Pre-op Issue

[behindthadeuce]

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49 yr old female suffers a mid-femur fracture late saturday night. Ortho schedules her for IM nail sunday morning. Patient has h/o DM2, htn - and is apparently otherwise healthy. Case is quoted as being "urgent" (not emergent).

On admission, her ecg is noted to have LBBB with no previous ecg for comparison. On further questioning, patient states she had an episode of CP and DOE a few weeks ago. Medicine sees the patient and recommends a Dobutamine stress echo prior to going to OR. Ortho, of course, is pushing to proceed with the case. They call you and say they will defer to you... What's the play?

[my thoughts are...this patient could have easily suffered an MI recently and/or still have heart tissue at risk. question is, if you stress her and it's positive, will they place a stent and go on ASA + plavix prior to drilling into her femur?]

 

[mhause]

How did it break?

 

[ProRealDoc]

49 yr old female suffers a mid-femur fracture late saturday night. Ortho schedules her for IM nail sunday morning. Patient has h/o DM2, htn - and is apparently otherwise healthy. Case is quoted as being "urgent" (not emergent).

On admission, her ecg is noted to have LBBB with no previous ecg for comparison. On further questioning, patient states she had an episode of CP and DOE a few weeks ago. Medicine sees the patient and recommends a Dobutamine stress echo prior to going to OR. Ortho, of course, is pushing to proceed with the case. They call you and say they will defer to you... What's the play?

[my thoughts are...this patient could have easily suffered an MI recently and/or still have heart tissue at risk. question is, if you stress her and it's positive, will they place a stent and go on ASA + plavix prior to drilling into her femur?]

Regional. Next.

 

[Noyac]

Do the case however you want to. But do it before cardiology gets their hands on her.

 

[Jeff05]

hip fracture + having to be bedbound for 6 weeks after stent = death.

a line. place epidural and slowly bring up level. minimal sedation.
have the attending do most of the nail - it should take 20 min.

then let cardiology do their thing. this way you, as a physician, would have chosen the BEST most REASONABLE way to take care of this human being. and not Dr. Smith, GED, BA, RN, DNP who putS together convenient patient care flow charts.

49 yr old female suffers a mid-femur fracture late saturday night. Ortho schedules her for IM nail sunday morning. Patient has h/o DM2, htn - and is apparently otherwise healthy. Case is quoted as being "urgent" (not emergent).

On admission, her ecg is noted to have LBBB with no previous ecg for comparison. On further questioning, patient states she had an episode of CP and DOE a few weeks ago. Medicine sees the patient and recommends a Dobutamine stress echo prior to going to OR. Ortho, of course, is pushing to proceed with the case. They call you and say they will defer to you... What's the play?

[my thoughts are...this patient could have easily suffered an MI recently and/or still have heart tissue at risk. question is, if you stress her and it's positive, will they place a stent and go on ASA + plavix prior to drilling into her femur?]

 

[Planktonmd]

Do the case however you want to. But do it before cardiology gets their hands on her.

Exactly.

 

[ProRealDoc]

hip fracture + having to be bedbound for 6 weeks after stent = death.

a line. place epidural and slowly bring up level. minimal sedation.
have the attending do most of the nail - it should take 20 min.

then let cardiology do their thing. this way you, as a physician, would have chosen the BEST most REASONABLE way to take care of this human being. and not Dr. Smith, GED, BA, RN, DNP who putS together convenient patient care flow charts.

GED= good enough diploma.

 

[Monty Python]

not Dr. Smith, GED, BA, RN, DNP who putS together convenient patient care flow charts.

 

[dfk]

hip fracture + having to be bedbound for 6 weeks after stent = death.

a line. place epidural and slowly bring up level. minimal sedation.
have the attending do most of the nail - it should take 20 min.

then let cardiology do their thing. this way you, as a physician, would have chosen the BEST most REASONABLE way to take care of this human being. and not Dr. Smith, GED, BA, RN, DNP who putS together convenient patient care flow charts.

where did the hip fx come from?

 

[cchoukal]

Agree with above, unless the orthopod is willing to operate on clopidogrel and ASA. If so, is there benefit to stressing her first (assuming the stress ultimately leads to a stent)? Is her morbidity/mortality lower for the IM nailing if she's revascularized first? There were a couple papers in Anesthesiology last year regarding timing on noncardiac surgery after stenting. With regard to drug-eluting stents, there was no significant assocation with timing, although outcomes were better if surgery was >1yr after stent. With bare metal stents, there was a significant effect for timing after 90 days. The upshot really was that, for either stent, the outcomes were better the longer you waited. What I don't recall, though, was whether these noncardiac surgeries were done on or off dual anti-platelet agents. Anyone remember? If the agents were stopped for the surgery, the timing recommendations don't really apply to this patient.

But my point, I guess, is that if the orthopod is willing to operate with the patient on dual anti-platelet agents, there might be benefit to stressing the patient, and THAT is the question to ask the orthopod when s/he "defers to you." The likelihood is s/he is not, and so you'd proceed. I think the epidural with the a-line is a great approach.

On the other hand, there's probably evidence that she is hypercoaguable during her IM nailing (even with the anti-platelet therapy) and that's maybe not the best thing with fresh stents.

 

[Calilove]

49 yr old female suffers a mid-femur fracture late saturday night. Ortho schedules her for IM nail sunday morning. Patient has h/o DM2, htn - and is apparently otherwise healthy. Case is quoted as being "urgent" (not emergent).

On admission, her ecg is noted to have LBBB with no previous ecg for comparison. On further questioning, patient states she had an episode of CP and DOE a few weeks ago. Medicine sees the patient and recommends a Dobutamine stress echo prior to going to OR. Ortho, of course, is pushing to proceed with the case. They call you and say they will defer to you... What's the play?

[my thoughts are...this patient could have easily suffered an MI recently and/or still have heart tissue at risk. question is, if you stress her and it's positive, will they place a stent and go on ASA + plavix prior to drilling into her femur?]

I agree with regional... Also I want to address the potential for cardiopulm decompensation. I'd be less worried over ONE previous episode of CP and DOE... i mean, was this anxiety related, GI, etc? If this were the case, full speed ahead.

If patient has had progressively worsening DOE and CP... hold it now! I'd remember that the regional anesthetic might turn into a general anesthetic secondary to difficulty of procedure, blood loss, failure of block, etc. As long as the patient is STABLE hemodynamically, I'd repeat EKG, baseline cardiac enzymes (especially if history of HTN and DM---silent ischemia), and least have the CARDIOLOGY consult evaluate the patient.

I wouldn't yield to the surgeon's requests to "just get on with the case". If that patient has an MI on the table, the surgeon will become the pillar of deference to the anesthesiologist's preoperative evaluation.

So, I'd definitely PAY ATTENTION to the patient's CP and DOE, while putting it into context. The patient's getting an a-line and central line...

If preexisting comorbidities and STABLE hemodynamically: HTN, DM, h/o recent CVA/MI, elderly, CHF, COPD.... and with progressive CP and DOE.... get Cardiology involved! I would NOT pass GO without that eval!
If no preexisting comorbidities and STABLE: if CP and DOE are NOT progressive, i'd repeat the EKG and take to OR, and see Cardiology post op
If NOT stable: to the OR, esmolol/NTG, not a teaching case!

 

[Trisomy13]

If NOT stable: to the OR, esmolol/NTG, not a teaching case!

not for ortho anyway.

great teaching case for the anesthesiology resident 👍

 

[jetproppilot]

Do the case however you want to. But do it before cardiology gets their hands on her.

👍👍