To do or not to do the case

[radslooking]

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Getting s/hit for authorizing the go ahead on this one

81 yo. severely demented man, diabetic, chf with ef 35%, mild-mod renal insufficiency with cr 1.2, pleural effusion (old), bnp 10,300 but no acute decompensation on cxr. fell 5 days ago at NH, but appeared uninjured and without complaints. begins to complain later in the week, brought into the ED, has a mildly displaced femoral neck fracture. Troponin is drawn and is .14 something. (god knows what it was drawn for). EKG mechanical reader says he has possible acute infarct, but i see artifact and no ST changes, or TWi's. Repeat troponin two draws later is .19.

I say do the surgery. Im getting flack b/c of doing a surgery with "rising troponins". I say his cardiac dysfunction is chronic and probably would have a troponin increase most days of his life. I think people are just *******.

 

[Planktonmd]

Getting s/hit for authorizing the go ahead on this one

81 yo. severely demented man, diabetic, chf with ef 35%, mild-mod renal insufficiency with cr 1.2, pleural effusion (old), bnp 10,300 but no acute decompensation on cxr. fell 5 days ago at NH, but appeared uninjured and without complaints. begins to complain later in the week, brought into the ED, has a mildly displaced femoral neck fracture. Troponin is drawn and is .14 something. (god knows what it was drawn for). EKG mechanical reader says he has possible acute infarct, but i see artifact and no ST changes, or TWi's. Repeat troponin two draws later is .19.

I say do the surgery. Im getting flack b/c of doing a surgery with "rising troponins". I say his cardiac dysfunction is chronic and probably would have a troponin increase most days of his life. I think people are just
*******.

Yesterday I did GA on a 85 Y/O for a cystoscopy to control hematuria.
His troponin was 6 and had risen from 1 the day before.
He had a LBBB so his EKG was worthless.
His EF was 25 % with apical dyskinesia and global hypokinesis.
So, I guess that was crazy.

 

[2ndyear]

Getting s/hit for authorizing the go ahead on this one

81 yo. severely demented man, diabetic, chf with ef 35%, mild-mod renal insufficiency with cr 1.2, pleural effusion (old), bnp 10,300 but no acute decompensation on cxr. fell 5 days ago at NH, but appeared uninjured and without complaints. begins to complain later in the week, brought into the ED, has a mildly displaced femoral neck fracture. Troponin is drawn and is .14 something. (god knows what it was drawn for). EKG mechanical reader says he has possible acute infarct, but i see artifact and no ST changes, or TWi's. Repeat troponin two draws later is .19.

I say do the surgery. Im getting flack b/c of doing a surgery with "rising troponins". I say his cardiac dysfunction is chronic and probably would have a troponin increase most days of his life. I think people are just *******.

In an ideal world, most families will not put their 81 year old severely demented father/grandfather/husband from a nursing home through this. But we're stuck with making the call on this one, so here goes. Round up the family. Have the big talk about how the likelihood of dying in the OR or PACU is very real. No numbers to quote, but just state that this might be it, are they sure that they would like to go through with it, they don't have to. I'd like a cardiologist comment in the chart if for no other reason than I'm not a cardiologist. Clearly there is some cardiac issue possibly going on and a heart specialist should address it. This isn't an emergency. If everyone was not on the same page then I would delay the case until they were.

 

[Arch Guillotti]

Getting s/hit for authorizing the go ahead on this one

81 yo. severely demented man, diabetic, chf with ef 35%, mild-mod renal insufficiency with cr 1.2, pleural effusion (old), bnp 10,300 but no acute decompensation on cxr. fell 5 days ago at NH, but appeared uninjured and without complaints. begins to complain later in the week, brought into the ED, has a mildly displaced femoral neck fracture. Troponin is drawn and is .14 something. (god knows what it was drawn for). EKG mechanical reader says he has possible acute infarct, but i see artifact and no ST changes, or TWi's. Repeat troponin two draws later is .19.

I say do the surgery. Im getting flack b/c of doing a surgery with "rising troponins". I say his cardiac dysfunction is chronic and probably would have a troponin increase most days of his life. I think people are just *******.

Who is giving you ****? Troponins seem like a minor concern compared to his severe dementia.

I would have done the case so long as the family was on board.

 

[proman]

I'd do the case. The non diagnositic troponin is likely from his low GFR. What's your role in this and who's giving you flack? Benefits greatly outweigh the risk.

 

[toughlife]

I'd do the case. The non diagnositic troponin is likely from his low GFR. What's your roll in this and who's giving you flack? Benefits greatly outweigh the risk.

Bingo! You'd be amazed how many people out there don't know that an elevated troponin in someone with chronic renal failure is very common and not a source of concern.

radslooking just do that case.

 

[TrustMe]

Ditto to what tough said. Minimally elevated tropinin means almost nothing in the setting of renal insufficiency and CHF (no exacerbation on CXR but BNP 10,000). A cardiologist would agree that those giving you flack are p*ssies.

 

[cchoukal]

Ditto to what tough said. Minimally elevated tropinin means almost nothing in the setting of renal insufficiency and CHF (no exacerbation on CXR but BNP 10,000). A cardiologist would agree that those giving you flack are p*ssies.

People always say this (that troponin can be high in renal failure), but it seems like a low GFR should only account for slower elimination of the troponin, not production of it. Doesn't the troponin have to come from somewhere in the first place? Or are we constantly secreting it without myocardial damage?

All that said, the level's super low and it probably wouldn't deter me.

 

[proman]

Troponins, while specific and sensitive for myocardial damage (and cardiovascular risk), isn't exclusively found in myocardium. Here's an article comparing healthy, chronic renal insufficiency, and ESRD patients and their biomarkers:

Cardiac troponin I in patients with chronic kidney disease treated conservatively or undergoing long-term haemodialysis.

Kardiol Pol. 2007 Sep;65(9):1068-75; discussion 1076-8.

BACKGROUND: Cardiac troponin I (cTnI) has been shown to be a specific marker of myocardial damage in the general population. In patients suffering from chronic kidney disease (CKD) cTnI may be increased in serum without other signs of acute myocardial damage confusing the diagnosis. AIM: To compare cTnI concentration in CKD patients, treated conservatively or with haemodialysis, with healthy controls, and to evaluate the cardiovascular risk factor profile in these groups. METHODS: The study population consisted of three groups: group I (n=10, 5 women, 5 men, mean age 32+/-4 years) - healthy, young volunteers without kidney diseases with creatinine clearance (CrCl) 97.13+/-23.24 ml/min; group II (n=21, 8 women, 13 men, mean age 51+/-15 years) - patients with CKD in stages 3-5 with CrCl=34.04+/-18.34 ml/min; and group III (n=30, 14 women, 16 men, mean age 50+/-14 years) - patients on long-term haemodialysis. The cTnI level was measured using an AxSYM analyzer (Abbott). In group III blood was taken before the haemodialysis session. The high sensitivity C-reactive protein (hsCRP), haemoglobin, parathyroid hormone (PTH) and phosphorus levels were determined. Blood pressure was also recorded. Echocardiography was performed and left ventricular mass index (LVMI) was calculated on the basis of the Devereux and Reichek formula. RESULTS: Compared with controls, the cTnI values were significantly higher in patients from group III and tended to be higher in patients from group II (0.01+/-0.03 vs. 0.063+/-0.08 and 0.066+/-0.162 ng/ml, respectively, p <0.05 and NS). In 46% of haemodialysed patients cTnI concentration was above the value of the 99th percentile in the apparently, healthy population but did not exceed the acute myocardial infarction diagnostic cut-off. The high sensitivity C-reactive protein value was significantly higher in groups III and II versus controls (4.92+/-5.12 and 2.26+/-2 vs. 0.85+/-0.48 mg/dl, p <0.05 respectively). The LVMI values were significantly higher in groups III and II than in controls (159+/-46 and 113+/-35 vs. 81+/-14 g/m2, respectively). There was a significant correlation between hsCRP and LVMI in group II (r=0.49, p <0.05). Blood pressure was significantly higher in groups III and II compared to controls (129+/-25 and 137+/-19 vs. 116+/-7 mmHg, respectively). Patients from group III had significantly decreased haemoglobin value and increased PTH as well as phosphorus concentration compared to subject from group II and controls. CONCLUSION: Chronic kidney disease is associated with accumulation of cardiovascular risk factors and increased cTnI concentration.

 

[CanGas]

I don't get it. An emergency is an emergency right? Old folks with broken hips have a 50% 6 mo mortality right? Who would piss on you for doing this case? The only thing is if this demented guy is bed-bound vegetative already then I guess you could leave him like that and go palliative on him but the pain meds needed for the # are gonna make him even more loopy.

I say 15mg of Ketamine with 1mg Midaz, turn him bad side down. Slip in a 22g sprott spinal with 10 mg isobaric Marcaine 0.5%, 75mcg Epimorph and let the surgeons go to town. Should just be a pin but if they are doing anything more you could consider an art line.

Wham, bam, thank-you mam. I'd have still done this even if he had a full, real, MI. Let the family know about the risk but in my opinion the risk of doing nothing is higher. MI's don't like the catecholamines released everytime your displaced femoral shaft grinds past itself when you move/are turned/go to the bathroom, ect.

Ditto for the cysto. Persons bleeding to death from the bladder with recent MI? Still bleeding post optimizing coags? Not amenable to embolization? Gotta go take a look! Explain the risks and off you go though I would put in an art line for that one.

CanGas

Getting s/hit for authorizing the go ahead on this one

81 yo. severely demented man, diabetic, chf with ef 35%, mild-mod renal insufficiency with cr 1.2, pleural effusion (old), bnp 10,300 but no acute decompensation on cxr. fell 5 days ago at NH, but appeared uninjured and without complaints. begins to complain later in the week, brought into the ED, has a mildly displaced femoral neck fracture. Troponin is drawn and is .14 something. (god knows what it was drawn for). EKG mechanical reader says he has possible acute infarct, but i see artifact and no ST changes, or TWi's. Repeat troponin two draws later is .19.

I say do the surgery. Im getting flack b/c of doing a surgery with "rising troponins". I say his cardiac dysfunction is chronic and probably would have a troponin increase most days of his life. I think people are just *******.

 

[Bertelman]

I say 15mg of Ketamine with 1mg Midaz, turn him bad side down. Slip in a 22g sprott spinal with 10 mg isobaric Marcaine 0.5%, 75mcg Epimorph and let the surgeons go to town. Should just be a pin but if they are doing anything more you could consider an art line.

Could you clue me in to why you position the bad side down?

 

[treasurefull2]

I don't know if i would necessary ask this question on this forum...

I think some people here would to a case on anybody as long as they're not dead...

but what do I konw, I'm just a med student...

But I agree, that troponin wouldn't scare too much...

 

[periopdoc]

I don't know if i would necessary ask this question on this forum...

I think some people here would to a case on anybody as long as they're not dead...

Why would you let death deter you from doing a case?

- pod

 

[proman]

There's always ECMO.

 

[huktonfonix]

I say 15mg of Ketamine with 1mg Midaz, turn him bad side down. Slip in a 22g sprott spinal with 10 mg isobaric Marcaine 0.5%, 75mcg Epimorph and let the surgeons go to town. Should just be a pin but if they are doing anything more you could consider an art line.

Wham, bam, thank-you mam. I'd have still done this even if he had a full, real, MI. Let the family know about the risk but in my opinion the risk of doing nothing is higher. MI's don't like the catecholamines released everytime your displaced femoral shaft grinds past itself when you move/are turned/go to the bathroom, ect.


CanGas

Seriously? you think the mortality of waiting a week for a hip fracture is greater than operating with a full blown MI? Arrhythmias, worsening of MI, CHF, could all occur with greater frequency in the acute period. I would have to question that. I would say, let them treat the MI. At the point he is well enough to have been discharged home for the MI, do the case. This fracture is an URGENT case, not an EMERGENT one.

Regarding Planks case, I dont know enough of the circumstances, but it sounds like the guy was bleeding substantially enough to warrant the risk. If its a minor bleed, transfuse as needed and go for surg when out of acute period. Carefully induced anesthesia of your choice. I probably woulda gone spinal catheter , coags permitting.

 

[urge]

I don't know if i would necessary ask this question on this forum...

I think some people here would to a case on anybody as long as they're not dead...

Keep in mind armchair anesthesia carries no risk of complications.

 

[Planktonmd]

I don't know if i would necessary ask this question on this forum...

I think some people here would to a case on anybody as long as they're not dead...

but what do I konw, I'm just a med student...

But I agree, that troponin wouldn't scare too much...

I actually had done cases on patients who wouldn't fit the definition of being alive in many aspects.

 

[Planktonmd]

I don't know if i would necessary ask this question on this forum...

I think some people here would to a case on anybody as long as they're not dead...

but what do I konw, I'm just a med student...

But I agree, that troponin wouldn't scare too much...

I actually had done cases on patients who wouldn't fit the definition of being alive in many aspects.

 

[CanGas]

I don't disagree but re-reading my post I can see what you mean. A large territory STEMI infarct is a different beast from a small NSTEMI. The original poster seemed to infer that colleagues would cancel a hip pinning if there was a pre-operative bump in trops. I was more commenting that I would not wait the traditional 4-6 weeks following an MI. I'm not sure I would wait the usual 3-5 days post mi (when they would usually go home), depends on on-going ischemia and degree of cardiac impairment post infarct. Lying in bed with a broken hip is not a benign thing. A DHS is a pretty benign procedure and my impression is the majority of patients have less pain post-surgery than before - a good thing when wishing to reduce circulating catecholamine levels.

Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression
Canadian Journal of Anesthesia 55:146-154 (2008)
http://www.cja-jca.org/cgi/content/abstract/55/3/146

Conclusions: In hip fracture patients, operative delay beyond 48 hr after admission may increase the odds of 30-day all-cause mortality by 41% and of one-year all-cause mortality by 32%. Potential residual confounding factors in observational studies may limit definitive conclusions. Although routine surgery within 48 hr after admission is hard to achieve in most facilities, anesthesiologists must be aware that an undue delay may be harmful to hip fracture patients, especially those at relatively low risk or those who are young.

As for why broken hip down?
Well that's a good question. When I have a really fast surgeon I usually use low dose (8mg) hyperbaric marcaine for a unilateral block so broken hip must be down. I tend to do the same for isobaric because I have been told that it is actually less painful because there is less movement at the fracture site and the site is held more stable (as it is lying flat and supported on the bed) than when the fracture is up (and the leg is hanging or moving while the person is held in a lateral position). However, a quick lit search did not pull up any references for this.

CanGas

Seriously? you think the mortality of waiting a week for a hip fracture is greater than operating with a full blown MI? Arrhythmias, worsening of MI, CHF, could all occur with greater frequency in the acute period. I would have to question that. I would say, let them treat the MI. At the point he is well enough to have been discharged home for the MI, do the case.

 

[huktonfonix]

I don't disagree but re-reading my post I can see what you mean. A large territory STEMI infarct is a different beast from a small NSTEMI. The original poster seemed to infer that colleagues would cancel a hip pinning if there was a pre-operative bump in trops. I was more commenting that I would not wait the traditional 4-6 weeks following an MI. I'm not sure I would wait the usual 3-5 days post mi (when they would usually go home), depends on on-going ischemia and degree of cardiac impairment post infarct. Lying in bed with a broken hip is not a benign thing. A DHS is a pretty benign procedure and my impression is the majority of patients have less pain post-surgery than before - a good thing when wishing to reduce circulating catecholamine levels.

Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression
Canadian Journal of Anesthesia 55:146-154 (2008)
http://www.cja-jca.org/cgi/content/abstract/55/3/146

Conclusions: In hip fracture patients, operative delay beyond 48 hr after admission may increase the odds of 30-day all-cause mortality by 41% and of one-year all-cause mortality by 32%. Potential residual confounding factors in observational studies may limit definitive conclusions. Although routine surgery within 48 hr after admission is hard to achieve in most facilities, anesthesiologists must be aware that an undue delay may be harmful to hip fracture patients, especially those at relatively low risk or those who are young.

As for why broken hip down?
Well that's a good question. When I have a really fast surgeon I usually use low dose (8mg) hyperbaric marcaine for a unilateral block so broken hip must be down. I tend to do the same for isobaric because I have been told that it is actually less painful because there is less movement at the fracture site and the site is held more stable (as it is lying flat and supported on the bed) than when the fracture is up (and the leg is hanging or moving while the person is held in a lateral position). However, a quick lit search did not pull up any references for this.

CanGas

No, a broken hip is not a benign thing. The topic has actually been discussed before about the increased morbidity and mortality involved in waiting for "preop clearance" for these cases. I agree in the OP scenario there is little point in delaying. In Planks case, it would depend on how quickly the man was bleeding, the surgeon, the patients clinical condition, etc.. I would tend to be a bit more cautious with an actual MI. As with most things in our job it comes down to a risk/benefit analysis. Is his risk of mortality immediately post MI greater than waiting in bed with a broken hip?

I tend to use hypobaric spinals in these cases. Or prop, ketamine, etc.. then hyperbaric. Again, I would probably do a catheter for titratability and better hemodynamic stability depending on anticoagulation status.

 

[radslooking]

did the case, everything went fine

 

[jennyboo]

- Troponin of 0.19 from 0.14 in setting of renal insufficiency is nondiagnostic. (Were CK-MB & index done?)

- In my institution, would get cardiology eval even though it won't change anything.

- Patient is nursing home bound, demented so probably does not need a bigger procedure that will return him to excellent function. This should be kind of a "palliative" surgical procedure, i.e. for pain management and comfort.

- Discuss periop cardiac morbidity, risk of prolonged ICU stay, risk of death with family.

- Discuss periop code status with family.

- Proceed with case.

 

[radslooking]

the anesthetic used was hyperbaric marcaine with epinephrine. then small amounts of fentanyl and midazolam were used on top of that.