Something Clinical for a change

[bostonblaz]

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).

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[Stillwater45]

hmm..... I would start with a long sobering talk with the family.

 

[Idiopathic]

epidural

 

[pgg]

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.

 

[El Dooderino]

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?

 

[pgg]

any worry about the epidural with the critical AS?

No, I'd just bolus it with 20 cc of 2% lidocaine. One big hit.







There's no reason you can't use an incrementally dosed epidural or intrathecal catheter in someone with critical AS. You just have to be careful and keep their BP up. Phenylephrine does nicely.

The single shot spinal with its rapid afterload drop is the classic clean kill here, but an epidural is fine.


I actually tend to prefer GA with an LMA in the 95 year old hips. Positioning them for anything neuraxial is a cruel ordeal, and it's hard on the patient too. Most of the time they're on Plavix or Coumadin anyway.

 

[OB1🤙]

If no coag concerns, spinal catheter all the way. Works beautifully for these types of cases, though AVA 0.3 combined with the MS and resultant pulm htn is.... just slightly concerning.

Could be done as epidural too, I just think the spinal catheter is a little more reliable for surgical anesthesia purposes.

 

[deleted126335]

Aline pre induction. Etomidate/sux/tube.

 

[pd4emergence]

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.

 

[nap$ter]

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.

orthopods believe all fractures to be mendable, not amendable. just avoid asystole.

 

[urge]

I would try to talk the orthopod out of it.

Although I am sure it can be done, I don't see the point. This pt will most likely die before completing rehab. Lawyers will have a field day.

I wonder why she hasn't had her heart fixed, but the hip needs fixing.

 

[gtb]

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.

 

[gaspasser2004]

Aline pre induction. Etomidate/sux/tube.

I second this. Control the airway/hemodynamics and keep it simple.

 

[pgg]

I would try to talk the orthopod out of it.

Not me ... this isn't a "full code" lost cause torture project in the ICU.

This patient can die in bed with a painful broken hip sometime in the next week or year or so. Or he can die in bed with a fixed not-quite-as-painful hip sometime in the next week or year or so.

If the patient wanted a morphine drip and Hospice care, I wouldn't argue. But provided the patient, family, and surgeon have had the appropriate realistic talk, to deny a person palliative surgery (whether a hemiarthroplasty or perc pin or whatever) because we know they're likely to die soon isn't right.

 

[sevoflurane]

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 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.

 

[Idiopathic]

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? Thats something that I would try and avoid. I think epidural is the way to go and so what if it takes a little extra time. Its probably the safest way to do the case, IMHO. Add in some precedex or very low dose prop/remi maybe...

 

[sevoflurane]

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.

I would add pressure support (if I had to) in order to keep him normocarbic. Easily done. Vigileo would show me reductions in CO if pulm. htn were to manifest itself.

Just another way idiopathic. If time is not of the essence, then epidural would be great for intra and post-operative management.

 

[dhb]

how comfortable are you letting the CO2 rise?

Pressure support is your friend

 

[bostonblaz]

I did have a few things in my favor. First, she was CV compensated w/ EF 50% and the ability to be asymptomatic despite BPs 150-180 on the floor. Also, pt had a normal mental status pre-op. my main peri-op goals were to maintain afterload, prevent tachycardia, and avoid RHF that could result from any exacerbation of her Pulm HTN (CO2, O2, H+, fluid shifts). Pre-op the pt got an a-line, TLC, and fascia illiaca block. I knew the FI block would not cover the entire surgical area but the benefits of any decrease need for post-op narcotics (HR control / sedation) outway the risk of this relatively benign block. Goals for induction were to maintain BP, prevent tachycardia and safely take over ventilation (high CO2 / low O2 can exacebate PAP). With BIS monitor on I started to induce with 40mg Propofol (BIS decreased from 90s-60s). Once I took over pt’s ventilation we gave ROC. Pt tolerated PPV well. BP decreased from 180-120 but responsive to Neo. I titrated another 60-80mg Propofol while ROC was setting in. Had an EZ intubation. I used TIVA for maintanace of amnesia. Dosing started at 75 ug/k/m and decreased to 25 by end of case. I titrated fentaly for analgesia. Starting Hgb was 9.1 so I slowly gave 1 unit RBCs over an hour and 10mg lasix to help prevent fluid overload. Also got 200cc crystaloid… EBL about 150, UO was 225cc for case. Pt woke up with baseline mental status in OR and transferred to MICU for observation overnight. was a great start to the new year.

 

[proman]

Nicely done. The echo info seems strange. I don't really believe an AVA of 0.3 WITH MS/MR and preserved EF. Do you know how the AVA was derived (planimetry maybe?) When was the CABG? Had there been a recent cath?

 

[Arch Guillotti]

TLC = Triple lumen cath? Seems unnecessary to me for the case unless access was very poor.

 

[proman]

TLC = Triple lumen cath? Seems unnecessary to me for the case unless access was very poor.

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.

 

[ucsfgaspain]

Haven't been on the board in a while. I did an exact case like this a few months ago. I gave him the sobering M&M statistics. I also gave the surgeon the stats but since he was cleared by cards. The patient and the surgeon still wanted to go ahead. I did it as a GETA, had my phenylephrine going ahead of time, before induction, titrated slowly in what ever induction agent you wanted, kept him as euvolemic during the case as best as I could determine with observation of blood loss and serial abg. Got him through the case great and out of the PACU fine. I ran him tight with phenylephrine titrated as needed in the pacu just to keep his map at his preop level as I was waiting for all the anesthetics to wear off. I insisted on him going to unit, despite the grumblings of everyone that I was overblowing the risks. That night 12 hours later, he told the nurse, "I don't feel well". Clutched his chest and died Getting him through the surgery is pretty easy, getting him through the post op period is what is hard. The unit despite their best intentions is not the OR. They do not respond in the same way as we do. I thought that the relatively recent chest article has shown that overall periop mortality is on the order of 20%. Just using stats you can have a decent run before a death occurs.

The solace I took from the case, is that I at least manned up and told the patient the truth about his risks. Everyone else was too much of a wimp to do so.

 

[pgg]

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.

 

[Arch Guillotti]

400 of fentanyl for a 91 year old lol.

I think the come to Jesus talk is important. It may not do anything medicolegally but I think it makes all of use feel better. If you make a connection with the family, clearly elaborate on the risks and document accordingly then I think that in the event of a bad outcome you will be as well shielded as possible.

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.

 

[Arch Guillotti]

I would try to talk the orthopod out of it.

I wouldn't. I would briefly read the orthopod the riot act, then do the case.

 

[Arch Guillotti]

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.

I still wouldn't do a TLC unless access was poor, especially a preinduction TLC. I think that an aline preinduction is fine to proceed ahead, but that's me. If she were to crump after the induction, you could always do a dirty stick on the IJ or put in a quick EJ. I have been involved in a few cases with CPR in progress with an aline and I always found it surprising the pressures that were generated.

So you put an introducer in MS patients preinduction? How well does that go over?

 

[jwk]

orthopods believe all fractures to be mendable, not amendable. just avoid asystole.

And don't forget they believe the heart exists solely to pump blood to the bones.

 

[proman]

So you put an introducer in MS patients preinduction? How well does that go over?

It's fine, a lot of local. The line of choice for cardiac anesthesia here is the 9fr MAC. A touch of sedation and "ok" anesthesia. The vast majority of patients here had preinduction central lines placed in the past (along with 100% getting a lines). When the hospital expanded the cardiac ORs they didn't build induction rooms. Now, only patients with a clinical indication for the preinduction line get them. There is a new hospital being built with induction rooms for the future. The belief is that turnover will be expedited with second cases getting preinduction lines.

We are, after all, the only ones in the hospital who do routine central lines under anesthesia.

 

[pgg]

400 of fentanyl for a 91 year old lol.

Yeah, not even a chronic pain patient. I kept expecting her to turn grayish blue but no.

 

[gtb]

Nice to chat medicine again instead of politics. Thanks for the posts.

 

[RT2MD]

Nice to chat medicine again instead of politics. Thanks for the posts.

I've had fun following along... even if I don't really understand a lot of it.

Thanks to all for the discussion.

 

[fakin' the funk]

And don't forget they believe the heart exists solely to pump blood to the bones.

Ours believe the heart exists solely to pump cefazolin to the bones.

Usually 2-3g for a 2-4 h joint replacement. Sometimes 1 or 2g to start. Sometimes 2g for <80kg patients, to start. Sometimes a bonus gram while the tourniquet for the TKA is still up.

Effing brilliant. I should probably just stop giving all the voodoo extra doses, but act like I did.

 

[periopdoc]

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).

Did pretty much the same case a few weeks ago, minus the MS, plus a small MI about an hour after his fall and 12-24 hours prior to surgery. Troponins were elevated but trending down. Latest cath report showed in-stent restenosis not amenable to further therapy and he had terrible targets for CABG. He also had pulmonary disease from asbestos exposure.

Quoted the guy a 40% chance of making it out of the OR and a 40% chance of making it out of the ICU if he survived the OR.

He was active and wanted his hip fixed and would rather die than convalesce.

A-line, PIV 50ish mg propofol, 50 mg of roc, some fent ETT and TEE for the hell of it. Did fine except for some transient pressure drops when they were drilling/ hammering and showering his PA with emboli.

Aortic stenosis by my exam was less significant than advertised. More in the severe range.

I would have extubated him at the end of the case, but at the insistence of the ICU doc I left him intubated so they could watch him overnight.

He was extubated the next day and didn't remember anything from the surgery. He was very happy and appreciative and (bad omen) nice.

~36h post-op had a massive MI and died.

Still think we did everything right, still ponder if perhaps we didn't.

That is the nature of this business IMHO.

- pod

 

[veetz]

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.

Careful w/ Dex in this situation...I've seen pretty significant drops in BP as a result of it.

 

[dhb]

He was very happy and appreciative and (bad omen) nice.
- pod

That's what killed him right there.