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95yo who presented for hip hemi arthoplasty s/p hip fx. h/o CAD s/p 3v CABG, afib + critical AS (0.3cm2), moderate to severe mitral stenosis (w/ mild-mod mitral regurg), severe pulm HTN (PAP 78).
Heh. High risk, a talk is in order, but just because he's already 83% dead doesn't mean that palliative surgery is unreasonable, so I wouldn't argue with the decision to operate.
Epidural or intrathecal catheter is an option. Is he anticoagulated because of his afib?
Rate control if needed, a-line. Minimal induction, amnestic, paralytic, narcotic, touch of gas, no nitrous, LMA. Keep him where he lives, barely.
any worry about the epidural with the critical AS?
I agree with the plans above. One thing I would do in the discussion with the family is see if this 95yo is bedbound or is actually able to get up and do things for themselves. If pt is bedbound, and if the fracture is amendable, maybe the orthopod could do a pinning instead of a hemi. The pinning may not be the best way to fix it, but in a bed bound pt and considering the risks involved it may be good enough. I've seen pinnings done under MAC/local, this would be a case where I would consider it.
Aline pre induction. Etomidate/sux/tube.
I would try to talk the orthopod out of it.
95yo who presented for hip hemi arthoplasty s/p hip fx. h/o CAD s/p 3v CABG, afib + critical AS (0.3cm2), moderate to severe mitral stenosis (w/ mild-mod mitral regurg), severe pulm HTN (PAP 78).
Thx for posting something clinical bostonblaz... something I feel the forum has been missing as of lately.
A lot of different approaches mentioned above. I like sticking needles in people... it's my favorite type of anesthetic. However, in the patient mentioned above LMA would be my weapon of choice supplemented with a fascia illiaca at the end of the case.
Rate controlled before seeing the white of my eyes. A-line with Vigileo/CO monitor, Neo drawn up, NTG in the room, mask induction with O2/Sevo + 5 mg amidate, gentle placement of LMA with .5 age adjusted MAC for the case. Keep em breathing throughout with boluses of 25 mcgs of fentanyl at a time --> looking for RR of 8-12 - avoiding resp. acidosis in light of his pulm/htn. Would also avoid nitrous as was mentioned above.
A lot of the time these older folk respond very well to IV narcs, and infiltrative/peripheral LA meds. Have the surgeon inject diluted LA in the capsule and skin. Supplement with a Fascia Illiaca. IMO, a hip is a lot less painful than knees and other ortho procedures.
I think epidural and spinal catheters are perfectly fine modalities. However, with AV area of .3cm Id dose it up slowly and that would take time. I think I can achieve the same intra and post operative goals with an LMA and FI and in a lot less time. I dont see the need of an ETT unless you really think the guy is going to code on the table or there is another reason to use one. In light of PA pressures nearing 80s and h/o afib, Id rather avoid sympathomimetics such as an ETT. That is just me though... I know some people don't like putting in LMA's in the lateral position. 95 y/o with a good AW would be OK with me. I've dropped ETT in the lateral position before. Not a problem with the easy AW.
Agree with pgg, mortality is nearly 100% if you dont fix the hip. Good conversation with patinet and family upfront and then back to the OR.
Lot's of diff. ways to skin this cat... this is just my approach.
Thx for posting something clinical bostonblaz... something I feel the forum has been missing as of lately.
A lot of different approaches mentioned above. I like sticking needles in people... it's my favorite type of anesthetic. However, in the patient mentioned above LMA would be my weapon of choice supplemented with a fascia illiaca at the end of the case.
Rate controlled before seeing the white of my eyes. A-line with Vigileo/CO monitor, Neo drawn up, NTG in the room, mask induction with O2/Sevo + 5 mg amidate, gentle placement of LMA with .5 age adjusted MAC for the case. Keep ‘em breathing throughout with boluses of 25 mcgs of fentanyl at a time --> looking for RR of 8-12 - avoiding resp. acidosis in light of his pulm/htn. Would also avoid nitrous as was mentioned above.
A lot of the time these older folk respond very well to IV narcs, and infiltrative/peripheral LA meds. Have the surgeon inject diluted LA in the capsule and skin. Supplement with a Fascia Illiaca. IMO, a hip is a lot less painful than knees and other ortho procedures.
I think epidural and spinal catheters are perfectly fine modalities. However, with AV area of .3cm I'd dose it up slowly and that would take time. I think I can achieve the same intra and post operative goals with an LMA and FI and in a lot less time. I don't see the need of an ETT unless you really think the guy is going to code on the table or there is another reason to use one. In light of PA pressures nearing 80‘s and h/o afib, I'd rather avoid sympathomimetics such as an ETT. That is just me though... I know some people don't like putting in LMA's in the lateral position. 95 y/o with a good AW would be OK with me. I've dropped ETT in the lateral position before. Not a problem with the easy AW.
Agree with pgg, mortality is nearly 100% if you don't fix the hip. Good conversation with patinet and family upfront and then back to the OR.
Lot's of diff. ways to skin this cat... this is just my approach.
how comfortable are you letting the CO2 rise?
TLC = Triple lumen cath? Seems unnecessary to me for the case unless access was very poor.
urge said:I would try to talk the orthopod out of it.
2 hours ago I finished one of these.
91 year old woman with a hip fracture (near-syncope fall) added on for a hemiarthroplasty.
CAD, hx 3 MIs, most recent Aug 2010. CABG, stents, pacer. Her cardiologist said her last admission was a "code to remember" with dozens of defibrillations, then said he regretted not implanting a pacer-AICD. EF 30% with mod-sev MR and AR, so who knows how much of that EF is going forward. Right carotid 90%, left 80%, multiple TIAs. Good lungs. DNR/DNI since last admission but she rescinded it for the surgery. Plavix last night, Lovenox this morning.
Looong talk with patient and daughter about high risk of surgery, 1 year mortality, and first 2-3 days postop risk. They acknowledged and accepted the risk. Ortho surgeon gave them the same grim talk (presumably with shorter words and some grunts, orthopod style ) and reserved an ICU bed for her.
She came to the OR with a 22 g PIV which was infiltrated. I put in a pre-induction a-line (right side ... felt for a pulse on the left for a good 30 seconds before noticing the scar ... "oh yeah they took that for my bypass" ). Got a 20 g PIV. Gentle induction with midazolam, fentanyl, phenylephrine, roc, and 6 of etomidate. Asleep, ETT. Phenylephrine infusion through most of the case, kept her MAP at preop levels. R IJ TLC because her access sucked. Fentanyl. Extubated awake in OR, with preop mental status.
This particular surgeon does a fascia-iliaca-like block himself intraop, usually 30-40 mL 0.5% ropivacaine to the compartment and infiltrated around the surgical site. Otherwise I'd have done one preop. His version usually seems to work OK, but not today ... she needed another 400 of fentanyl from me after waking up.
We do these all the time. I can't remember the last time I argued not to do one ... yeah, they're high risk patients, but it's palliative surgery, you can't just leave them in bed like that until they die unless they're already comfort care.
I would try to talk the orthopod out of it.
I think it's pretty reasonable. Mitral stenosis is underappreciated risk for induction. The combination of MS and pulmonary HTN is a killer. AS makes it even worse. CPR is worthless and would never circulate peripheral drugs. The only hope is to give centrally. After a several unfortunate cases we now put in preinduction central lines in all of our MS patients.
orthopods believe all fractures to be mendable, not amendable. just avoid asystole.
So you put an introducer in MS patients preinduction? How well does that go over?
400 of fentanyl for a 91 year old lol.
Nice to chat medicine again instead of politics. Thanks for the posts.
And don't forget they believe the heart exists solely to pump blood to the bones.
95yo who presented for hip hemi arthoplasty s/p hip fx. h/o CAD s/p 3v CABG, afib + critical AS (0.3cm2), moderate to severe mitral stenosis (w/ mild-mod mitral regurg), severe pulm HTN (PAP 78).
At 95 years, even if he were completely healthy, the likelihood of being alive in one year is 50% (US actuarial data). Add in a pinhole aortic outlet, pulmonary hypertension, mitral stenosis, and the other problems associated with his extreme age, and his survival living until tomorrow is probably just 50%. Does he even want the surgery, or instead is the family asking for all measures? Even if the orthpods fix the hip, and lives to get to a ward, will he survive to discharge? Read the rest of the echo report for systolic & diastolic function. Assuming normal coags, cooperative surgeons, and everybody chooses to move forward knowing the risks, then incrementally dosed epidural as tolerated, lots of local, supplement with dexmedetomidine gtt with all the goals for AS, MS, CAD, and Pulm HTN. Oh, and also clarify exactly what the patient/family wants when he becomes pulseless.
He was very happy and appreciative and (bad omen) nice.
- pod