and volume status

Intraop
Exam answer here has to involve:

Blood - Id give 1 unit preinduction. With some lasix handy.
Pre induction aline, ET, avoid measures that would incr PVR (eg aim normal EtCO2 - why i dont like LMA as an answer. I dont know if LMA would pass the exam? Obese with RVSP 81?)
Induce cardiac stable - midaz,fent, 2 cc's ppf, no sux
Inotropic support. Have Dob available
Pressors - Have a little vaso too
Judicious fluids
Post op Femoral nerve block/catheter
Of course CVS goals as per Mitral stenosis, slow and tight

Postop
Whatever lol

It might be overkill but in an exam this to me seems an obvious test of knowledge of PVR

 

[deleted697535]

She's definitely high-risk, but unless you fix the femur then she's looking at palliative care (and even then, fixing the femur could be considered palliative). LMA vs ETT doesn't matter much as long as you prevent any significant respiratory acidosis... A dilated RV w/ PA pressures >2/3 systemic is bad, but from the story she doesn't strike me as someone who would try to die as soon as she gets any positive pressure ventilation. Regional would be a nice addition; femoral nerve block, adductor canal, pick your poison... Would even be reasonable to consider a spinal catheter (yes I'm serious). Dose it SLOWLY, compensate with pressors/volume as needed. Obviously the heparin complicates this plan, but I wouldn't rule it out- everything is risk/benefit.

That's all fun academic masturbation, but in real life I'd probably give prop --> roc --> tube and get on with my day. Agree with art line, though.

You'd do a spinal catheter in someone on Heparin infusion?

 

[DrOwnage]

This is a case i would like regional if at all possible, depending on where the fracture is... If i could get away with just a fem nerve block single shot. If we would need posterior coverage a subgluteal sciatic really wouldn't be possible because im assuming she cannot move it. Have heparin stopped 4 hours prior given its a moderate risk surgery for the block. For this would be ok with standard monitors and phenylephrine gtt ready.

Could also place an epidural if single shot blocks not possible however would have to be titrated very carefully, again just make sure heparin has been off. In this situation more inclined to place a line with phenylephrine gtt.

Keep her as awake as possible, could do 20 mcg/kg/min of prop to keep comfy but not dis-inhibited.

Oh and most important thing out of all, large bore IV access.

If at any point doesnt work convert to GA LMA with a splash of prop and ketamine.

Have 4 units in room.

 

[anbuitachi]

You'd do a spinal catheter in someone on Heparin infusion?

everything is benefit vs risk. it wouldn't be unreasonable to tell them to stop the heparin infusion. for the case. i would imagine the risk of significant spinal hematoma on heparin drip with a 25g needle is.. very low. we dont do it for legal reasons

 

[Hork Bajir]

In this case, no I would not. But if you changed the stem to say that she was a pulmonary cripple, I would at least seriously think about holding the heparin for a few hours to do it.

My point was more that it’s an underutilized technique, one that I feel like we should at least consider for the “chronically critically ill” Ortho trauma population. Also, to point out that when you’re faced with high-risk patients, there are very few absolute contraindications to anything... Its all risk benefit, and sometimes it pays to think outside the box.

I guess my points were less specific to this case, sorry. I do think this case is an interesting example of where the “boards answer” and the real world answer might be substantially different.

 

[drmwvr]

everything is benefit vs risk. it wouldn't be unreasonable to tell them to stop the heparin infusion. for the case. i would imagine the risk of significant spinal hematoma on heparin drip with a 25g needle is.. very low. we dont do it for legal reasons

Kidding? A spinal in this patient is asking for a kick in the groin. Anticoagulation has nothing to do with it.

 

[Ronin786]

Low dose isobaric bupivicaine spinal and dexmedetomidine.

It's a DVT, stop the heparin. Keep her pressures at baseline and don't let her get hypoxic or hypercarbic. Seems like this story comes up once every other month around here. You can either go full bore with a PAC, ETT and long ICU stay or keep it simple.

This isn't the oral boards. Keep it simple.

 

[Hork Bajir]

NEJM Journal Watch: Summaries of and commentary on original medical and scientific articles from key medical journals

 

[anbuitachi]

Kidding? A spinal in this patient is asking for a kick in the groin. Anticoagulation has nothing to do with it.

pretty sure the poster said spinal catheter. titrate to effect

 

[deleted697535]

Cant read that. What does it say?

I dont know if id do a straight spinal here. Cse be much better. Or just slow titrated epidural. Her rvsp is almost systemic!!
You can laugh all you want but a bad rv and a spinal are not good bed fellows

Personally i wouldn't touch her back until i had a long conversation about her dvt, what vein it is in exactly, how long it is etc...
She has so many risk factors it would take a ballsy thrombosis doc to agree with you to stop the heparin i think. Preop ivc filter then stop heparin i do agree. Thats a good option. I like that. Then titrated epidural/cse

 

[drmwvr]

pretty sure the poster said spinal catheter. titrate to effect

so what? A spinal isn't analgesia. It's on or off. but knock yourself out.

 

[Ronin786]

Cant read that. What does it say?

I dont know if id do a straight spinal here. Cse be much better. Or just slow titrated epidural. Her rvsp is almost systemic!!
You can laugh all you want but a bad rv and a spinal are not good bed fellows

Personally i wouldn't touch her back until i had a long conversation about her dvt, what vein it is in exactly, how long it is etc...
She has so many risk factors it would take a ballsy thrombosis doc to agree with you to stop the heparin i think. Preop ivc filter then stop heparin i do agree. Thats a good option. I like that. Then titrated epidural/cse

They're not going to operate on her with the heparin going. I don't see why this is even a question.

 

[daneeka]

Preoperative:
Clarify goals of care. Difficult here, as it could be argued that the operation is for pain relief rather than function.
If we're really going to press on, consider an IVC filter so that the heparin can stop (and maybe it'd catch the fat emboli the surgeons will cause?). I'd imagine the surgeons aren't going to operate on heparin.
I wouldn't give blood at this stage; an Hb of 85 is fine if asymptomatic, and lower viscosity is better. TRALI would be the end of this patient.

Intraoperative:
Awake arterial line and big drip.
Have pads on to cardiovert AF. Aim to maintain SVR and preload to support the RV; keep the rate slow.
Plenty of fentanyl on induction, a bit of propofol and some pressor running in the background. Hyperventilate to keep the CO2 down. ETT.
Could have nebulised iloprost/milrinone, but it probably won't help if all the pHTN is from the mitral valve.
Put in a block at some point. Avoid ketamine.

Postoperative:
Once the operation's done, and if she's survived induction, I wouldn't expect her to be any worse that she started.
Get her warm, comfortable and awake.
Pull the tube, go to the ward, and see what happens.

I really don't think neuraxial blockade is a good idea; severe MS is a fixed cardiac output state just like severe AS and few people would stick in a spinal for that.

 

[deleted59964]

I'd be selling this as a life ending injury and promoting the benefits of morphine, and a fascia iliaca block

 

[Hork Bajir]

so what? A spinal isn't analgesia. It's on or off. but knock yourself out.

Have you ever actually placed an intentional spinal catheter and dosed it slowly? It is definitely not ‘on or off’. Furthermore, the idea isn’t to decrease the final density of the block, but to adjust the speed with which the sympathectomy develops so that you have time to compensate the hemodynamics (and abort the plan before it’s too late if the patient is really not going to tolerate).

 

[deleted59964]

if I were really going to do this case - an art line, some titrated pressor, and a slowly topped up intrathecal catheter would be a nice option.
I'd do a block at the end to give her a chance of having minimal sympathetic response to surgery post operatively too

 

[Southpaw]

Just curious... what was the plan for her mitral valve before the fall?

 

[T-burglar]

pulmonary htn from MS is not the same as primary pulmonary HTN in terms of peri intubation risk. I’d still place a sedated arterial line because I’m a huge fan of that .

Then prop roc tube

 

[vector2]

Distal femur? Fem catheter, subglut sciatic catheter, 0.5%, headphones, ipad with matlock reruns

 

[pgg]

I really don't think neuraxial blockade is a good idea; severe MS is a fixed cardiac output state just like severe AS and few people would stick in a spinal for that.

They're not really the same.

The problem with AS is the hypertrophied LV, and guaranteed concommitent bad diastolic dysfunction that raises LVEDP, impairing myocardial perfusion pressure (DBP - LVEDP). You drop their systemic pressure in a hurry and they are very vulnerable to subendocardial ischemia and dysrhythmmias, which may be unrecoverable.

People with (just) MS usually have normal or near-normal LVs. A transient reduction in afterload isn't the same kind of clean kill as it is with AS. That's not to say that the resulting tachycardia won't be. 🙂

 

[Noyac]

My approach:
Preop A line and FNB with Ant Sciatic. I would use 1.5% mepiv for fast dense block. She won’t need a bunch of pain control post op because the fax will be fixed.

I would try sedation for the case but I wouldn’t hesitate to intubate with good LTA topicalization. I would keep her HR in the 60’s and BP just over 100/60 or as close to this as I could. ETCO in the 30’s.

Induction meds would be no more than 5cc of propofol and muscle relaxant of choice (roc for me).

If she were to crump I would start dobutamine and consider milrinone or inhaled nitric.

 

[drmwvr]

Have you ever actually placed an intentional spinal catheter and dosed it slowly? It is definitely not ‘on or off’. Furthermore, the idea isn’t to decrease the final density of the block, but to adjust the speed with which the sympathectomy develops so that you have time to compensate the hemodynamics (and abort the plan before it’s too late if the patient is really not going to tolerate).

The baseline systolic blood pressure is 90. The RVSP is 81 on echo which means it is more than likely an under estimation. The patient in all likelihood in the 90/90 club. Intentionally bringing about a sympathectomy with a spinal no matter how slowly is asking for trouble. The first indication of "not tolerating it" can be the irretrievable spiral to arrest. If you carefully put this patient to sleep with something like a vasopressin drip going and she arrested, there really wouldn't be any fault in that. An arrest with a spinal, not so much.

 

[Hork Bajir]

@drmwvr agree to disagree. I think inducing a sympathectomy via the IV or intrathecal route are both safe as long as it’s done in a slow and controlled fashion.

@pgg is right on the money, as usual. Afterload is not the critical parameter here, so long as we’re not dropping below the critical coronary perfusion pressure. What will kill this lady is a tachyarrhythmia, to which she is prone because of her huge left atrium. One could even argue that if forced to choose between a sympathectomy and a sympathetic surge that could precipitate tachycardia, SVT, AF, etc, the sympathectomy is the lesser of the two evils.

I worry that a slow induction titrated to loss of consciousness could precipitate just such a sympathetic surge upon intubation unless you’re careful to avoid it... @Noyac good call with the LTA for intubation, I wouldn’t have thought of that. But why dobutamine? If it was pure RV failure/high PVR driving the picture that would be a great choice, but any inotropic dose of a beta 1 agonist is gonna hurt the LV filling. I suppose this is why severe MS needs to be respected: once they spiral there’s very little you can do short of cardiovert a tacchyarrhythmia or crash on to bypass.

Great discussion on this thread btw thanks OP

 

[anbuitachi]

Very impressed that most people here would do arterial line. Really different from most of the case discussions I see

 

[coffeebythelake]

Very impressed that most people here would do arterial line. Really different from most of the case discussions I see

are you being facetious? this is a slam dunk a-line case in my mind.

 

[vector2]

are you being facetious? this is a slam dunk a-line case in my mind.

It's some sort of bizarre point of pride here for many to do sick cases without an a-line. Granted, the longer I've been out the more cavalier I've become as far as managing hemodynamics using NIBP, but this lady has 100% bought herself an a-line no matter how you do the anesthetic.

 

[deleted162650]

It's some sort of bizarre point of pride here for many to do sick cases without an a-line. Granted, the longer I've been out the more cavalier I've become as far as managing hemodynamics using NIBP, but this lady has 100% bought herself an a-line no matter how you do the anesthetic.

P*ssy

 

[Hork Bajir]

Lol it does seem like saying “I would put in a pre-induction ultrasound-guided a-line” is a pretty good way to derail most case discussions on here

 

[daneeka]

People with (just) MS usually have normal or near-normal LVs. A transient reduction in afterload isn't the same kind of clean kill as it is with AS. That's not to say that the resulting tachycardia won't be. 🙂

I totally agree; the LV is relatively protected in MS. I also haven't anaesthetised more than a handful of patients with severe MS so I will defer to those more knowledgable.

Still, with a RV working against near-systolic pressures, I'm worried that coronary perfusion takes on an LV-like pattern; i.e. it becomes more dependent on diastolic perfusion and diastolic pressure. In that circumstance, I think what you're worried about with the LV in AS could happen to the RV in MS if I put a spinal in.

Having said that, a carefully titrated epidural is rarely the wrong answer (or spinal catheter, I guess).

 

[T-burglar]

I do so many pre induction sedated ultrasound guided arterial lines it would make you want to cross clamp your own nutsack

 

[deleted171991]

My approach:
Preop A line and FNB with Ant Sciatic. I would use 1.5% mepiv for fast dense block. She won’t need a bunch of pain control post op because the fax will be fixed.

I would try sedation for the case but I wouldn’t hesitate to intubate with good LTA topicalization. I would keep her HR in the 60’s and BP just over 100/60 or as close to this as I could. ETCO in the 30’s.

Induction meds would be no more than 5cc of propofol and muscle relaxant of choice (roc for me).

If she were to crump I would start dobutamine and consider milrinone or inhaled nitric.

I almost agree with Noyac, at least with the idea of GA plus regional. Except that with a PASP of 81, I'd want an aortic BP much higher than 100/60, otherwise she won't perfuse that RV properly, plus the squeeze of the RV is dependent on the bulging of the LV into it. I would keep her BP (and HR) close to her home values (if known), or recent values in the chart. Probably much higher than 100/60. That's actually a rule of thumb I find very useful whenever I do cases on sick people, even "without an a-line".

Her LV should be fine, it just needs time to fill. A tachyarrhythmia may kill her, so dobutamine is not a friend here. Spontaneous ventilation while maintaining a decent pCO2 is, so I would encourage PSV, IF possible (and I would use sux, not roc, to give her a chance for SV).

Pain is also a pulmonary vasoconstrictor. The regional blocks should also help with avoiding a deep GA and maintaining SV. I would judiciously titrate in fentanyl, during the case, instead of a lot of sevo.

If possible, I would also place an LMA instead of an ETT (obese women are not like obese men, and there is obese and OBESE) if NPO allows - pre-induction gastric ultrasound may be a good idea. The less sympathetic stimulation, the better she'll do, but also the less aspiration...

This is also a case that would benefit from a PAC. Now that should generate the usual "a-line" type of discussion. 😛 If she misbehaves in any way during induction, I would place one.

I would avoid neuraxial like the plague. Single-shot spinal is out; I have never done a spinal catheter and I think the room for error is very small here. An epidural cannot be relied upon for surgical anesthesia. The only reason to do an epidural would be as part of an epidural/GA technique, instead of a regional/GA one. I disagree that dropping the afterload in a controlled fashion wouldn't be a problem. It could be a HUGE one: the moment the RV coronary perfusion goes away it could be bye-bye, so I wouldn't drop that afterload much (from her usual values). Unless one has a PAC in place, one doesn't know crap about her current PA pressures (the PASP of 81 was without the pain and stress of a femoral fracture - her PA pressures could be 100/60 as far as we know).

She should also get an IVC filter during the procedure.

tl;dr: For this patient I want to maintain the preload, maintain her usual afterload, avoid hypoxia/hypercarbia/pain, avoid (tachy)arrhythmias, maintain SV if possible, use regional blocks to avoid deep GA and the need for CV.

The usual disclaimer: I am not a cardiac anesthesiologist, just an "experimental (patho)physiologist", so educate me. 😉

 

[pgg]

I totally agree; the LV is relatively protected in MS. I also haven't anaesthetised more than a handful of patients with severe MS so I will defer to those more knowledgable.

Still, with a RV working against near-systolic pressures, I'm worried that coronary perfusion takes on an LV-like pattern; i.e. it becomes more dependent on diastolic perfusion and diastolic pressure. In that circumstance, I think what you're worried about with the LV in AS could happen to the RV in MS if I put a spinal in.

Having said that, a carefully titrated epidural is rarely the wrong answer (or spinal catheter, I guess).

Agreed I wouldn't do a spinal. MS is usually accompanied by PHTN, and a spinal is liable to drop your systemic pressure below your pulmonary pressure.

 

[anbuitachi]

Agreed I wouldn't do a spinal. MS is usually accompanied by PHTN, and a spinal is liable to drop your systemic pressure below your pulmonary pressure.

Spinal also drop pulmonary pressures right

 

[vector2]

Spinal also drop pulmonary pressures right

Pulmonary pressures are not the same thing as PVR (which is (mPAP - wedge)/ CO)). There's a chance that the pulmonary vascular resistance will be fixed if the mitral stenosis has been long standing.

 

[drmwvr]

Spinal also drop pulmonary pressures right

Pulmonary pressure will certainly drop if the RV craps out.

 

[Twiggidy]

I’ll derail....

I’m impressed with people giving an ESRD patient rocuronium but maybe I’m a bit more academic than others

 

[buccsmf1]

An epidural cannot be relied upon for surgical anesthesia.

Curious about this statement. where i trained we had an orthopod that did 40 total joints a week, all under lidocaine epidurals +mac. had no issues completing total knees and hips with this technique. Are you implying the amount of LA required would cause too much of a sympathectomy?

 

[pgg]

I’ll derail....

I’m impressed with people giving an ESRD patient rocuronium but maybe I’m a bit more academic than others

I've never understood this reluctance. I mean, rocuronium is fine in ESRD. Even if people can't think it through for themselves, it's right there in the package insert.

I once had an attending delay a case mid-induction, to send me to the pharmacy to get cis-atracurium, because I was so irresponsible to want to use rocuronium for a patient with some renal insufficiency (Cr 1.8 I think).

 

[deleted162650]

Curious about this statement. where i trained we had an orthopod that did 40 total joints a week, all under lidocaine epidurals +mac. had no issues completing total knees and hips with this technique. Are you implying the amount of LA required would cause too much of a sympathectomy?

Why not spinals??

 

[Twiggidy]

I've never understood this reluctance. I mean, rocuronium is fine in ESRD. Even if people can't think it through for themselves, it's right there in the package insert.

I once had an attending delay a case mid-induction, to send me to the pharmacy to get cis-atracurium, because I was so irresponsible to want to use rocuronium for a patient with some renal insufficiency (Cr 1.8 I think).

Because in actual practice renal failure will prolong rocuronium and if you plan on extubating the patient you aren’t doing yourself any favors by using it in a patient was with renal failure when you have an option that doesn’t undergo renal clearance.

 

[nimbus]

Curious about this statement. where i trained we had an orthopod that did 40 total joints a week, all under lidocaine epidurals +mac. had no issues completing total knees and hips with this technique. Are you implying the amount of LA required would cause too much of a sympathectomy?

Sharrock out of HSS published dozens of papers about “hypotensive epidural anesthesia” for total hips in the 1990s and 2000s. Their protocol included a goal MAP in the 50s with an Aline, cvp, and an epi drip so they probably dosed theirs up pretty good. Always seemed like a MRB (or maximal billing) anesthetic to me.

 

[anbuitachi]

Because in actual practice renal failure will prolong rocuronium and if you plan on extubating the patient you aren’t doing yourself any favors by using it in a patient was with renal failure when you have an option that doesn’t undergo renal clearance.

But reversal is also prolonged in esrd. Therefore no adjustment in reversal dosage is required

 

[Southpaw]

Because in actual practice renal failure will prolong rocuronium and if you plan on extubating the patient you aren’t doing yourself any favors by using it in a patient was with renal failure when you have an option that doesn’t undergo renal clearance.

Suggamadex is renally cleared also. I've had no issues using roc-sugg in ESRD though I understand the concern of it being more difficult to reparalyze should a patient need re-intubation.

 

[pgg]

Suggamadex is renally cleared also. I've had no issues using roc-sugg in ESRD though I understand the concern of it being more difficult to reparalyze should a patient need re-intubation.

THAT concern is what the cis-atracurium is for. 🙂

 

[Southpaw]

THAT concern is what the cis-atracurium is for. 🙂

Yessir