New Case to Ponder

[TrojanGopher]

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50ish F with a hx of polysubstance abuse (heroine/cocaine), COPD (3L oxygen at home, day and night), chronic pain, and chronic ankle osteomyelitis who presents for a combo of COPD exacerbation and new lower extremity cellulitis (same side as the osteo). Patient is worked up, surgeons decide that the patient needs a BKA.

Vitals: 100s/60s, HR 100s, Sat 94% on 6 L NC
Alert, mild respiratory distress, but able to talk in full sentences
Erythema to mid-calf
WBC trending down following antibiotics

Just as you are leaving the room, the patient's nurse notes that the patient been requiring increasing amounts of oxygen throughout the morning, so a CTA-PE protocol was done, which revealed bilateral PE's. There is nothing in the chart yet to detail the extent of pulmonary vascular involvement. The patient is started on lovenox, 1 mg/kg BID by the medicine team.

How would you proceed if this was going to be you patient the following morning?

Do the case? If so, how would you proceed?

Cancel the case? If so, when would you ok her for surgery?

 

[pgg]

I'm not sure there's any point in delaying. Last cocaine use? Anything else on the tox screen? She might benefit from an IVC filter preop. Does she really have a COPD exacerbation or was her dyspnea @ admission from previous PEs? Probably doesn't matter WRT the anesthesia, but I wonder if she really needs all the steroids she's probably getting.

Assuming comparable vitals and no overnight events, I'd do a sciatic block and high saphenous vs femoral block, and be done with it. I know ASRA guidelines caution against regional within 24 hrs of high dose Lovenox but I think the r/b math favors u/s guided blocks here over GA.


And thanks for posting the case.

 

[TrojanGopher]

I'm not sure there's any point in delaying. Last cocaine use? Anything else on the tox screen? She might benefit from an IVC filter preop. Does she really have a COPD exacerbation or was her dyspnea @ admission from previous PEs? Probably doesn't matter WRT the anesthesia, but I wonder if she really needs all the steroids she's probably getting.

Assuming comparable vitals and no overnight events, I'd do a sciatic block and high saphenous vs femoral block, and be done with it. I know ASRA guidelines caution against regional within 24 hrs of high dose Lovenox but I think the r/b math favors u/s guided blocks here over GA.


And thanks for posting the case.

First, I can't comment on whether she was truly having a COPD exacerbation or if her symptoms were from her PE. Last cocaine use was 3 days prior to admission. I should also note that the cellulitis was not life-threatening, but her chronic osteomyelitis meant that the cellulitis would likely never fully resolve without a BKA.

I agree with you that RA is a better choice than GA, but even with ultrasound-guidance, there is no guarantee for success. Complicating matters further, the was actually scheduled for "BKA vs AKA," making the need area to be covered by a block even larger.

The question must be asked "What if the block doesn't work?" One could make the argument to wait until her respiratory symptoms from her PE, given that converting to a GA in a moderately-decompensated patient with very little baseline respiratory reserve could be very problematic.

 

[pgg]

First, I can't comment on whether she truly having a COPD exacerbation or if her symptoms were form her PE. Last cocaine use was 10 3 days prior to admission. I should also note that the cellulitis was not life-threatening, but her chronic osteomyelitis meant that the cellulitis would likely never fully resolve without a BKA.

I agree with you that RA is a better choice than GA, but the question must be asked "What if the block doesn't work?" Even with ultrasound-guidance, there is no guarantee for success. Complicating matters, it was scheduled actually scheduled for "BKA vs AKA." One could make the argument to wait until her respiratory symptoms from her PE, given that converting to a GA in a patient with very little respiratory reserve at baseline could be very problematic.

Block failure rate is really low. Moreover, it's not a c-section where a failed epidural obligates you to convert to GA ... it's an urgent-ish extremity case where a failed block means you can apologize to the surgeon and try again in a while. The oral boards will take you down a regional failure mid-case route but I don't think that's a significant real world risk here.

If they're talking AKA ... that gets a little more interesting and maybe we should talk IVC filter, no Lovenox for 24 hours, and a spinal.


Delaying for her resp function to improve in a meaningful way (presuming most of her not-baseline dyspnea is from her PEs) is going to be a long delay, not just a day or two. Meanwhile, with all the inflammatory crap and evil humors cooking in her leg, she continues to be at elevated risk for more PEs. I would argue against delaying.

 

[Idiopathic]

i want to see an echo prior. i agree the case needs to be done. i think i would pin down the surgeons on AKA vs BKA. if she has chronic ankle osteo, then she gets a BKA. if they are concerned about some necrotizing process or progressive infection, we should know that.

if she hasnt gotten lovenox yet, IV heparin bridge overnight, spinal in the AM. if she has gotten lovenox try to hold the PM dose.

 

[Oggg]

Femoral and sciatic blocks. If pt has pain or they go AKA, convert to GETA and probably leave intubated and destined for trach. I like the IVC filter preop.

 

[caligas]

GA with post op vent.

 

[nap$ter]

IVC filter, then femoral and subglut sciatic catheters and LMA (best sedation for a chronic pain pt undergoing amputation is isoflurane) - she's likely going to be coming back for a revision if the skin/bone is infected.

 

[proman]

Why exactly does this case need to be done? Cellulitis isn't an indication for emergency surgery. With an active cardiac condition (which an acute PE is), only emergency surgery should be done. If the surgeon wants to call it an emergency then fine, I'd do a single shot spinal so they can heparinize for the PE. If the patient is already on heparin, I'd do a femoral nerve catheter and single shot sciatic. I think 7 days of anticoagulation is more appropriate for a semi-urgent BKA. The filter will help for future PE but not the ones she already has. Postoperative pulmonary complications will be greatly increased no matter the anesthetic technique. Now if it's gangrene, that's a different story.

 

[dhb]

Why exactly does this case need to be done? Cellulitis isn't an indication for emergency surgery. With an active cardiac condition (which an acute PE is), only emergency surgery should be done. If the surgeon wants to call it an emergency then fine, I'd do a single shot spinal so they can heparinize for the PE. If the patient is already on heparin, I'd do a femoral nerve catheter and single shot sciatic. I think 7 days of anticoagulation is more appropriate for a semi-urgent BKA. The filter will help for future PE but not the ones she already has. Postoperative pulmonary complications will be greatly increased no matter the anesthetic technique. Now if it's gangrene, that's a different story.

👍
whta's a BKA? cannot be bilateral knee arthroplasty right

 

[TrojanGopher]

Why exactly does this case need to be done? Cellulitis isn't an indication for emergency surgery. With an active cardiac condition (which an acute PE is), only emergency surgery should be done. If the surgeon wants to call it an emergency then fine, I'd do a single shot spinal so they can heparinize for the PE. If the patient is already on heparin, I'd do a femoral nerve catheter and single shot sciatic. I think 7 days of anticoagulation is more appropriate for a semi-urgent BKA. The filter will help for future PE but not the ones she already has. Postoperative pulmonary complications will be greatly increased no matter the anesthetic technique. Now if it's gangrene, that's a different story.

This was my original thought. Active cardiac condition trumps non-emergent surgery. She did have lower extremity dopplers some which revealed no DVT. An IVC filter does her no good at this point.

 

[cchoukal]

With an active cardiac condition (which an acute PE is), only emergency surgery should be done. .

I don't disagree but I've never seen this on the ACC/aha list of active cardiac conditions. Is this a new update?

 

[nap$ter]

This was my original thought. Active cardiac condition trumps non-emergent surgery. She did have lower extremity dopplers some which revealed no DVT. An IVC filter does her no good at this point.

in my humble experience trying to delay this case is just going to piss off your partners, the surgeon, and the patient. sounds like her respiratory status is at baseline for a COPD'er on home O2 via crack pipe.

how long should you wait after a dx of small-mod PE before semi-urgent surgery? a delay isn't doing anyone any favors. the leg is gonna just get more infected and turn to sepsis (you're right that surgeons don't do bka's for cellulitis - this is more than just a skin infection). she'll lay in bed getting septic hollering for a pound of dope, forming more clots in her leg and continuing to shower her lungs.

the ivc filter is for the clots missed by the doppler or more likely the ones she's forming right now. lmwh ain't that great for preventing further clotting in a lady with pe's immobile in bed with an infection.

step up the mic and get round 1 over with - she'll be back for round 2, and probably round 3.

 

[pgg]

whta's a BKA?

BKA = below knee amputation
AKA = above knee amputation

This was my original thought. Active cardiac condition trumps non-emergent surgery.

Accepting for the sake of argument that a PE is an active cardiac condition per the AHA/ACC guidelines (is it?), is there any reason to believe it's going to get significantly better with a modest delay (days not weeks)? This can't be just cellulitis and low grade chronic osteomyelitis or the surgeon wouldn't be so eager to chop it off.

Exactly what are we expecting to improve if we wait a day, or three, or a week? She's really NOT that far off her home respiratory baseline (3L NC 24/7).

She did have lower extremity dopplers some which revealed no DVT. An IVC filter does her no good at this point.

I have less than solid faith in LE dopplers under the best of circumstances, which these aren't. In a patient with multiple documented PEs and risk factors for having more, I'd still lobby for the IVC filter.



Also, I agree with everything slavin wrote.

 

[SexPanther]

I'm with the majority that the case gets done, but like Idio I want the echo.

With the report of bilateral PEs and hypotension ( systolic of 100 if I remember right) I want to know how that RV looks.

RV dysfunction without proper preparations is what kills this lady with the quickness IMO. She is a bitch so I want to know if she'll be at the party ahead of time.

I'm not too concerned with the type of anesthetic administered as both can be done well and safely in this lady.

Although I'd lean towards regional to avoid instrumenting the airway, I don't think GA definitively means prolonged mechanical ventilation post-op. One of the few definitive indications for BiPAP is hypercarbic respiratory failure and I'd have no problem extubating her to it.

 

[RxBoy]

RV dysfunction without proper preparations is what kills this lady with the quickness IMO. She is a bitch so I want to know if she'll be at the party ahead of time..

👍👍 My thoughts exactly

I would def talk to the surgeon first and understand how urgent is urgent. Communication is key. Once they know she is at high risk for post op morbidity/mortality, they may be more reluctant to think its urgent.

Does she have confirmed COPD by PFTs? She could have some underlying coag issue (b/l PE) with repeated pulm infarcts causing severe pulm HTN.

If still deemed urgent:

I would do a TTE myself in preop and look at the RV, assess severity of pulm HTN and RV failure.(TVR, estimated RVSP, RVH, RV shape, bulging septum ect.). If looks good, would proceed with spinal and minimal sedation. If lovonox still on board would do combined sciatic/femoral. If she had signs of RV failure, would postpone unless deemed emergency. I would consider this an active cardiac condition (acute decompensation of CHF).


If I could delay:

Inpatient TEE, Pulm c/s for workup/optimization of respiratory status (COPD/pulm HTN). IVC filter placement. Get pulm advice on when best to proceed in lieu of anticoagulation and PE. I'm sure there is some study out there. Proceed as above plan.

 

[RxBoy]

Don't forget McConnell's sign 😉

[YOUTUBE]http://www.youtube.com/watch?v=x4bVhnL3Ix8[/YOUTUBE]


Another example (minus right sided thrombus):

[YOUTUBE]http://www.youtube.com/watch?v=Tklaxe-kPrk&feature=related[/YOUTUBE]

 

[TrustMe]

For me this hinges on the severity of the PE. She is mildly hypotensive and tachycardic. Is this from pending sepsis or hemodynamic compromise of her PE. Since her WBC is downtrending and she is on abx I am leaning toward this being from her PE. She is having some mild respiratory distress, likely again from her PE. I would want to see a TTE and look at the CT images myself. If there is RV dysfunction and/or significant clot burden on CT then I would want a couple of days of anticoagulation, preferably heparin. If her cellulitis gets worse or WBC goes back up, turn the heparin off and go to the OR. I hate delaying cases, but this one sounds like she needs a couple of days of tuning up before she goes to the OR (heparin, abx, and IVC filter). If her cellulitis and WBC is getting better on abx then this is not an emergency. A PE large enough to cause a change in hemodynamics (hypotension and tachycardia) is large enough to wait a few days for the anticoagulation to work.

She will probably need the sciatic catheter for post-op pain control (esp. if she is a junkie) but a spinal is more reliable if you really don't want to manipulate her airway. You probably have more time with anitcoagulation as I am sure that the ortho guys will not be in a hurry to start heparin (or lovenox) too early following a BKA.

 

[proman]

I don't disagree but I've never seen this on the ACC/aha list of active cardiac conditions. Is this a new update?

No update, the ACC/AHA guidelines don't include pulmonary conditions in "active". But, acute PE, to me, is a cardiac condition.

in my humble experience trying to delay this case is just going to piss off your partners, the surgeon, and the patient. sounds like her respiratory status is at baseline for a COPD'er on home O2 via crack pipe.

how long should you wait after a dx of small-mod PE before semi-urgent surgery? a delay isn't doing anyone any favors. the leg is gonna just get more infected and turn to sepsis (you're right that surgeons don't do bka's for cellulitis - this is more than just a skin infection). she'll lay in bed getting septic hollering for a pound of dope, forming more clots in her leg and continuing to shower her lungs.

the ivc filter is for the clots missed by the doppler or more likely the ones she's forming right now. lmwh ain't that great for preventing further clotting in a lady with pe's immobile in bed with an infection.

step up the mic and get round 1 over with - she'll be back for round 2, and probably round 3.

I don't need guidelines for this. If you can't argue clinical judgement without evidence, then why go to medical school? If we had guidelines for every conceivable condition, we wouldn't need the critical thinking that doctors provide. To argue that a patient 1 day after an acute pulmonary embolism is "medically optimized" is a stretch. To say that you can justify doing an elective procedure (orthopedic with tourniquet no less) in a patient with a fresh PE, to me, is indefensible.

The patient has a history of substance abuse, doesn't imply that she's smoking crack or yelling for dope. That's a ridiculous statement. Drug addicts die too. I'm sorry you're in a practice where you can't practice good medicine and exercise judgement. We don't stop being physicians when we become anesthesiologists. I've posed this scenario to several of my friends in private practice and all of them said they would defer and all said their surgeons would listen. Step up to the MIC and be a doctor.

For me this hinges on the severity of the PE. She is mildly hypotensive and tachycardic. Is this from pending sepsis or hemodynamic compromise of her PE. Since her WBC is downtrending and she is on abx I am leaning toward this being from her PE. She is having some mild respiratory distress, likely again from her PE. I would want to see a TTE and look at the CT images myself. If there is RV dysfunction and/or significant clot burden on CT then I would want a couple of days of anticoagulation, preferably heparin. If her cellulitis gets worse or WBC goes back up, turn the heparin off and go to the OR. I hate delaying cases, but this one sounds like she needs a couple of days of tuning up before she goes to the OR (heparin, abx, and IVC filter). If her cellulitis and WBC is getting better on abx then this is not an emergency. A PE large enough to cause a change in hemodynamics (hypotension and tachycardia) is large enough to wait a few days for the anticoagulation to work.

She will probably need the sciatic catheter for post-op pain control (esp. if she is a junkie) but a spinal is more reliable if you really don't want to manipulate her airway. You probably have more time with anitcoagulation as I am sure that the ortho guys will not be in a hurry to start heparin (or lovenox) too early following a BKA.

Agree with above, but the internists have started LMWH so no spinal for now. I'd recommend switching to IV heparin and waiting 7 days for treatment. Why? When I was an intern, I had a patient with a 10 cm lung mass (meso) and acute PE. The hematologist said it takes at least 7 days until the clots are either dissolved or organized. If this is truly chronic osteo with cellulitis, then IV ABX and heparin are what the patient needs.

 

[nap$ter]

No update, the ACC/AHA guidelines don't include pulmonary conditions in "active". But, acute PE, to me, is a cardiac condition.



I don't need guidelines for this. If you can't argue clinical judgement without evidence, then why go to medical school? If we had guidelines for every conceivable condition, we wouldn't need the critical thinking that doctors provide. To argue that a patient 1 day after an acute pulmonary embolism is "medically optimized" is a stretch. To say that you can justify doing an elective procedure (orthopedic with tourniquet no less) in a patient with a fresh PE, to me, is indefensible.

The patient has a history of substance abuse, doesn't imply that she's smoking crack or yelling for dope. That's a ridiculous statement. Drug addicts die too. I'm sorry you're in a practice where you can't practice good medicine and exercise judgement. We don't stop being physicians when we become anesthesiologists. I've posed this scenario to several of my friends in private practice and all of them said they would defer and all said their surgeons would listen. Step up to the MIC and be a doctor.



Agree with above, but the internists have started LMWH so no spinal for now. I'd recommend switching to IV heparin and waiting 7 days for treatment. Why? When I was an intern, I had a patient with a 10 cm lung mass (meso) and acute PE. The hematologist said it takes at least 7 days until the clots are either dissolved or organized. If this is truly chronic osteo with cellulitis, then IV ABX and heparin are what the patient needs.

whoa there good buddy. i didn't ask for the evidence - my point was that there isn't any for this situation. would you really wait 7d on a hot leg? a hot leg that antibiotics aren't gonna do much for? that's why the surgeon wants to take it off, instead of consulting medicine.

i agree with your assessment that clinical judgment should be exercised. if your judgment is to wait, so be it. i just don't agree. i also don't think an echo is necessarily indicated in the absence of clinical evidence of RV dysfunction. and remember this lady was on home o2. tachycardia and hypotension in a lady 3d out from her last coke use with an infected leg might not be from a PE. if you can't sort it out with a detailed H&P get the echo.

i've often wondered how many anesthetics we give to sick patients with undiagnosed PE's.

sorry if i offended your sensitivities about substance abuse. my point is merely that patients with substance abuse and tolerance are difficult to care for. and they have been known to sometimes holler for dope and smoke crack - drug addicts abusing drugs is not just a stereotype.

surgical control of infection is not an elective orthopedic procedure. i agree that this doesn't sound emergent, but delaying beyond the time for a filter won't make this lady more optimized.

i will neglect your angry comments in favor of wishing you a pleasant evening.

 

[TrojanGopher]

So in the end the case was cancelled, but not by me (anesthesia). The patient's primary team (family medicine) felt that the patient was not stable enough for surgery, so orthopedics cancelled the case before I came in the following morning.

 

[Idiopathic]

would you have cancelled the case?

 

[geogil]

Some of you were posing the AKA v BKA question earlier. What does this change from an anesthetic standpoint?

 

[TrojanGopher]

would you have cancelled the case?

Given that I am still very early in my training, I was admittedly a bit skiddish doing the case. But the more I thought about it (with the help of this discussion), the more I would be willing to do it. I would have done femoral and sciatic blocks. As some others have said, I would have wanted a TTE (which she didn't have) prior to the procedure to evaluate right heart function in case she has to be converted to GA.

 

[Idiopathic]

Some of you were posing the AKA v BKA question earlier. What does this change from an anesthetic standpoint?

BKA can be done under extremity block fairly easily, AKA usually needs spinal/epidural or GA. planning a regional for BKA is all well and good until you have to convert to GA during the case when they arent happy with the tissues.

 

[dhb]

I've done plenty of AKA under regional, i wouldn't do it any other way.

 

[Planktonmd]

This patient had COPD exacerbation and bilateral PE's so she is likely to get intubated with or without the surgery.
pent/sux/tube, do the surgery and send her to ICU intubated.

 

[Idiopathic]

I've done plenty of AKA under regional, i wouldn't do it any other way.

I havent, so there you go. Whats the technique of choice