Paralysis of lower legs after Total hip replacement

[deleted682700]

This case happenEd in Ca to my anesthesiologist friend. i am not involved in the case. This is second hand information. Patient is 75 year old elderly female had Htn, CAD,
s/p CABG A few years ago now is cleared by cards and is scheduled for total hip replacement. A spinal was given and achieved good anesthesia level with routine monitors.

Intraop significant blood loss is noted and was resuscitated with crystalloids. Post op the patient was sent to PACU. The nurses / anesthesiologist have documented That spinal regression is complete. Patient had low BP and was sent to the floor. floor nurses called anesthesiologist re hypotension and hemoglobin comes at 6. Anesthesiologist goes back to the hospital in the evening calls the ortho, the Ortho refuses to let the patient have blood transfusion.

patient survived the night, next day she cannot move the legs and the orthopedic promptly blames anesthesia spinal. The paralysis does not improve and neurology comes in and after MRI concludes Spinal Cord ischemia.

The case was litigated. Went to trial. The lawyer for the anesthesiologist did a wonderful job defending the case.

Do you guys in big centers see spinal cord ischemia after acute blood loss? Could this have been prevented by giving blood transfusion early and what hematocrit level is acceptable in such a patient

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[epidural man]

Holy smokes. You say they did a great job defending the case - I hope they won.

I have no idea what HCT level is adequate. I don't think anyone can say that. Obviously a Hgb of 6 wasn't enough in this case.

I'd like to know what the ortho thought the mechanism of action of the spinal paralysis was. I don't think anyone has reported complete paralysis from a spinal (in the absence of hematoma) in something like 50 years. (people have reported neurological injury, or anterior chord syndrome, etc)

 

[deleted480308]

Holy smokes. You say they did a great job defending the case - I hope they won.

I have no idea what HCT level is adequate. I don't think anyone can say that. Obviously a Hgb of 6 wasn't enough in this case.

I'd like to know what the ortho thought the mechanism of action of the spinal paralysis was. I don't think anyone has reported complete paralysis from a spinal (in the absence of hematoma) in something like 50 years. (people have reported neurological injury, or anterior chord syndrome, etc)

Medicine tends to use a Hgb 7, 8 with some coronary disease.

 

[Aether2000]

It would be interesting to know the lowest sustained BP during the surgery. If there was hypotension (https://www.nature.com/articles/sc199454.pdf?origin=ppub) combined with a surgeon who lost control of surgical bleeding and refused to allow the patient to receive an indicated transfusion it could predispose to cord ischemia. Of course there are many case reports of arterial thrombosis due to TXA use. It would be interesting to know what the MRI/MRA and EMG/NCV showed post op.

 

[Hoya11]

This case happenEd in Stockton, Ca to my anesthesiologist friend. i am not involved in the case. This is second hand information. Patient is 75 year old elderly female had Htn, CAD,
s/p CABG A few years ago now is cleared by cards and is scheduled for total hip replacement. A spinal was given and achieved good anesthesia level with routine monitors.

Intraop significant blood loss is noted and was resuscitated with crystalloids. Post op the patient was sent to PACU. The nurses / anesthesiologist have documented That spinal regression is complete. Patient had low BP and was sent to the floor. floor nurses called anesthesiologist re hypotension and hemoglobin comes at 6. Anesthesiologist goes back to the hospital in the evening calls the ortho, the Ortho refuses to let the patient have blood transfusion.

patient survived the night, next day she cannot move the legs and the orthopedic promptly blames anesthesia spinal. The paralysis does not improve and neurology comes in and after MRI concludes Spinal Cord ischemia.

The case was litigated. Went to trial. The lawyer for the anesthesiologist did a wonderful job defending the case.

Do you guys in big centers see spinal cord ischemia after acute blood loss? Could this have been prevented by giving blood transfusion early and what hematocrit level is acceptable in such a patient

Though I have not seen or heard of such a case, what else could it be?

You've got low BP and low HCT and you end up having end organ ischemia

This an usual spot to get ischemic, but maybe she had some pre-existing vascular disease in that area and the spinal cord was vulnerable in one particular area..

I think the low BP was probably more detrimental than the HCT, probably needed a intra, and post op neo drip after the spinal on the old lady, but all parties probably too unwilling to do that. "Lets just send her to the floor shes fine we bolused her 500 of LR, if we do a neo drip she has to go to a higher level of care, too much hassle"

 

[caligas]

I’ve seen this before in a medico legal context, Multifactorial spinal cord ischemia after total joint in sick patient. The spinal is a red herring, happens with GA too.

Make sure your systems have good post op procedures for documenting Post op hemodynamics, UOP, regression of neuraxial (especially in PACU where you are still responsible) and that these things are treated when appropriate.

 

[GassYous]

Jesus Christ. We do too many joints for sick 70+ patients. Of course the surgeon would throw the anesthesiologist right under the bus. Try being a doctor and taking responsibility for your decisions.

 

[epidural man]

I’ve seen this before in a medical legal context, Multifactorial spinal cord ischemia after total joint in sick patient. The spinal is a red herring, happens with GA too.

Make sure by your systems have good post op procedures for documenting Post op hemodynamics, UOP, regression of neuraxial (especially in PACU where you are still responsible) and that these things are treated when appropriate.

This!

IN FACT, the anesthesia lawyer should argue that the spinal helped the problem not be worse! If the anesthesiologist was on top of their game maintaining adequate MAPS, then they could argue that the local anesthetic had a vasodilatory action on the blood vessels to the cord, thus helping maintain better perfusion.

 

[epidural man]

Though I have not seen or heard of such a case, what else could it be?

You've got low BP and low HCT and you end up having end organ ischemia

This an usual spot to get ischemic, but maybe she had some pre-existing vascular disease in that area and the spinal cord was vulnerable in one particular area..

I think the low BP was probably more detrimental than the HCT, probably needed a intra, and post op neo drip after the spinal on the old lady, but all parties probably too unwilling to do that. "Lets just send her to the floor shes fine we bolused her 500 of LR, if we do a neo drip she has to go to a higher level of care, too much hassle"

There are many case reports of cord ischemia from hypotension. But I don't think there are any from just a spinal.

 

[deleted480308]

Jesus Christ. We do too many joints for sick 70+ patients. Of course the surgeon would throw the anesthesiologist right under the bus. Try being a doctor and taking responsibility for your decisions.

We certainly do too many in that population with an expectation of the same outcomes for healthy 20yr olds.

 

[Hork Bajir]

Oxygen delivery = CO x arterial oxygen content. The CO needs to be delivered to the organs (heart, brain, kidneys, spinal cord) at an adequate perfusion pressure to allow for oxygen extraction and expansion of microcirculatory capillary networks.

If the CO (or BP in this case) is low, higher Hgb will help to compensate by maintaining a normal DO2. Conversely, anemia is pretty well tolerated as long as there is a compensatory increase in CO. This is the reason we will sometimes transfuse VA ECMO patients to a hgb of 9 or 10 when we’re not able to flow at a high cardiac index.

In this case, anemia and hypotension probably caused exponential drop in oxygen delivery to the cord. Can argue about whether it’s the anesthesiologist’s responsibility (read: duty to the patient) to treat hypotension and anemia at various points in time and locations postop.

 

[MirrorTodd]

Basically, this lady needed a real doctor making her medical decisions and not some arrogant hopped up scalpel jockey. I'd like to hear more about that "refuses to let the pt have a blood transfusion." Was the Ortho at the bedside during that discussion? Were they even in the hospital? Why was the anesthesiologist called first and not the Ortho doc once the pt was on the floor? Cause that's really the dividing line...once the pt is discharged from the pacu, the pt has been transferred out of our care. Now, I get it, if somebody called me about a pt not doing well postop even after the pacu, I'd still go and see them. Ultimately, the way this reads is that the care team didn't make the right decision which lead to a bad outcome.

 

[Man o War]

Basically, this lady needed a real doctor making her medical decisions and not some arrogant hopped up scalpel jockey. I'd like to hear more about that "refuses to let the pt have a blood transfusion." Was the Ortho at the bedside during that discussion? Were they even in the hospital? Why was the anesthesiologist called first and not the Ortho doc once the pt was on the floor? Cause that's really the dividing line...once the pt is discharged from the pacu, the pt has been transferred out of our care. Now, I get it, if somebody called me about a pt not doing well postop even after the pacu, I'd still go and see them. Ultimately, the way this reads is that the care team didn't make the right decision which lead to a bad outcome.

I can’t tell you how many medicine discussions I’ve had over the years with clueless, arrogant ortho surgeons.
It is so backwards that they are among the highest paid physicians.

 

[okayplayer]

Interesting discussion but if you were my friend and I told you about this, I might not want you to 1. Post about this on a public Internet forum and 2. Include the really unnecessarily specific detail of the city this took place in. Consider editing your post.

 

[coffeebythelake]

I can’t tell you how many medicine discussions I’ve had over the years with clueless, arrogant ortho surgeons.
It is so backwards that they are among the highest paid physicians.

Its all $$$. Once they get into ortho residency they forget most of medicine.

 

[IlDestriero]

The only service that’s ever called me for medical decision making after discharge from the pacu was OB. The patient should not be discharged to the floor unless stable and recovered, and when on the the floor they should have called the surgeon. This anesthesiologist got totally screwed. They notified the surgeon about an issue in a timely manner that they were responsible for managing and the ahole ignored the problem and then blames the anesthesiologist.
My father in law was sued for a similar kind of problem. They noted a post op problem, appropriately notified the responsible physician who didn’t do anything about it and it directly lead to a catastrophic outcome. It went to trial as they alleged he had a responsibility to follow up on the patient because he knew the surgeon was home. Ridiculous. Not his patient. He won, but it was a couple years of unnecessary stress, etc. The surgeon claimed he misunderstood what the other physician told him. BS. Documentation was key. Surgeon could have read the report the next AM, but didn’t, and also ignored worsening vitals, etc. until it was too late to recover. The dbag just wanted to shed some of the blame and dilute the settlement around. The story is actually much more complicated and has twists that are unbelievable. Unfortunately the surgeon that ignored the problem only ended up catching 1/2 the blame, when it should have been all. It was his arrogance and laziness that lead to the completely avoidable catastrophe.

 

[deleted682700]

Only for educational and awareness purpose. Just order blood transfusion and if Ortho wants, he can write his own orders. That way you have made a decision and documented in the chart. Too restrictive criteria for blood transfusion in Small community settings may be a disaster. The saving graCe in this case was that there was clear documentation that the spinal regression was noted. The anesthesiologist did go back to the hospital physically.

This an usual spot to get ischemic, but maybe she had some pre-existing vascular disease in that area and the spinal cord was vulnerable in one particular area. Excellent point. Is there any way to recognize This vulnerability preop

 

[epidural man]

Basically, this lady needed a real doctor making her medical decisions and not some arrogant hopped up scalpel jockey......... Was the Ortho at the bedside during that discussion? Were they even in the hospital? Why was the anesthesiologist called first and not the Ortho doc once the pt was on the floor?

you may have answered your own question.

it is possible that this ortho has the reputation of not responding or making the right decisions and the anesthesiologist was known for his diligent and spectacular patient care, and is kind to the nurses.

 

[nimbus]

In the setting of hypotension with a hemoglobin of 6, I would give the blood and let the surgeon know as a courtesy. I would not be asking their opinion.

 

[IlDestriero]

In the setting of hypotension with a hemoglobin of 6, I would give the blood and let the surgeon know as a courtesy. I would not be asking their opinion.

But at that point when they are on the floor, they’re not your patient anymore, are they? I suppose you, in your confrontation with the surgeon after giving the blood, could say your OR management lead to the low HGB, so you were obligated to act and order the product. Of course when you’re defending good and sound medical practice you would have to deliver it with a heaping pile of faux apologies and dripping in sarcasm.

 

[GassYous]

But at that point when they are on the floor, they’re not your patient anymore, are they? I suppose you, in your confrontation with the surgeon after giving the blood, could say your OR management lead to the low HGB, so you were obligated to act and order the product. Of course when you’re defending good and sound medical practice you would have to deliver it with a heaping pile of faux apologies and dripping in sarcasm.

What if it were something directly attributable to your intraoperative management? Can't think of a good situation but let's say a patient was inadequately reversed and hypoventilated but somehow managed to make it out of pacu to the floor.

 

[Maverikk]

Ouch, that's a terrible outcome for that patient. Others have said it above: what medical decision are you asking when you talk to orthos? Keep it sweet and simple and lets both do our jobs. Most of the ones don't care/don't want to know until the end of the case if I've given blood, if they're hitting a lot of bleeding they let me know (usually after a liter is already in the bucket and I'm already transfusing). I have to say if the anesthesiologist is the one getting called or going back to the hospital for hypotension something is wrong beyond the levels of this specific case. My 2 cents: older, CADers I usually keep a lower threshold for transfusing but most of the orthos I work with don't spill too much, I do give them albumin (don't tell anyone). I'm sure if I had some crazy partner transfusing to high levels it'd be noticed.

 

[coffeebythelake]

why didn't ortho want to transfuse? they were afraid of surgical site infection??

 

[anbuitachi]

why did the anesthesiologist get called from home about a patient on floor? unless this is specifically how this practice works... otherwise i wouldve just told them to call the surgeon. i dont even want to know the story. if surgeon isnt responding, call medicine/ICU/EM consult/rapid response, whoever is in house. once the patient leaves PACU, its not my patient. its probably a violation of some sort to provide treatment to patient that isnt yours. i certainly do not put in orders for not my patients

 

[deleted171991]

In my short presence here tonight, let me fix some really bad medicine on this thread, before the trainees start drinking the Kool-Aid, too (especially the latest generations which have been discouraged to transfuse blood).

Before I start, let me remind everybody that some people live with Hgb of 4 g/dL, without complications. But that anemia is CHRONIC, and those people's blood pressures are at baseline.

The problem in this case wasn't that the Hgb was 6 and the patient was not transfused. Heck, she could have paralyzed even with a Hgb of 8. The crux of this case is that we have a patient who loses a lot of blood, an anesthesiologist that thinks like a CRNA and keeps giving crystalloids, despite the hypotension not resolving, a PACU team that discharges the patient with a borderline/low BP, and a surgeon who's also stupid and uses protocols instead of medical knowledge and brain. I wouldn't be surprised if this was a patient with a baseline MAP of 110 (BP 150/90), and the postop MAP was 60-70 (BP 80/50-90/60).

Now back to the physiology. Why does chronicity matter in this case? Because chronicity allows the body to compensate, especially by adjusting its Hgb-O2 dissociation curve. Those 2,3-DPG changes don't just happen in hours. This was untreated severe ACUTE anemia. What makes it severe? It's not the Hgb of 6. Had the patient started with a chronic Hgb of 8, she probably wouldn't have even noticed the anemia. It's the DELTA, the difference between the starting hemoglobin and the one the patient ended up with. She must have lost like 1/3 of the blood volume.

Let's mention again the stupid protocols that say that one should transfuse at 7 g/dL (and 8 for patients with cardiac comorbidities). Not at 7.1, and definitely at 6.9, say the protocol bureaucrats. Those numbers are based on weak studies. There is no proof that 8 is safe, especially not in ACUTE anemia. There is no proof that 7 is the magic number, just that a transfusion target of 9-10 is no better than 7-8. It's just that the studies most protocols are based on were done with a transfusion threshold of 7 g/dL in the restrictive group. We don't have good studies with 6-7, AFAIK. So do NOT transfuse based on numbers, but based on the patient's clinical status.

What does oxygen delivery to tissues depend upon? I am not going to use some stupid formula, just common sense:

1. Flow to tissue. More flow, more O2. Vasoconstriction, e.g. due to hypotension, is bad.
2. Amount of Hgb in the blood.
3. Saturation of said Hgb with O2.
4. The extraction ratio in the periphery (e.g. the heart can extract way more oxygen than other tissues), aka the difference in the oxygen content of the blood between the arteriolar and venous end of the peripheral capillary. (Most healthy tissues get about 4-5x more O2 than they need, but that's also because most suck at oxygen extraction when ischemia hits the fan. What's the lowest SvO2 you have ever seen in sepsis? Even the heart can't extract more than 75%.)

What happened in this case? The patient bled, A LOT. The blood loss was replaced by the CRNA++ only with crystalloid. Bad move. The persistent hypotension should have been a serious red flag that the patient needed blood, even if the finger O2 sat was OK. Let me explain why.

BP is directly proportional to CO and SVR. If one replaces acute blood loss with crystalloid, the CO remains unchanged. However, if you take a careful look at the formula of resistance to laminar blood flow through a vessel (image borrowed from Wikipedia):

where

• R = resistance to blood flow
• L = length of the vessel
• η = viscosity of blood
• r = radius of the blood vessel

Everybody who looks at this equation tends to forget about η. Every anesthesia trainee will recite that the resistance is directly proportional to the length of the IV line, and inversely proportional to the fourth power of the radius, but usually not one remembers VISCOSITY as a component of resistance to flow. If viscosity drops, as when there is significant blood loss diluted by crystalloid-only replacement, SVR drops. If SVR drops, BP drops, and then peripheral flow drops as a result of reflex vasoconstriction. And, voila, ischemia!

OP, your anesthesiologist friend was extra-lucky for not being found responsible for 50% of the damages. Had I been an expert witness, that's what I would have suggested. An anesthesiologist's work doesn't end until the patient is discharged from the PACU. If the patient was hypotensive at the time, the anesthesiologist of record (or the on-call anesthesiologist s/he had signed out the patient to) was responsible.

tl;dr:
"Kids", do not transfuse patients based on numbers, but on clinical status. Humans are not machines; each individual is different. Do not treat numbers, treat patients. A Hgb of 8, coming from 13, is way more dangerous than a Hgb of 6, coming from 7. A blood loss of 1.5L in 3 hours is way more dangerous than the same over a month. Acute anemia should be treated with blood (at least partially), whenever the blood loss is significant (e.g over 1L). Postoperative hypotension that does not easily resolve with crystalloid requires administration of blood. It doesn't take much; many times, just 1-2 units of PRBC for all problems to go away. Like magic.

If you EVER get into a similar situation, do 4 things:
1. Tell the nurse to call the in-house surgical team and the surgeon.
2. Call the surgeon yourself, if you feel it's warranted.
3. Call your in-house colleague and have them go evaluate the patient, and even order blood transfusion if needed.
4. Document everything, either remotely, or have your colleague write a note that you will addend the next day.

Always do what's right for the patient. NEVER LET BUREAUCRACY OR LAZINESS, OR THE SURGEON, STAY IN THE WAY OF GOOD PATIENT CARE! "Not my patient" doctors don't deserve a medical license. Don't abandon your patients the second they roll out of the PACU. Use the Silver Rule: don't do onto other people's loved ones what you wouldn't want to be done to yours, especially in an urgent/emergent situation.

Good night and good luck! The break is over.

 

[anbuitachi]

Always do what's right for the patient. NEVER LET BUREAUCRACY OR LAZINESS, OR THE SURGEON, STAY IN THE WAY OF GOOD PATIENT CARE! "Not my patient" doctors don't deserve a medical license. Don't abandon your patients the second they roll out of the PACU. Use the Silver Rule: don't do onto other people's loved ones what you wouldn't want to be done to yours, especially in an urgent/emergent situation.

Good night and good luck! The break is over.

there needs to be an order of how things should be done. call the surgeon. if the surgeon needs help and no in house ppl to help, id be willing to help. but dont call me first. thats not how it works. i always hated it when im covering PACU and surgery team just puts in orders of blood/fluid boluses or whatever without even telling me.