Today's Case

[DET0897]

76 y/o man, bad PVD with left AKA, CAD s/p MI and stent, s/p pacer, Afib recently off coumadin (INR1.1), COPD, s/p R pneumonectomy requires nasal O2 round clock, DM, small esophageal fistula, bad scoliosis and kyphosis. Pt falls and fractures right femur. Seen at outside hospital and anesthesia refuses to gas him for IM rod and gamma nail to right leg. xferred to our hospital, pacer interrogation indicates that he is pacer dependent. Labs otherwise unremarkable (about what you would expect given above). Any thoughts?

---

Members don't see this ad.

 

[Planktonmd]

76 y/o man, bad PVD with left AKA, CAD s/p MI and stent, s/p pacer, Afib recently off coumadin (INR1.1), COPD, s/p R pneumonectomy requires nasal O2 round clock, DM, small esophageal fistula, bad scoliosis and kyphosis. Pt falls and fractures right femur. Seen at outside hospital and anesthesia refuses to gas him for IM rod and gamma nail to right leg. xferred to our hospital, pacer interrogation indicates that he is pacer dependent. Labs otherwise unremarkable (about what you would expect given above). Any thoughts?

Spinal.

 

[videolectures]

spinal and epidural seems to be the best (and easy route)

would be a pretty stressful case if you had added patient last took his plavix yesterday

 

[dfk]

first thought was spinal.
clearly.

 

[videolectures]

to make it a challenge suppose the patient is anticoagulated and neuraxial anesthesia is out of the question.

would be interesting to know:

cardiac: what his last echo was...EF, etc
pulmonary: Spirometry: lung volumes/capacities are prob just as bad
renal: BUN/Cr... suprised the kidneys are still well with the presumed nl labs

fistula: potential full stomach
heme: hows the h/h?

 

[isoman2000]

FNB with sciatic block

 

[9french]

With severe COPD, he may be dependent on accessory muscles for ventilation. With a spinal you are taking a chance of knocking out those muscles and inducing respiratory distress.

As far as his cardiac status, spinals have yet to be adequately shown to reduce mortality from cardiac causes when compared to general anesthesia.

Lastly, I'd be shocked if he wasn't on plavix.

 

[Planktonmd]

With severe COPD, he may be dependent on accessory muscles for ventilation. With a spinal you are taking a chance of knocking out those muscles and inducing respiratory distress.

As far as his cardiac status, spinals have yet to be adequately shown to reduce mortality from cardiac causes when compared to general anesthesia.

Lastly, I'd be shocked if he wasn't on plavix.

What makes you think that this guy is taking Coumadin and Plavix together?
As for the spinal: you give some Ketamine and turn him on his side with broken leg down then you do a hyperbaric spinal and keep him in lateral position 5 minutes, you will get a unilateral spinal.
If you don't want to do a spinal then Fem/sciatic is good too.

I am not sure what the OP means by "small esophageal fistula", could he be talking about an esophageal diverticulum? a Zenker for example?

 

[DET0897]

Not sure what I was thinking typing "small esophageal fistula". Actually he had a bronchopulmonary cutaneous fistula with small air leak. He also had urgent esophagectomy (remote) secondary to esophageal rupture.

Also h/o diverticular abscess with persistant enterocutaneous fistula with drainage (smelled great). His pneumonectomy was secondary to stage II lung cancer.

Not on plavix, only aspirin 325mg.

Put in awake A-line. patient was to be supine so took an epidural kit, stuck the touhy subarachnoid and threaded the epidural cath for continuous spinal. Dosed him with 15mcg fentanyl , transfered to OR table, then dosed hyperbaric bupi with rev trend for T9-10 level. Worked great. Didn't want to push our luck with duramorph, pulled out spinal in PACU

 

[mille125]

Not sure what I was thinking typing "small esophageal fistula". Actually he had a bronchopulmonary cutaneous fistula with small air leak. He also had urgent esophagectomy (remote) secondary to esophageal rupture.

Also h/o diverticular abscess with persistant enterocutaneous fistula with drainage (smelled great). His pneumonectomy was secondary to stage II lung cancer.

Not on plavix, only aspirin 325mg.

Put in awake A-line. patient was to be supine so took an epidural kit, stuck the touhy subarachnoid and threaded the epidural cath for continuous spinal. Dosed him with 15mcg fentanyl , transfered to OR table, then dosed hyperbaric bupi with rev trend for T9-10 level. Worked great. Didn't want to push our luck with duramorph, pulled out spinal in PACU

wouldnt have been my first choice but it sounds like it went well (spinal catheters are controversial)

 

[isoman2000]

FNB and sicatic due to fewer if any hemodynamic changes, and fewer oppurtunnities for introperative pulmonary complications R/T
1. GA
2. loss of accessory muscles as stated above
In addition it would be possible to manage post op[ pain far more effectivley, (assuming that it is significant in this case, which it may not be)

 

[mille125]

FNB and sicatic due to fewer if any hemodynamic changes, and fewer oppurtunnities for introperative pulmonary complications R/T
1. GA
2. loss of accessory muscles as stated above
In addition it would be possible to manage post op[ pain far more effectivley, (assuming that it is significant in this case, which it may not be)

do you think that it is impt to block the obturator in this case and if so do you think that this block would do it...

 

[DET0897]

wouldnt have been my first choice but it sounds like it went well (spinal catheters are controversial)

That's why I posted this case. To see some thoughts on continuous spinal. First time I used one. No one recommended it after to OP, so I guess it's really not first choice.

 

[isoman2000]

No it will not block obturator and no for the need to block it.

 

[Noyac]

Why do the case at all?

Where academics fail is they teach you how to do these cases, they don't teach how NOT to do these cases.

Outside hospital is spot on.

 

[DET0897]

Probably right, Noyac. My dream job is to work at an "outside" hospital

 

[Planktonmd]

Why do the case at all?

Where academics fail is they teach you how to do these cases, they don't teach how NOT to do these cases.

Outside hospital is spot on.

Hey Noy, the guy has a broken femur. someone is going to have to do the case

 

[Noyac]

Hey Noy, the guy has a broken femur. someone is going to have to do the case

Not necessarily.

I know its a tough call. But I'd bet he doesn't use walk much at all. Hell he probably broke it trying to move from his wheelchair to his bed. He is already an amputee, right. Why not put him in a wheelchair for good. You think I am unsympathetic, I say I am realistic. What happens when he gets showered with fat emboli with his history? I've seen a few of these cases go wrong and I always think, it didn't have to happen. The guy has severe PVD. Is the leg even worth saving? An amputation maybe an easier operation on him.

Someone like this doesn't get around very much with an AKA maybe a BKA but not an AKA. If he is the exception then maybe you do the case but I doubt it. The problem is, we all seem to think that you have got to fix the leg. We can't seem to let them be. In the process of fixing it we make them worse.

The other thing that gets me is the OP states that he was seen at an outside hospital and "anesthesia refuses to gas him." Well I bet the orthopod didn't want to do it either but instead of making that call he just washed his hands of it and sent him to the University or wherever. If you ask me the anesthesiologist is the only reasonably sane person here.

 

[Noyac]

And another thing. If it is decided that this guy is going to have his femur rodded then I say the best place may be the outside hospital where the case lasts about 1hr. Not at the big academic hospital where it lasts 3 hrs.

So in my opinion, someone (the orthopod, hospitalist, ICU, Anesthesiologist) needs to have a real heart to heart talk with him and his family and explain all of this to them. Let them decide on the coarse of action but give them all the information. Don't think of it as doing nothing. You can splint it till it heals, use traction, whatever but get them out of the hospital asap or they will get worse. Just b/c a femur is broken doesn't mean it needs a rod put in it.

 

[OB1🤙]

Noy,

Amen.

HB

 

[2ndyear]

Not sure what I was thinking typing "small esophageal fistula". Actually he had a bronchopulmonary cutaneous fistula with small air leak. He also had urgent esophagectomy (remote) secondary to esophageal rupture.

Also h/o diverticular abscess with persistant enterocutaneous fistula with drainage (smelled great). His pneumonectomy was secondary to stage II lung cancer.

Not on plavix, only aspirin 325mg.

Put in awake A-line. patient was to be supine so took an epidural kit, stuck the touhy subarachnoid and threaded the epidural cath for continuous spinal. Dosed him with 15mcg fentanyl , transfered to OR table, then dosed hyperbaric bupi with rev trend for T9-10 level. Worked great. Didn't want to push our luck with duramorph, pulled out spinal in PACU

There are few things in life that satisfy me as much as CSF flowing through a Touhy. Just damn impressive.

 

[thegasman]

No it will not block obturator and no for the need to block it.

what about lat fem cutaneous?

 

[thegasman]

what's wrong with ga? Zippy would say pent sux tube next and I am inclined to agree. Put in a fem block for post op pain if you want.

 

[isoman2000]

3 in 1 for lateral femoral cutaneous.

 

[Planktonmd]

what's wrong with ga? Zippy would say pent sux tube next and I am inclined to agree. Put in a fem block for post op pain if you want.

Does the broncho-cutaneous fistula worry you a little bit?

 

[Noyac]

Does the broncho-cutaneous fistula worry you a little bit?

Somewhat.
So use an LMA or keep him breathing spontaneous with a ETT.
That is if you are going to do the case.

By the way, if I did this case I'd do a GA. I hate it when pts get all hypotensive and can't breath after the fat embolism. Most pts get a spinal from me for these but I don't think this guy will tolerate the smallest amount of FE.

 

[isoman2000]

Noy not to be argumentative, but how is GA going to prevent FE?

 

[Noyac]

Noy not to be argumentative, but how is GA going to prevent FE?

I knew when I wrote it that this was confusing.

You see when you induce Ga on someone like this you change the dynamics of the vascular system. We notice the vasodilation that occurs with induction and it is that vasodilation that protects these guys from FE. It is the hydrostatic pressure in the marrow that drives the fat out as the rod is going in. If you drop this pressure and keep it down the fat is less likely to escape the marrow.


If you don't believe that, then try this. I would choose GA b/c I don't want the guy gasping for air in front of me, wondering why he is dying. Ga doesn't prevent FE it just makes it slightly easier to deal with, slightly. I've seen it once and that is enough. But I wouldn't criticize someone for doing a spinal. Lateral fem cut block, FNB, sciatic block are all fine but be ready to intubate.

 

[Planktonmd]

I knew when I wrote it that this was confusing.

You see when you induce Ga on someone like this you change the dynamics of the vascular system. We notice the vasodilation that occurs with induction and it is that vasodilation that protects these guys from FE. It is the hydrostatic pressure in the marrow that drives the fat out as the rod is going in. If you drop this pressure and keep it down the fat is less likely to escape the marrow.


If you don't believe that, then try this. I would choose GA b/c I don't want the guy gasping for air in front of me, wondering why he is dying. Ga doesn't prevent FE it just makes it slightly easier to deal with, slightly. I've seen it once and that is enough. But I wouldn't criticize someone for doing a spinal. Lateral fem cut block, FNB, sciatic block are all fine but be ready to intubate.

When people have weird things going on with their lungs I generally try to stay away from GA if I can, but I agree with being ready to intubate if things suddenly deteriorate.

 

[isoman2000]

Outstanding answer noy, appreciate it. I will have to think on that one. Thanks a lot.

 

[Noyac]

You guys know I'm joking about the hypotension preventing FE, right?

 

[Planktonmd]

You guys know I'm joking about the hypotension preventing FE, right?

I am pretty sure if you research it you will find that someone somewhere did a study that proves that hypotension decreases the incidence of fat embolism.

 

[Noyac]

I am pretty sure if you research it you will find that someone somewhere did a study that proves that hypotension decreases the incidence of fat embolism.

Or would hypertension be more likely to prevent FE. Something like VAE.

 

[thegasman]

3 in 1 for lateral femoral cutaneous.

is this reliable?

 

[Planktonmd]

is this reliable?

Yes, if you inject a big volume and if you know how to do it.

 

[thegasman]

Does the broncho-cutaneous fistula worry you a little bit?

yeah - I missed that part. I saw the esophogeal fistula at the top and missed the later correction. I'm not sure if this precludes ga but it makes me think a little harder about regional. agree with noy that if doing ga sv is probably better.

 

[amyl]

what do you guys do to treat FE? i looked it up and it was vague -- fluids, ?steriods. it also listed the mortality around 10-20%. is that about right?
a friend of mine just died from FE in the OR following femoral fx, thats why i really want to know....

 

[Planktonmd]

what do you guys do to treat FE? i looked it up and it was vague -- fluids, ?steriods. it also listed the mortality around 10-20%. is that about right?
a friend of mine just died from FE in the OR following femoral fx, thats why i really want to know....

There is no specific treatment.

 

[amyl]

so whats your approach? supportive care? fluids? steroids? pray?

 

[Planktonmd]

so whats your approach? supportive care? fluids? steroids? pray?

Ok, in the OR when you suspect a fat embolus has happened (long bone FX with a sudden hypoxia or unexplained hypotension) from this point on you are resuscitating the patient and you should follow an ABC approach:
If the patient is not intubated then gently induce GA and intubate and start mechanical ventilation.
There is a good chance that you will need some positive inotrope support and vaso active drugs in addition to fluid resuscitation (remember this a combination of right sided heart failure caused by mechanical obstruction and vaso dilation caused by the inflammatory response).
The severity of symptoms is proportional to the amount of fat and to the underlying health status.
Get invasive BP monitoring as soon as possible and if things are not looking good get a central line as well (it helps if you are not by yourself so call for help if you can).
Your main goal is to optimize filling pressures without overloading the patient and to treat the peripheral vasodilation.
Which positive intrope to use is really a question of personal preference.
Which fluid: Blood and blood products should be on top of the list if possible.
You might have to correct coagulopathy as well so keep an eye on the surgical field and send coagulation studies.
Steroid therapy is a good idea although some people might argue against it but you have nothing to lose, so I would give a big dose of a highly anti inflammatory steroid like Dexamethasone.
Remember to tell the orthopod that you are having a problem and that we need to get things going.
If the circulation is just not responding to your treatment you might need TEE or a PA catheter to guide your fluid + inotropes treatment.
The post op care in the unit will be just a continuation of steps that we already mentioned in addition to the usual ICU care (DVT prophylaxis, ulcer prevention, ATBX, TPN.....)
Get the usual labs, check the urine for fat globules, get a helical chest CT and you might need to get a brain MRI if they develop encephalopathy and coma.
These patients if they make it initially (first few hours) they have a good chance of recovering without any residual problems, but a small percentage have a massive embolus and there is nothing you can do to help them.

 

[amyl]

thanks!