How would you approach this case?

[anbuitachi]

A little similar to thread below but would like you opinions! Learning a lot from these boards even after residency!

Alone at night, patient brought in from nursing home,, 75 yo M 70kg ESRD, HTN, A fib on eliquis, DM, CAD LAD stent 10 yrs ago, CHF EF 10% on coreg, mod MR, mod TR , dementia, severe pHTN, reduced RV function w severely elevated CVP, fell, now w slowly expanding thigh hematoma needs to be drained. No detailed info/cath regarding CAD.
Vitals normal/stable after 2 unit transfusion. 120/50 hr 80 on coreg

how would you approach this case? honestly im not even sure the risk of anesthesia + postop< benefit of surgery but then again im not a surgeon so I'm not up to date with literature on this surgery.

Also noticed in the previous thread, numerous posters mentioned inhalational induction in adults with very low EF. Can someone explain the concept of this? volatiles depress myocardium and vasodilates, why do it over IV? and how would you even do it? Ive only done inhalational in kids/adults w normal heart

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[T-burglar]

mac local if possible.

Try to find out why he fell.

Zolls on just for the hell of it

 

[vector2]

Femoral/FI block, surgeon supplements local. Headphones. Give him my phone and let him watch old reruns of wheel of fortune.

 

[narcotics999]

Block, local by surgeon, a touch of versed and/or ketamine prn. Pray.

 

[dchz]

How high up is the proposed incision point above the thigh?

Regional and local as by others.

One key point to keep in mind: if the pt gets hypotensive, giving fluids will likely worsen the problem.

The pressor of choice will be titrations of 5 mcg of epinephrine. pre induction a line if you must go general and refer to the low EF induction thread.

 

[Hoya11]

It sounds like the person is still on eliquis so no block from me.

I would do 6mg of etomidate, 2mg versed, maybe 20 of ketamine and put an LMA in for IV induction.

I would do inhalational to LMA if they are small and thin with an easy airway. IME it works well with frail old thin people (hip fracture old ladies)

The theory with inhalational is that sevo is breathed in to the exact level that you need, maintaining spontaneous ventilation, whereas an IV induction (unless done very slowly) can overshoot with the bolus all at once and cause hypotension, apnea and need for PPV.

awake aline, neo gtt of course.

i would also consider local mac is possible with versed, fent, ketamine

 

[Mikkel]

Local + nitrous.

 

[anbuitachi]

Local + nitrous.

why nitrous? does't it worsen pHTN?

my plan was also to do regional with oxygen therapy +/- midaz/ketamine

 

[Direct Laryngoscopy]

Zolls (if they don't have an AICD), O2 cannula, tell the surgeon your concerns (I find surgeons be more receptive to my concerns when I explain the pharmacology and physiology behind my thought process and concerns, and they know I'm a reasonable person ie I don't cancel cases for BS reasons, I'm also a cardiac anesthesiologist if that has anything to do with anything) and light propofol with small fentanyl titrations. You would be surprised how older folks handle these cases with minimal narcotic requirements (If you live long enough your pain fibers fail to fire lol and DM kills off the rest). Keeping this pt well oxygenated is of the upmost concern and avoid wild swings in the hemodynamics.

 

[Mikkel]

why nitrous? does't it worsen pHTN?

my plan was also to do regional with oxygen therapy +/- midaz/ketamine

75 years old and dementia, you don't need much nitrous to get him comfortable, is analgesic but doesn't cause hypoventilation.

Easy to titrate. You can back off easily if his heart can't tolerate (extremely unlikely). It's very easily tolerated, even by the sickest of the sick.

The pulmonary hypertension concerns are overblown, and academic (ie not seen in the real world)..

 

[anbuitachi]

I think one person mentioned ketamine. anyone else? why or why not? instead of midaz+ fent which cause resp depression, ketamine provides amnesia and analgesia. seems better than midaz/fent combo?

 

[Mikkel]

I think one person mentioned ketamine. anyone else? why or why not? instead of midaz+ fent which cause resp depression, ketamine provides amnesia and analgesia. seems better than midaz/fent combo?

Ketamine isn't an amnestic, patients can hallucinate and remember it very easily.

 

[Skribbles]

It sounds like the person is still on eliquis so no block from me.

Not even a single shot? It's a compressible space, worried about developing a second thigh hematoma?

 

[dhb]

Ketamine isn't an amnestic, patients can hallucinate and remember it very easily.

That's were the dementia comes in handy

 

[anbuitachi]

Ketamine isn't an amnestic, patients can hallucinate and remember it very easily.

I mean yes, it's no where 100 percent in the same way midaZ is not close to 100 percent either. And yes they work by diff mechanisms


On another note. Etomidate infusion anyone?

 

[Hoya11]

Not even a single shot? It's a compressible space, worried about developing a second thigh hematoma?

your right it would probably be OK, but im just not going to break the rules in this situation when i could do sedation or light GA

 

[anbuitachi]

your right it would probably be OK, but im just not going to break the rules in this situation when i could do sedation or light GA

I don't think there are specific rules about it. Asra has recs for deep blocks but I don't see any definition of what deep blocks are

 

[deleted59964]

i’d look at the hematoma and discuss the surgery with the surgeon first this may be a bigger or smaller case than thought

probably a light GA from me.
pre induction art line
then
about 100mcg of fentanyl, and a slow induction with small doses of propofol (10-20mg) at a time, add in a whiff of sevo (an end tidal of 1 would be plenty i suspect ) - LMA and pressure support.
surgeon can infiltrate local - they’ll be keen for the epi anyway

 

[Noyac]

Whatever you do or give just remember to give it time to work. For example, if I were to give some propofol and slip in an LMA (probably my preferred method) I would give less than 50mg and as the heart will take its sweet time pumping that propofol around to the brain. Then if I need more, I’d give a tiny bit more (20mg). Repeat as necessary. It may take a few minutes to achieve the goal but vitals will not budge. Then turn on some gas and gently increase it. Make sure the pt is deep enough for the incision because if not and they buck or bite down of have a high pain response then you will have blow a very smooth induction. Once the hematoma is evacuated then start turning things down. The severe pain is resolved.
What’s the H/H? Replace fluids very gently or give blood if needed.

 

[Noyac]

i’d look at the hematoma and discuss the surgery with the surgeon first this my big a bigger or smaller case than thought

probably a light GA from me.
pre induction art line
then
about 100mcg of fentanyl, and a slow induction with small doses of propofol (10-20mg) at a time, add in a whiff of sevo (an end tidal of 1 would be plenty i suspect ) - LMA and pressure support.
surgeon can infiltrate local - they’ll be keen for the epi anyway

I was typing my response as you posted yours. Like minds my friend.

 

[dannyboy1]

EF of 10%. FI block would be my first approach. No I don’t care about the eliquis. It’s just a field block and this patient has bigger problems. If I have to do GA it’s art line/etomidate/LMA/prayers

 

[MoMoGesiologist]

People are comfortable doing blocks when the pt is on eliquis?

I would try to avoid midaz in the demented pt. I’m also concerned about the EF 10 and severe pHTN with RV dysfunction. My plan would be induce with ~10mg etomidate, roc, ETT. I don’t like LMAs at nighttime for add on cases. Keep some epi around

 

[deleted171991]

So an elderly ESRD patient got a surgical level thigh hematoma from falling while on eliquis, and people would do a block on him? Interesting, to say the least. Dear Big Pharma was careful not to include non-HD ESRD patients in their study for the FDA. I wonder why. Actually, I don't think there are any studies on these patients, so we don't know how much they will bleed. And if the bleed was spontaneous, and not from a fall...

My problem is with the entire surgery. Why is it needed now? What will it accomplish? And, first of all, when was the last dose of apixaban? Because, if it hasn't worn off yet, there is no rhyme or reason for doing the surgery. This is an ESRD patient (not on HD I assume), so it will take a while. Cut him at bedside, see how he bleeds, before playing blood transfusions in the OR on a bad heart. Or do a TEG, if you have one, or have andexxa ready (if the hospital has 25-50K to throw out).

This is a person who does NOT need emergency surgery. That's 100% clear. It's a SLOW bleed. This guy needs a family meeting (risks v benefits and alternatives), not a greedy surgeon. This is the case where I ask the surgeon to write a note why the surgery is emergent and cannot wait. First do no harm.

 

[dannyboy1]

So an elderly ESRD patient got a surgical level thigh hematoma from falling while on eliquis, and people would do a block on him? Interesting, to say the least. Dear Big Pharma was careful not to include non-HD ESRD patients in their study for the FDA. I wonder why. Actually, I don't think there are any studies on these patients, so we don't know how much they will bleed. And if the bleed was spontaneous, and not from a fall...

My problem is with the entire surgery. Why is it needed now? What will it accomplish? And, first of all, when was the last dose of apixaban? Because, if it hasn't worn off yet, there is no rhyme or reason for doing the surgery. This is an ESRD patient (not on HD I assume), so it will take a while. Cut him at bedside, see how he bleeds, before playing blood transfusions in the OR on a bad heart. Or do a TEG, if you have one, or have andexxa ready (if the hospital has 25-50K to throw out).

This is a person who does NOT need emergency surgery. That's 100% clear. It's a SLOW bleed. This guy needs a family meeting (risks v benefits and alternatives), not a greedy surgeon. This is the case where I ask the surgeon to write a note why the surgery is emergent and cannot wait. First do no harm.

Definitely agree that if not emergent should wait and have family (and hospice) meeting. That being said I can see that most of the surgeons I work with will be like “patient is bleeding out, it’s an emergency”. There is only so much you can fight with these people. FI block is a field block not near any major vascular structures. The goal is to inject a large volume. It is essentialy no different than field local by the surgeon. Would definitely prefer this to the very real risk that my 10% EF patient arrests on the table ....

 

[deleted171991]

Definitely agree that if not emergent should wait and have family (and hospice) meeting. That being said I can see that most of the surgeons I work with will be like “patient is bleeding out, it’s an emergency”. There is only so much you can fight with these people. FI block is a field block not near any major vascular structures. The goal is to inject a large volume. It is essentialy no different than field local by the surgeon. Would definitely prefer this to the very real risk that my 10% EF patient arrests on the table ....

So if THIS guy had a slow GI bleed we would rush to surgery (or endoscopy)? After just 2 units in say 12 hours? Instead of waiting for the bleed to slow down and even stop, first? Really? I would be afraid to be a patient in that hospital. Heck, we should probably be afraid of any hospital that hires management companies for staffing, just on principle.

As I said, dear surgeon is free to write his professional epitaph about how this is an emergency with risk to life or limb, absent surgery, and we can go play. Otherwise... it ain't happening. I find this approach suddenly increases the surgeon's IQ in many cases.

If he's so concerned about the bleed, unless there is distal LE ischemia, I'll help him with some common sense: Wrap the damn thigh in some compressive dressing. Put the patient in the ICU with a pulse ox on that foot and monitor the LE. Talk some more in the morning. Bye. You don't fix a medical bleed with surgery.

Oh, and if he has ESRD, the guy will need some platelets and/or DDAVP, too. That should come BEFORE any surgery.

 

[T-burglar]

If the hematoma was causing pain and there was a possibility of vessel injury from fall related leg trauma that could be stopped by surgery then I wouldn’t hesitate to anesthetize this guy personally

This procedure doesn’t sound like it’s a big deAl

 

[deleted59964]

So an elderly ESRD patient got a surgical level thigh hematoma from falling while on eliquis, and people would do a block on him? Interesting, to say the least. Dear Big Pharma was careful not to include non-HD ESRD patients in their study for the FDA. I wonder why. Actually, I don't think there are any studies on these patients, so we don't know how much they will bleed. And if the bleed was spontaneous, and not from a fall...

My problem is with the entire surgery. Why is it needed now? What will it accomplish? And, first of all, when was the last dose of apixaban? Because, if it hasn't worn off yet, there is no rhyme or reason for doing the surgery. This is an ESRD patient (not on HD I assume), so it will take a while. Cut him at bedside, see how he bleeds, before playing blood transfusions in the OR on a bad heart. Or do a TEG, if you have one, or have andexxa ready (if the hospital has 25-50K to throw out).

This is a person who does NOT need emergency surgery. That's 100% clear. It's a SLOW bleed. This guy needs a family meeting (risks v benefits and alternatives), not a greedy surgeon. This is the case where I ask the surgeon to write a note why the surgery is emergent and cannot wait. First do no harm.

couple of good points there


some thoughts -

the esrf and associated platelet dysfunction will add to the coagulation defect.... i think some ddavp MAY be useful here.

lots of factors as to whether the surgery is emergent / urgent / can wait. it’s a good point though , and i think it should be the first decision point in any case scenario.

whether to do the case
now / later / never
here / somewhere else (specialist centre)

 

[epidural man]

Local for skin.

Alfentanil, midazolam, maybe some ketamine. Give enough alfetnanil to maybe have to breath for him - his eyes may be open, but he may not breath. That's okay. the small amount of midazolam will take care of that.

 

[Planktonmd]

Let him breath some Sevo + Nitrous oxide by mask while they drain the hematoma.

 

[anbuitachi]

Local for skin.

Alfentanil, midazolam, maybe some ketamine. Give enough alfetnanil to maybe have to breath for him - his eyes may be open, but he may not breath. That's okay. the small amount of midazolam will take care of that.

Not concerned about the rv failure w phtn with the build up in co2?

I'm pretty conservative still w that combo . Hear too many cases where patient codes after 25 of fentanyl

 

[urge]

Despacito

 

[Noyac]

So an elderly ESRD patient got a surgical level thigh hematoma from falling while on eliquis, and people would do a block on him? Interesting, to say the least. Dear Big Pharma was careful not to include non-HD ESRD patients in their study for the FDA. I wonder why. Actually, I don't think there are any studies on these patients, so we don't know how much they will bleed. And if the bleed was spontaneous, and not from a fall...

My problem is with the entire surgery. Why is it needed now? What will it accomplish? And, first of all, when was the last dose of apixaban? Because, if it hasn't worn off yet, there is no rhyme or reason for doing the surgery. This is an ESRD patient (not on HD I assume), so it will take a while. Cut him at bedside, see how he bleeds, before playing blood transfusions in the OR on a bad heart. Or do a TEG, if you have one, or have andexxa ready (if the hospital has 25-50K to throw out).

This is a person who does NOT need emergency surgery. That's 100% clear. It's a SLOW bleed. This guy needs a family meeting (risks v benefits and alternatives), not a greedy surgeon. This is the case where I ask the surgeon to write a note why the surgery is emergent and cannot wait. First do no harm.

I appreciate the response but I disagree with quite a few statements here.
I have seen large volumes evacuated from the thigh due to hematomas on people taking asa alone. These are extremely painful and are a result of significant blunt trauma. A simple well placed needle for a block should stay well away from any major vessels and not lead to the type of bleeding that is noted already in this case.

Second, I highly doubt this is a greedy surgeon. No surgeon I know wants to take this type of pt to the OR. They won’t even seen a dime from this case.

I assume this pt is either extremely uncomfortable or has had a significant drop in Hct or both. If this pt has dementia the pain, hypotension and resulting medication to treat this will make everything worse with the exception of PRBC’ s. I’d do the case.

 

[deleted171991]

I appreciate the response but I disagree with quite a few statements here.
I have seen large volumes evacuated from the thigh due to hematomas on people taking asa alone. These are extremely painful and are a result of significant blunt trauma. A simple well placed needle for a block should stay well away from any major vessels and not lead to the type of bleeding that is noted already in this case.

First of all, we don't know whether this was trauma at all. It may have been spontaneous. Second, it was not aspirin. Had it been, I wouldn't have flinched. Throw a pack of platelets at the problem and it's solved.

Except this one was a NOyAC, which requires respect. No cheap reversal available, and prolonged duration of action in a dysfunctional kidney. This on top of already fracked up platelets. If this bleed was spontaneous, or from minor trauma, I wouldn't stick a needle in him. But this is not my expertise.

Second, I highly doubt this is a greedy surgeon. No surgeon I know wants to take this type of pt to the OR. They won’t even seen a dime from this case.

Point taken.

I assume this pt is either extremely uncomfortable or has had a significant drop in Hct or both. If this pt has dementia the pain, hypotension and resulting medication to treat this will make everything worse with the exception of PRBC’ s. I’d do the case.

IF. IF! There are a number of modifiers that could make this case into an emergency, although pain can be treated in various ways, and the bleeding was slow, hence there was no hypotension. Absent those modifiers, this is a textbook case of watchful waiting. To me. I wouldn't remove the tamponade, but rather would use it for hemostasis. Your experience is richer, so it may differ.

Maybe it's time for @anbuitachi to tell us how the story ended.

 

[epidural man]

Not concerned about the rv failure w phtn with the build up in co2?

I'm pretty conservative still w that combo . Hear too many cases where patient codes after 25 of fentanyl

totally worried - got to be on top of it.

I don't remember - but there is a formula that predicts the rise of CO2 per minute.

Residents - can you recite?

 

[Noyac]

FFP-First of all, we don't know whether this was trauma at all. It may have been spontaneous. Second, it was not aspirin. Had it been, I wouldn't have flinched. Throw a pack of platelets at the problem and it's solved.

NOY-I was making a point that I have seen hematomas like this on pts only on asa. And it can be a significant hematoma with a liter or so of blood. I wasn’t stating that additional blood thinners were like asa. And I personally don’t care if it is spontaneous or not. It can still be significant.

FFP-Except this one was a NOyAC, which requires respect. No cheap reversal available, and prolonged duration of action in a dysfunctional kidney. This on top of already fracked up platelets. If this bleed was spontaneous, or from minor trauma, I wouldn't stick a needle in him. But this is not my expertise.

NOY-Thanks for the respect and I will say it is mutual. This is however just a discussion of “how would you do this case”. I just haven’t seen spontaneous thigh hematomas. If you have then fine I’ll believe you but that to me is a zebra of massive proportions. And even the ones that may be quantified as “spontaneous” I highly doubt. These people can’t remember what they had for breakfast much less Running into the dining room table last night. I am not saying you need to do a block since these thing are nearly painful compared to before evacuation. If someone wanted to do a block in order to avoid sedation or GA then that’s an option. I would just do a quick GA.

FFP-Point taken.


FFP-IF. IF! There are a number of modifiers that could make this case into an emergency, although pain can be treated in various ways, and the bleeding was slow, hence there was no hypotension. Absent those modifiers, this is a textbook case of watchful waiting. To me. I wouldn't remove the tamponade, but rather would use it for hemostasis. Your experience is richer, so it may differ.

NOY-Hypotension can not be counted on even in this pt. However, significant EBL in this pt would be probably noticeable. The pain of the hematoma is enough to keep BP respectable. Just treating the pain and not addressing the cause is not how I would approach this pt. If there is any dementia you will unmask it ten fold. And then the family will point fingers and talk smack about the surgeon the anesthesiologist and the hospital. I know we don’t treat family members per se’. But don’t underestimate the importance of this.


FFP-Maybe it's time for @anbuitachi to tell us how the story ended.

Well I obviously suck at the multi quote part of this. You all will have to read btw the lines.

 

[Noyac]

I guess my point here is, don’t be afraid of the pt. They were walking around alive, barely maybe but still alive. You have the skills to keep it this way. If this Pt had something like, let’s say a meat impaction, then you would find a way to do it safely.

 

[anbuitachi]

First of all, we don't know whether this was trauma at all. It may have been spontaneous. Second, it was not aspirin. Had it been, I wouldn't have flinched. Throw a pack of platelets at the problem and it's solved.

Except this one was a NOyAC, which requires respect. No cheap reversal available, and prolonged duration of action in a dysfunctional kidney. This on top of already fracked up platelets. If this bleed was spontaneous, or from minor trauma, I wouldn't stick a needle in him. But this is not my expertise.


Point taken.


IF. IF! There are a number of modifiers that could make this case into an emergency, although pain can be treated in various ways, and the bleeding was slow, hence there was no hypotension. Absent those modifiers, this is a textbook case of watchful waiting. To me. I wouldn't remove the tamponade, but rather would use it for hemostasis. Your experience is richer, so it may differ.

Maybe it's time for @anbuitachi to tell us how the story ended.

it ended in a very unexciting way. discussed with surgeon about the very high risk of anesthesia and decision was made to not proceed. they ended up deciding to watch and wait, and give some ddavp and stuff

 

[bcat85]

I guess my point here is, don’t be afraid of the pt. They were walking around alive, barely maybe but still alive. You have the skills to keep it this way. If this Pt had something like, let’s say a meat impaction, then you would find a way to do it safely.

I agree--the numbers look bad, but he was presumably mostly alive before he fell. I'm on board with some regional and sedation, but if you have to do GA, stick an a-line in, give him some norepinephrine until the blood pressure goes up, and give him some medication to put him to sleep and go for it.

 

[Noyac]

All this mental masturbation and we don’t even get to see how you did the case. That’s f’d up man.