Tight AS and hip surgery

[loveumms]

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So we had a very interesting case scheduled for the OR today - ended up not going but I think it's worth a discussion.

95 year old female who broke her hip after falling. Pt has a history of hypertension, CVA in the past without residual defects and aortic stenosis. She also had a history of DVT for which she was on coumadin up until admission (which was two days ago) - she had gotten an IVC filter and was on heparin subQ.

Last echo was in February (after her first hip repair following a fall) and showed a peak gradient of 95 and a valve area of 0.5. Pt has not been doing anything but recovering since February and had a very difficult time with rehab.

To throw a wrench in the case; pts family member is a surgeon and doesn't want general anesthesia. Pt had her other hip fixed in February and had a tough time with GA. I mean, what 95 year old doesn't?

Pts vitals are stable and she is beta-blocked. She has a platelet count of 120 and an INR of 1.4.

What would you do?????

 

[Gas you down]

So we had a very interesting case scheduled for the OR today - ended up not going but I think it's worth a discussion.

95 year old female who broke her hip after falling. Pt has a history of hypertension, CVA in the past without residual defects and aortic stenosis. She also had a history of DVT for which she was on coumadin up until admission (which was two days ago) - she had gotten an IVC filter and was on heparin subQ.

Last echo was in February (after her first hip repair following a fall) and showed a peak gradient of 95 and a valve area of 0.5. Pt has not been doing anything but recovering since February and had a very difficult time with rehab.

To throw a wrench in the case; pts family member is a surgeon and doesn't want general anesthesia. Pt had her other hip fixed in February and had a tough time with GA. I mean, what 95 year old doesn't?

Pts vitals are stable and she is beta-blocked. She has a platelet count of 120 and an INR of 1.4.

What would you do?????

First set it straight that they have to consent to general as a backup plan. Make a point to bring up AS as a contraindication to spinal.
May be tough to position a fracture without eliciting tachycardia, so have some fentanyl and esmolol handy. Epidural,and slowly bolus up.

 

[DrBeaker]

She doesn't get any neuraxial procedure unless her coags are stone cold normal. INR of 1.4 wouldn't cut it for me. AS is another reason I wouldn't want to do spinal. Maybe epidural carefully titrated but I don't have much experience with this where I train. This needs to go urgently, and surgeon dude needs to understand that GA is what she gets. The aortic valve area is severe, and I bet she would have symptoms if able to exert herself (angina, SOB, etc). But, she has been recovering from hip surgery. Awake arterial line, phenyl ready. Keep afterload up, preload normal/up, heart rate normal to a little slow. She gets a TEE probe too.

Just curious why the case didn't go...

 

[G0S2]

Carefully titrated continuous spinal. Even with current coags.

 

[Arch Guillotti]

In a perfect world:

Frank discussion with everyone involved.
Awake art line.
Spinal catheter.
Pressors as needed.
Bombs away.

 

[pgg]

What did you delay for? Better coags?

Spinal catheters are great and I would do one with an INR of 1.4. But not if they adamantly refused GA as plan B.

My perfect world plan is an endotracheal tube and FI block, but surgeons and families dictating anesthetic plans make the world imperfect.

 

[somedumbDO]

Lumbar plexus block/ fascia iliaca w a lma and a touch o gas or sedation de jour

 

[VentdependenT]

So we had a very interesting case scheduled for the OR today - ended up not going but I think it's worth a discussion.

95 year old female who broke her hip after falling. Pt has a history of hypertension, CVA in the past without residual defects and aortic stenosis. She also had a history of DVT for which she was on coumadin up until admission (which was two days ago) - she had gotten an IVC filter and was on heparin subQ.

Last echo was in February (after her first hip repair following a fall) and showed a peak gradient of 95 and a valve area of 0.5. Pt has not been doing anything but recovering since February and had a very difficult time with rehab.

To throw a wrench in the case; pts family member is a surgeon and doesn't want general anesthesia. Pt had her other hip fixed in February and had a tough time with GA. I mean, what 95 year old doesn't?

Blood on hand. Fer $hits n giggles run TXA.



Pts vitals are stable and she is beta-blocked. She has a platelet count of 120 and an INR of 1.4.

What would you do?????

If more than anything except gamma nail
Lumbar plexus block.

or

FFP, neosynephrine on hand, epidural with slow titration of local.


If just fracture:
local with etomidate squirt for the gamma nail.

She is old and if she wants any quality of the remainder of her life she needs something done. And we should help her get it done. If she is willing to risk heart failure and death during the procedure then gear up.

Or call cards, do TAVR or ballon dilation then do whatever. This carries tons of risks too.

 

[sevoflurane]

This is a case I would not do a lumbar plexus.

 

[risnwb]

I see severe AS as being a relative contraindication to spinal. Coagulopathy is an absolute contraindication to neuraxial and also deep blocks (lumbar plexus) . Nothing is an absolute contraindication to 2 iv's, awake a-line, and GA. Not gonna do this case under spinal. Neither surgeon nor patient dictates the anesthetic. GA all the way.

 

[Jay K]

This history encompasses almost every ****in emergent hip fx that shows up on call here; Agree with the pre-induction Aline and GA. The spinal catheter intrigues me though - my n=1, but it was effective up until the surgeon changed plans and decided he wanted to cross-clamp the aorta.

 

[sevoflurane]

How long has it been since the last dose of heparin? This may be an issue for spinal catherter placement. Spinal catheter is a great way to do this case if possible (meeting anticoagulation criteria). Give fluids as you are slowly dosing up and checking your levels. I've done this for many patients like the one described.

Lumbar plexus is not my first line here. I have a lot of experience with LP blocks and I can say that 99.9% of the time they are wonderful. However, I have had a couple of epidural spreads. Since it is a volume block, there can be significant hypotension with LPB that have gone epidurally. You know it pretty quickly. Not a good combo with a tight AV. Something that is more titratable is much safer IMHO.

Of course, GA is perfectly acceptable and a fine way to do this case. No one dictates your anesthetic, but YOU as the anesthesiologist in charge. Don't ever be forced to do something you don't want to do because when push comes to a shove, it's your license on the line.

Do what is safe and the rest will follow.

 

[sevoflurane]

I see severe AS as being a relative contraindication to spinal.

But not necessarily a spinal catheter... the trick here is be able to titrate your spinal levels and have frequent BP checks (aline or otherwise) in order to make sure you keep your afterload up (and have a full tank).

 

[OB1🤙]

Spinal catheter all the way. Perfect for these cases, especially when pt and family are adamant about avoiding GA.

I put a stopcock on the end of the catheter, aspirate back a little csf, then give a cc of isobaric 0.25% bupi. Chase it with the csf. Wait a couple minutes, repeat if necessary. That 5mg will probably get you through the case, if not, redose 2.5mg at a time.

That's how I do these. How about others?

 

[Idiopathic]

awake retrograde

 

[VentdependenT]

Of course I have no business posting on cases anymore but I still enjoy the discussions.

Why spinal catheter vs epidural? Is there that much lower risk of hypotension? "Ease" of titration? We did a prone spinal fusion under mac with hypobaric on a single level laminectomy on some old dude in residency. Wicked. Never really used intrathecal catheters though. Only time I saw them was as a "rescue" for tuohy into intrathecal space.

Same attending did a VATS with thoracic epidural awake in a kid with horrible lung disease who everyone in the city of chicago refused to do...ahh that dude was a stud.

Thanks again

 

[Idiopathic]

i dont see much benefit in this case which should be quick, so building up a slow level with an epidural would be my preferred choice, also i think you would get less of a sympathectomy but i also havent done many primary IT catheters (we woudl typically place them in OB following a wet tap)

 

[Gern Blansten]

Opened this thread for the first time. Was expecting something different from the thread title. A bit of a freudian slip in my thinking and my reading skills. I really thought I saw a second "s."

 

[OB1🤙]

Less sympathectomy with an incrementally mini-dosed IT catheter (assuming an isobaric solution), with much more reliable surgical anesthesia.

In other words, it's everything you want and nothing you don't.

 

[OB1🤙]

It is also my own theory (i.e. worthless conjecture) that the risk of hematoma with an IT catheter is less than an epidural. That is, the risk of hematoma with the IT catheter is mostly related to insertion, since you don't have a catheter banging around the epidural venous plexus during advancement, during its indwelling course, or during removal.

Just my own medicolegally meaningless thoughts, backed up by exactly zero data.

 

[ssmallz]

I see severe AS as being a relative contraindication to spinal. Coagulopathy is an absolute contraindication to neuraxial and also deep blocks (lumbar plexus) . Nothing is an absolute contraindication to 2 iv's, awake a-line, and GA. Not gonna do this case under spinal. Neither surgeon nor patient dictates the anesthetic. GA all the way.

Pts dictacte their anesthetics all the time and if they say no GA it's not an option w/out looking forward to an assualt charge and loss of licence. It's important to realize that the only absolute contraindication to regional anesthesia is pt refusal. Coags, AS, and all the other stuff is really just degrees or relative contraindications that you have to weigh against the benefits and alternatives. As w/all high risk cases, documentation is key here but I have a feeling you will be on much stronger footing form a medicolegal stand point with proper documentation and a bad outcome doing a regional technique this pt accpets then doing a GA that this pt refuses

 

[Gern Blansten]

Pts dictacte their anesthetics all the time and if they say no GA it's not an option w/out looking forward to an assualt charge and loss of licence.

My stance on patients dictating their anesthetic differs if it is based on actual knowledge vs ignorance. Generally, I am able to explain to a patient why the way I plan to do it is the safest way and get them to be on board with it. If the way they wish to dictate is logical and safe, I have no problem honoring their request.

 

[risnwb]

I have a feeling you will be on much stronger footing form a medicolegal stand point with proper documentation and a bad outcome doing a regional technique this pt accpets then doing a GA that this pt refuses

Interesting, do others agree? Of course if the case was done under general it would only happen if patient and family agreed, so assuming that, is regional still the lower risk from a medico legal standpoint?

 

[Gern Blansten]

Interesting, do others agree? Of course if the case was done under general it would only happen if patient and family agreed, so assuming that, is regional still the lower risk from a medico legal standpoint?

I don't think it really matters. You explain your reasoning for your technique of choice and give the patient true informed consent explaining the pros and cons of each approach and explain to them that they have a bad disease that puts them at very high risk for a cardiac complication during surgery. If done well, they will know it is high risk (so that it is a no lose situation for the anesthesiologist). If you get them through it, you are a hero. If they have a complication (or die), the family knows you did your best and were honest with them about how sick the patient was. I think it is when you neglect to have those conversations and have a bad outcome is when you expose yourself to legal risk. The majority of people are reasonable and just want to be informed when they are at risk of dying so that they can make an informed decision about the process. In addition, if you can establish rapport with the patient and family, they are usually open to doing it the way you suggest, because "you're the doctor."
The key is to let them know they are definitely at high risk (when they really are-I am not condoning scaring all patients). When done elegantly, it can change a tense situation into a situation where everyone is on the same page and the same team instead of causing animosity.

 

[Idiopathic]

Interesting, do others agree? Of course if the case was done under general it would only happen if patient and family agreed, so assuming that, is regional still the lower risk from a medico legal standpoint?

neither should be considered malpractice, assuming plan and technique are appropriate (i.e. careful pressure monitoring, appropriate dosing, etc)

the problem in cases like this comes from "convincing" a patient or family that your suggested way is the best, and being able to do that and still maintain a rapport, because if something does happen its a lot harder to justify to them.

 

[loveumms]

It wasnt a complete fracture so disnt need to go right away. Surgeon didn't want to do it late in the evening for staffing reasons.

Pt was taken off heparin late last night, platelets checked and INR came down further. I didn't do the case but they did an arterial line and the IT catheter. Positioned pt and then slowly bolused with hypobaric bupi. Pt was doing well mid way through case (which was the last time I talked to the team doing the case). Hopefully she will survive this admission. Now she has another hip surgery to recover from.

Academic dogma says never place a spinal in tight AS. I didn't have any experience with it prior to this case and now see it can work beautifully.

I agree that epidural would cause more hemodynamics disturbances with higher risk of epi hematoma. I probably wouldn't ever do an LP either. I've seen quite a few turn into large volume epidurals (plus I just don't like them as blocks and many "experts" in the regional field no longer so them).

 

[GoldnLead]

If more than anything except gamma nail
Lumbar plexus block.

or

FFP, neosynephrine on hand, epidural with slow titration of local.


If just fracture:
local with etomidate squirt for the gamma nail.

She is old and if she wants any quality of the remainder of her life she needs something done. And we should help her get it done. If she is willing to risk heart failure and death during the procedure then gear up.

Or call cards, do TAVR or ballon dilation then do whatever. This carries tons of risks too.

Lumbar plexus is overkill for this.

unlike what someone above said, this case isn't urgent. Can wait a day or so to normalize coags.

Once they're normal, awake art line, epidural and slow titration of a couple ccs of 2% lido until adequate anesthesia achieved.

Like someone mentioned, frank discussion of significant periop morbidity and mortality risk and GA as a backup plan.

 

[GoldnLead]

Same attending did a VATS with thoracic epidural awake in a kid with horrible lung disease who everyone in the city of chicago refused to do...ahh that dude was a stud.

Thanks again

WTH???
How did you get lung isolation in a spontaneously breathing patient?

Was it just a pleur-x catheter placement or something???

 

[psychbender]

WTH???
How did you get lung isolation in a spontaneously breathing patient?

Was it just a pleur-x catheter placement or something???

There's actually a decent body of literature on awake intrathoracic and cardiac surgery under high thoracic epidural. Once you violate the pleura (open PTX), the operative lung collapses, as the intrathoracic pressure on that side equals atmospheric pressure. At the end of the procedure, a chest tube or other pleural drain can be left in, the defect sealed, and the lung will reinflate once the mechanics of regular negative pressure ventilation are allowed to resume. In the literature, this has actually been tolerated fairly well, and in the awake cardiac literature, saved some patients being urgently converted to GA in the middle of the case when the surgeons nicked the pleura, causing a small PTX, and making the awake patient cough during his off-pump CABG.

 

[fakin' the funk]

Pts vitals are stable and she is beta-blocked. She has a platelet count of 120 and an INR of 1.4.

This INR is the ONLY concern I have about doing a continuous neuraxial block, whether epidural or intrathecal.

Whether or not anyone is scared about giving this person FFP...she's a little old lady with an acute illness and therefore by definition hypovolemic unless proven otherwise.

I would give a unit of FFP and then put in an IT catheter.

 

[fakin' the funk]

How do people dose their IT catheters? 0.5-1 cc of 0.75% hyperbaric bupi at a time?

 

[fakin' the funk]

To throw a wrench in the case; pts family member is a surgeon and doesn't want general anesthesia. Pt had her other hip fixed in February and had a tough time with GA.

Family member is 100% right

 

[psychbender]

0.5-1 mL at a time of 0.25% bupivicaine is usually what I have seen and done.

 

[loveumms]

This INR is the ONLY concern I have about doing a continuous neuraxial block, whether epidural or intrathecal.

Whether or not anyone is scared about giving this person FFP...she's a little old lady with an acute illness and therefore by definition hypovolemic unless proven otherwise.

I would give a unit of FFP and then put in an IT catheter.

She also had a DVT and history of PE.

This brings up another issue - giving platelets for neuraxial placement. I usually say NO because I don't want to subject the pt to a transfusion (especially platelets) for neuraxial. Plus, I was always taught that it takes several hours after a platelet transfusion to actually have functional platelets.

 

[loveumms]

How do people dose their IT catheters? 0.5-1 cc of 0.75% hyperbaric bupi at a time?

In this case, you wouldn't want to use hyperbaric because of the lateral decub position.

They used hypobaric 0.5% bupi and boluses 1cc at a time. Patient did well.

 

[Idiopathic]

Academic dogma says never place a spinal in tight AS.

i dont know if its academic dogma so much as it is pathophysiology of disease. if you drop this patients preload and afterload acutely you put her at a much greater risk of coronary and cerebrovascular complications, thats just fact.

i dont consider an IT catheter "a spinal" as it can be more carefully titrated than a single shot spinal, which is what the above statement refers to.

 

[Mman]

I basically did this exact case a few months ago. Except we send her for a transcutaneous aortic valve replacement first and then come back and do the hip a few days later. Makes managing the AS a bit easier 🙂

 

[nap$ter]

what catheter/needle/kit do you guys use for IT placement? i've never done one or seen one done...

 

[sevoflurane]

what catheter/needle/kit do you guys use for IT placement? i've never done one or seen one done...

Any epidural kit... but I prefer the spring wound catheters as they are very soft.

I like to dose with .375% or .5%. 1 CC, then .5 cc at a time with ongoing fluids. Wonderful anesthetic, but you can't rush it. So you need patient surgeons.

 

[pgg]

what catheter/needle/kit do you guys use for IT placement? i've never done one or seen one done...

Ordinary epidural kit.

I'm going to remember Hawaiian Bruin's stopcock / CSF flush method next time I do one. Clever.


A few years ago I was talking with an OB anesthesia academic who said she expected a microcatheter kit to be available on the market again in a few years, had a prototype and everything. But that doesn't seem to have happened. Don't know if it was delayed or they quit on it.

 

[Mman]

In the literature, this has actually been tolerated fairly well, and in the awake cardiac literature, saved some patients being urgently converted to GA in the middle of the case when the surgeons nicked the pleura, causing a small PTX, and making the awake patient cough during his off-pump CABG.

Just shoot me if I'm ever party to an awake off-pump CABG. There is so much wrong with that scenario I don't know where to start.

 

[Oggg]

Opened this thread for the first time. Was expecting something different from the thread title. A bit of a freudian slip in my thinking and my reading skills. I really thought I saw a second "s."

Me too

 

[sevoflurane]

Just shoot me if I'm ever party to an awake off-pump CABG. There is so much wrong with that scenario I don't know where to start.

[YOUTUBE]http://www.youtube.com/watch?v=I_UQXUWBG6I[/YOUTUBE]

Some of you old timers might remember this pic:

Is it photoshoped? Not sure. But it's been done.

I agree though... give me some 80 proof GA with that shait.

 

[Mman]

[YOUTUBE]http://www.youtube.com/watch?v=I_UQXUWBG6I[/YOUTUBE]

Some of you old timers might remember this pic:

Is it photoshoped? Not sure. But it's been done.

I agree though... give me some 80 proof GA with that shait.

I like the fact the patient is asking for a glass of water to drink during surgery with his chest cracked open. Who needs NPO before surgery when you can just drink DURING surgery? I also hope his nose doesn't get itchy for the 4+ hours he's going to be laying there or that he doesn't have to sneeze. Surgeon might not appreciate the movement when he's trying to sew some distals.

 

[psychbender]

Awake cardiac surgery was my CA3 grand rounds topic this year, and was really interesting to research. The first ones were done in Turkey in 1998, single vessel (H-graft with radial artery segment) through thoracotomy, and had skin-to-skin times of as little as 34 minutes. With median sternotomy and more conventional grafting techniques, surgical time approached more of what we are used to in this country (and started involving SVG, harvested under femoral block). One of the most interesting things from one of the larger case series (137 patients), was that some patients were able to be discharged from the hospital six hours post-op, opening up the possibility for outpatient cardiac surgery. The overall utility of this technique is likely restricted to resource-limited areas like China and parts of India, but it remains interesting, nonetheless.

 

[cchoukal]

This history encompasses almost every ****in emergent hip fx that shows up on call here; Agree with the pre-induction Aline and GA. The spinal catheter intrigues me though - my n=1, but it was effective up until the surgeon changed plans and decided he wanted to cross-clamp the aorta.

We cross-clamp the aorta for all our hips here. No big deal.

 

[sevoflurane]

Awake cardiac surgery was my CA3 grand rounds topic this year, and was really interesting to research. The first ones were done in Turkey in 1998, single vessel (H-graft with radial artery segment) through thoracotomy, and had skin-to-skin times of as little as 34 minutes. With median sternotomy and more conventional grafting techniques, surgical time approached more of what we are used to in this country (and started involving SVG, harvested under femoral block). One of the most interesting things from one of the larger case series (137 patients), was that some patients were able to be discharged from the hospital six hours post-op, opening up the possibility for outpatient cardiac surgery. The overall utility of this technique is likely restricted to resource-limited areas like China and parts of India, but it remains interesting, nonetheless.

Nice topic. 👍

And yes... I've heard it has been researched and investigated and used in countries with limited resources.

Discharging any post-op heart patient in any secenario is not wise.... even if your bring back rate is well under the national average.

 

[Gern Blansten]

Awake heart surgery using acupuncture was described 4 decades ago. Here is an article about its use.

http://detroitstreetpress.com/2010/11/30/conscious-open-heart-surgery-things-that-blow-my-mind-1/

 

[Jay K]

We cross-clamp the aorta for all our hips here. No big deal.

Ha, yeah this was a fem-pop that progressed to fem-fem that progressed to aorto-profunda and so forth...

BTW saw your ad on Gaswork.

 

[dutchmaster]

I would have done an awake a-line, two good IVs. GA. If you cant get two good IVs or ones you're comfortable running rocket fuel through, then a CVC.

I wish I had more experience with IT catheters, the technique sounds good. I think i would still place an a-line for it.

Any large bolus or volume regional/neuraxial technique (single shot spinal, lumbar plexus) is fraught with danger with a gradient near 100 over that aortic valve. The most recent echo is nearly 6 months old - who knows what the gradient is now.