Myocardial Infarction

[militarymd]

I got a 87 year old guy who busted his hip yesterday, and then he proceeds to evolve a NSTEMI. Cards says he's OK for surgery...less than 24 hours after his MI.

Cards says there are no plan for any other intervention, so take him to the OR today....Does everyone agree?

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[zippy2u]

Sure, take him to surgery. Cards OKed him for surgery-- you're golden. ---Zippy

 

[Tenesma]

i think a good sympathectomy will do his heart wonders...

 

[militarymd]

Sure, take him to surgery. Cards OKed him for surgery-- you're golden. ---Zippy

Ever hear of a second opinion?

 

[militarymd]

Sure, take him to surgery. Cards OKed him for surgery-- you're golden. ---Zippy

Oh yeah, I forgot to mention....this is the same Cards who said it was "OK only for a spinal".

Are we still "golden" ?

 

[Noyac]

Well at least you fixed him/her of the "OK for spinal" consult.
This guy needs his hip fixed sooner rather then later because if he gets pneumonia he's dead. His heart won't tolerate it. An infarct within 3 mon of surgery can carry a 30% risk factor, b/w 3-6mon it 15%, after 6mon its 6%. Clearly this pt can't wait 3 months. Things that would make me hesitate are recurrent pain, signs of CHF and dysrhythmias. With these present I may delay 12 - 24 hrs for rate control, dysrhythmia correction, fluid balance, etc,etc. Without these I would proceed, but a stress echo would be nice.
Type of anesthesia would depend on anticoagulants, surgeon, type of repair (screws, plate, THA,etc.)

 

[jetproppilot]

Well at least you fixed him/her of the "OK for spinal" consult.
This guy needs his hip fixed sooner rather then later because if he gets pneumonia he's dead. His heart won't tolerate it. An infarct within 3 mon of surgery can carry a 30% risk factor, b/w 3-6mon it 15%, after 6mon its 6%. Clearly this pt can't wait 3 months. Things that would make me hesitate are recurrent pain, signs of CHF and dysrhythmias. With these present I may delay 12 - 24 hrs for rate control, dysrhythmia correction, fluid balance, etc,etc. Without these I would proceed, but a stress echo would be nice.
Type of anesthesia would depend on anticoagulants, surgeon, type of repair (screws, plate, THA,etc.)

just as worrisome is pulmonary embolus.

Immobile 87 year olds dont do well, especially with a broken hip. Fixing it is his only real chance at surviving more than twelve months. Despite short term risk, > 12 month risk/benefit ratio is what needs to be considered. I'd wanna do it on my grandmother.

Last LMWH dose the night before surgery, bring him into the OR in the morning, propofol 50 mg, sit him up, 22" spinal needle paramedian, etc etc etc

Its worth the risk in my humble opinion.

 

[jetproppilot]

Type of anesthesia would depend on anticoagulants, surgeon, type of repair (screws, plate, THA,etc.)

I'd use neuraxial anesthesia regardless. The only one of worry above IMHO is the anticoagulation (as we all know), which can be orchestrated to fit the surgery date.
Got a surgeon that takes way too long? I'd access the SAS with a 22" SN, dose it with 15 mg hyperbaric bupivicaine with a splash of epi, then thread an epidural catheter through it in case you need to redose, then DC it as soon as you get to PACU. Epidural would be great but might be very technically challenging in this scenerio.
Type of repair has no bearing on GA vs neuraxial IMHO.

 

[militarymd]

So here are the details. The patient comes in with a broken hip and a NSTEMI. Which came first is not clear....perhaps he had one and it caused him to fall, or he fell and the pain caused him to have a NSTEMI.

Anyways, the very next day, the family wants it fixed, and the cardiologist says go ahead.

The orthopedic surgeon is reluctant....that's right...he does NOT want to do it, and CLEARLY says it can wait a few days.

The anesthesiologist on call agrees that the patient should not have surgery within 18 hours of evolving a NSTEMI, but there is pressure from the family and cardiologist to do it that day.

The orthopedic surgeon asks the anesthesiologist on call to get a second opinion from me, and here is my opinion:

If a patient has a NSTEMI, there is enough of a risk for death that the ACC recommends admission to a "monitored unit" for care and risk stratification. A patient would be in the hospital regardless of a broken hip. I would do the case when the cardiologist would discharge a patient from the hospital when treatment and montioring is done from the MI perspective....usually 2 to 3 days.

During the early period after an MI, there is sufficient inflammation around the dead myocardium that there is significant risk of dysrhythmia and further infarction, that I think it is wise to wait until regular medical therapy is complete.....The orthopedic surgeon likes my recommendation and is planning the Bi-polar hip for Sunday...3 days after the MI.

My recommendation is based only on my perception and understanding of care of the MI patient, and not based on any evidence.

If there is any evidence out there that anyone knows of...please post.

Obviously if the orthopedic surgeon said it needed to be done right now, and the cardiologist says it is ok....I would still recommend against it, but would have no problem doing the case.

 

[VentdependenT]

OK MMD, you wait 3 days. The guy is beta blocked, on an ace, some zocor, some anticoag, has a tolerable hemoglobin, and has been puffen on his spirometer. How do you proceed with the intraop management. I'm a young'n so school me brother.

One more q. Will neuraxial block vs an LMA make a large impact in outcome?

I guess I would be afraid about pressure dropping so fast with a neuraxial but I suppose thats what art lines, fluid, and neosynephrine are made for.

 

[militarymd]

How do you proceed with the intraop management. I'm a young'n so school me brother.

One more q. Will neuraxial block vs an LMA make a large impact in outcome?

Ahhh....the perpetual regional vs general debate. There is some weak data in the form of meta-analyses that say perhaps some type of regional anesthesia is better for patients like this, but my feeling is that if there is a raging debate about something...it means that it really doesn't matter.

I probably would put the patient to sleep.....or not....I don't think it matters. The important stuff is

The guy is beta blocked, on an ace, some zocor, some anticoag, has a tolerable hemoglobin, and has been puffen on his spirometer.

oh...and I would avoid hypotension and tachycardia, and that is the honest truth.

 

[jetproppilot]

oh...and I would avoid hypotension and tachycardia, and that is the honest truth.

Chi, add avoid hypoxemia to your statement and you can pad your income as a cardiologist doing pre-op clearances. 😀

 

[jetproppilot]

OK MMD, you wait 3 days. The guy is beta blocked, on an ace, some zocor, some anticoag, has a tolerable hemoglobin, and has been puffen on his spirometer. How do you proceed with the intraop management. I'm a young'n so school me brother.

One more q. Will neuraxial block vs an LMA make a large impact in outcome?

I guess I would be afraid about pressure dropping so fast with a neuraxial but I suppose thats what art lines, fluid, and neosynephrine are made for.

Forgive me Mil, but if you say your desire to wait is based on perception only, and if pushed you'd have no problem doing the case, then why wait?
What about the additional inherent patient risk added by lying in bed immobile with a fxed hip?
I dont think 48 additional hours of internal medicine doc intervention will reduce intra-op risk enough to justify waiting.

 

[zippy2u]

Military, sounds like same head game, different day. Your colleague said 18 hours and then you tell the ortho guy 3 days but if push came to shove you'd do pt. in 18 hrs. Ain't got the Unity yet I see and probably still lookin' for people to work for you. Your ortho guy needs to get with the program. The cat's meow is when the big cards doc And the family jump on one side of the fence. You and the ortho guy need to meander over to their side and make it all good. Regards, ---Zippy

 

[militarymd]

Chi, add avoid hypoxemia to your statement and you can pad your income as a cardiologist doing pre-op clearances. 😀

Damn, I always forget the hypoxia part!!!

 

[militarymd]

Forgive me Mil, but if you say your desire to wait is based on perception only, and if pushed you'd have no problem doing the case, then why wait?

The ortho guy wanted to wait, and asked how long?

What about the additional inherent patient risk added by lying in bed immobile with a fxed hip?

I think recent data (with new methods of DVT prophylaxis) suggest that the risks of thromboembolism is not as high as previously believed.

I dont think 48 additional hours of internal medicine doc intervention will reduce intra-op risk enough to justify waiting.

Risk of death after a NSTEMI is highest during the 24 to 48 hours after they occur.

 

[militarymd]

Military, sounds like same head game, different day. Your colleague said 18 hours and then you tell the ortho guy 3 days but if push came to shove you'd do pt. in 18 hrs. Ain't got the Unity yet I see and probably still lookin' for people to work for you. Your ortho guy needs to get with the program. The cat's meow is when the big cards doc And the family jump on one side of the fence. You and the ortho guy need to meander over to their side and make it all good. Regards, ---Zippy

SDN is pissing me off....my longer posts keep getting lost, so I will reply in short bursts.

 

[militarymd]

Military, sounds like same head game, different day. Your colleague said 18 hours and then you tell the ortho guy 3 days but if push came to shove you'd do pt. in 18 hrs. Ain't got the Unity yet I see and probably still lookin' for people to work for you. Your ortho guy needs to get with the program. The cat's meow is when the big cards doc And the family jump on one side of the fence. You and the ortho guy need to meander over to their side and make it all good. Regards, ---Zippy

Z,
You are not reading my posts accurately.

 

[militarymd]

Military, sounds like same head game, different day. Your colleague said 18 hours and then you tell the ortho guy 3 days but if push came to shove you'd do pt. in 18 hrs. Ain't got the Unity yet I see and probably still lookin' for people to work for you. Your ortho guy needs to get with the program. The cat's meow is when the big cards doc And the family jump on one side of the fence. You and the ortho guy need to meander over to their side and make it all good. Regards, ---Zippy

My colleague did not say 18 hours, and I did not tell the ortho guy 3 days.

 

[militarymd]

Military, sounds like same head game, different day. Your colleague said 18 hours and then you tell the ortho guy 3 days but if push came to shove you'd do pt. in 18 hrs. Ain't got the Unity yet I see and probably still lookin' for people to work for you. Your ortho guy needs to get with the program. The cat's meow is when the big cards doc And the family jump on one side of the fence. You and the ortho guy need to meander over to their side and make it all good. Regards, ---Zippy

Family wanted surgery at 18 hours and cards said it was ok....

NO ONE wanted to do it then....anesthesia and ortho...ortho is an experienced/excellent surgeon who's been around the block a few times and knows when patients will do well or not.

 

[militarymd]

Military, sounds like same head game, different day. Your colleague said 18 hours and then you tell the ortho guy 3 days but if push came to shove you'd do pt. in 18 hrs. Ain't got the Unity yet I see and probably still lookin' for people to work for you. Your ortho guy needs to get with the program. The cat's meow is when the big cards doc And the family jump on one side of the fence. You and the ortho guy need to meander over to their side and make it all good. Regards, ---Zippy

They, colleague and Ortho, ask me if it was ok to proceed with surgery....I said no, but I did NOT give a time frame.

 

[militarymd]

My recommendations:

Do the surgery when the cardiologist is done treating the MI and is ready to discharge the patient from the hospital.

If the cardiologist routinely discharges his patients 18 hours after a NSTEMI, then that is when the surgery should be done.

I will tell you that the ACC definitely does not recommend sending patients home 18 hours after a NSTEMI.

If you have not read ACC's statements and guidelines, I can provide links

 

[militarymd]

Ortho agrees with me....he books the case for 3 days after reconsultation with cards...I suspect the cardiologist sends his patients home 3 days after a NSTEMI.

AND emergency surgery TRUMPS all of the above.....straight to the OR in that case.

 

[militarymd]

Z,
You are not reading my posts accurately.

How much more "Unity" can you get beyond a colleague saying "let me ask Military what he thinks, and that's what we'll do"....

How much more "Unity" can you get when the Ortho guy says "we'll do what the anesthesia guy says, and not what the Cards guy says"?

Zip, are you in a group? Does your group have enough rep that the ortho guys say "we'll listen to anesthesia and not the cards?"

 

[jetproppilot]

SDN is pissing me off....my longer posts keep getting lost, so I will reply in short bursts.

My sentiments exactly...lost a LONG post more than once right after the storm describing everything...last night lost a post 3 times before it posted on the 4th try....ridiculous...cant write a lengthy post until the problem is fixed.

 

[VentdependenT]

Nice fusillade of posts mmd.

 

[jetproppilot]

How much more "Unity" can you get beyond a colleague saying "let me ask Military what he thinks, and that's what we'll do"....

How much more "Unity" can you get when the Ortho guy says "we'll do what the anesthesia guy says, and not what the Cards guy says"?

Zip, are you in a group? Does your group have enough rep that the ortho guys say "we'll listen to anesthesia and not the cards?"

Hoehhhhhh.........sounds like Jedi Warrior making impact in redneck country!!!
Hory Crap!

 

[AJM]

My sentiments exactly...lost a LONG post more than once right after the storm describing everything...last night lost a post 3 times before it posted on the 4th try....ridiculous...cant write a lengthy post until the problem is fixed.

jpp and mmd - the problem should be fixed now. Let me know if you're still having problems. 🙂

 

[jetproppilot]

Nice fusillade of posts mmd.

Uh, Venty, I'll preface my statement with the fact that I'm not homophobic, and in all truth about half my friends are lesbians (true folks, but thats an entirely different thread), but your avatar is the gayest Prince picture I've ever seen. I mean, its even an insult to gay dudes!

Carson on Queer Eye For The Straight Guy would have that pic removed immediately. I vote for a cooler Prince pic, like from the 1999 days!!!

 

[VentdependenT]

Uh, Venty, I'll preface my statement with the fact that I'm not homophobic, and in all truth about half my friends are lesbians (true folks, but thats an entirely different thread), but your avatar is the gayest Prince picture I've ever seen. I mean, its even an insult to gay dudes!

Carson on Queer Eye For The Straight Guy would have that pic removed immediately. I vote for a cooler Prince pic, like from the 1999 days!!!

I tried to make it as flammen as possible but I think those flowers were a bit much. I like prince and everything but maybe I crossed deep into the abyss with that pic. Oh well I'm back and as such I'm glad you are too my man. 😉