Typical 4pm Add on

[JohnnyRock]

---

Members don't see this ad.

Its Friday at 4pm and instead of heading home I get asked to do an add on hip hemiarthroplasty. Its a 91 yr old sick lady, with AS with a gradient of 60 & and AVA of 0.7cm, diastolic HF but an EF of 60%, and troponins of 3.8 as of noon that day (but stable from the day before).

This is private practice where this will take 60-80min of surgical time with about 200-300cc of blood loss roughly.

The cardiologist cleared her but wrote in his note that the Pt will need a Swan for the surgery and for post op management.

On top of it all, the pt's son and daughter-in-law are both physicians at the bedside.

How would you guys do the anesthetic?

 

[Jeff05]

isn't this the exact patient population in which swans increase morbidity and mortality?

she is a high risk patient for a low/med risk procedure.

why are her trops elevated? is she infarcting? if so, her periop risk is very high. ischemia and critical AS - the holy grail of intraop risk. a hemi is an ELECTIVE procedure, which should be postponed until her cardiac status is stable.

however, you could do the case
1. preop - optimize volume (and No, you can't use a swan for that) preop, just a nice slow bolus of 10-20ml/kg of crystal. rate control with beta blockers. aline preinduction.
2. induction - nice and gentle. maintain svr. keep HR down. intubate when nice and deep. spraying with LA before tube may be helpful.
3. maint - a bit of vapor and liberal narcotic.
4. may have to keep tube in at the end if narcotic still around.

or...
a line. epidural. bring up level slowly and compensate with phenylephrine infusion. keep her awake for hemi. but, if the starts bleeding or things don't go perfectly and she CHFs, you may need to tube her under less than ideal circumstances.


whatever you do, have a real discussion with family and her (if she's competent) that she needs a cardiac tuneup. and if they forgo that, explain that her risk of having decompensated AS and associated morbidity and mortality is high.

 

[IceDoc]

I think the primary issue here is informed consent about risk/benefit because the "how" you are going to do this case will be fairly straight forward. Even assuming the Trops are from myocardial ischemia (they may not be), would you have a difference in outcome by waiting? How long, 6 weeks? Sitting on a broken hip for that long is no good either. The discussion would have to focus on the belief that the hemiarthroplasty is going to improve the quality of this pt's life, and that the risk of cardiac morbidity and mortality is accepted.

Getting through the surgery is actually the easy part: Aline, GA, CVP for expected vasopressors. The swan has some risk, and little outcome data etc... but if this cardiology guy wants to manage a swan in the ICU, then sure I'll put one in and use it too.

Or just put an LMA in.

 

[Noyac]

How you do this case depends on a few things. For example, if you want to be home by 5pm just do a spinal.😱

I'd probably slip her off to sleep gently and slide in an LMA.

 

[jetproppilot]

LMA like Noy said.

No central line.

No SWAN.

 

[jetproppilot]

the cardiologist cleared her but wrote in his note that the pt will need a swan for the surgery and for post op management.

hahahahahahahahahahahahahahahahahah

 

[JohnnyRock]

As usual you guys are all over this one. The fact that the cardiologist wrote that a swan should be placed almost made me go postal. What a douchebag, and then I have to explain to the Pt's 2 physician family members why its not needed.

Considered regional but didn't seem like she would tolerate positioning.

A-line, smooth intubation, neo on and neo off, extubated at end of case.

I reluctantly put in a triple lumen and made it clear on the chart that a swan would not change my management but I would place a triple lumen for access and so the ICU staff could swap to a swan if ever needed post-operatively.

POD #1: back to floor, troponin down to 1.5. Cardiologist still a douche.

 

[OB1🤙]

Good case.

We had a somewhat similar case recently- 80something y/o with known severe AS, AVA 0.6, on new echo now found to have biventricular dysfunction, LVEF around 25-30%, and mod-severe pulm htn. Also paroxysmal a-fib on coumadin, admit INR 1.7.

Fell down, went boom, bad hip fx. Slip dropped for ORIF.

Cards says they recommend swan and intraop TEE.

Waddya do?

 

[Planktonmd]

I wish they would make it mandatory for cardiologists to spend a few months in the OR during fellowship so they could have some degree of basic understanding about what we do.

 

[2ndyear]

Good case.

We had a somewhat similar case recently- 80something y/o with known severe AS, AVA 0.6, on new echo now found to have biventricular dysfunction, LVEF around 25-30%, and mod-severe pulm htn. Also paroxysmal a-fib on coumadin, admit INR 1.7.

Fell down, went boom, bad hip fx. Slip dropped for ORIF.

Cards says they recommend swan and intraop TEE.

Waddya do?

At the end of the day, we have a surgery with little to no blood loss, nil fluid shifts, and in and out in roughly 1 hour. A-line. Everything else is overkill. If this were a big bowel or vascular case things might be different. But it's not.

 

[Jeff05]

my question is....
if we are, as anesthesiologists, specifically trained to both select and interpret the appropriate monitors and risk stratify, then why the HE11 do we keep getting these assinine c/s from cardiology that NEVER say anything that doesn't frustrate and annoy us?

 

[Planktonmd]

my question is....
if we are, as anesthesiologists, specifically trained to both select and interpret the appropriate monitors and risk stratify, then why the HE11 do we keep getting these assinine c/s from cardiology that NEVER say anything that doesn't frustrate and annoy us?

2 reasons:
1-Anesthesiologists in this country never really wanted to be perioperative physicians until very recently, and this is why other specialists are used to assume that role and they don't feel that they are infringing on your field when they tell you what monitors to use or when they "clear" the patient for you.
2-Because of the lawyers it became desirable to have as many doctors involved as possible so they can share the liability, although the only ones benefiting from this behavior are the lawyers because it allows them to make more money.

 

[9french]

As usual you guys are all over this one. The fact that the cardiologist wrote that a swan should be placed almost made me go postal. What a douchebag, and then I have to explain to the Pt's 2 physician family members why its not needed.

Considered regional but didn't seem like she would tolerate positioning.

A-line, smooth intubation, neo on and neo off, extubated at end of case.

I reluctantly put in a triple lumen and made it clear on the chart that a swan would not change my management but I would place a triple lumen for access and so the ICU staff could swap to a swan if ever needed post-operatively.

POD #1: back to floor, troponin down to 1.5. Cardiologist still a douche.

I think stupid recomendations like this are something we've all run into. When something similar happened to me (cardiologist recommended spinal anesthesia for a case that needed a GA), I called the cardiologist to discuss this with him. I was very nice about it, but I let him know that I would apprciate him not recommending anesthetic techniques until after he completes a 4 year anesthesiology residency. When this happens, it is easy to complain to your partners and others who are sympathetic, but it is far more effective to let the offending cardiologist know that it is not appreciated.

 

[jwk]

.

Cards says they recommend swan and intraop TEE.

Waddya do?

That's funny right there, I don't care who y'are, that's funny.

This is a common community hospital case. Most community hospitals 1) don't have TEE available and/or 2) don't have a cardiac-trained anesthesiologist to use it even if they did.

 

[SOUNDMAN]

I think the primary issue here is informed consent about risk/benefit because the "how" you are going to do this case will be fairly straight forward. Even assuming the Trops are from myocardial ischemia (they may not be), would you have a difference in outcome by waiting? How long, 6 weeks? Sitting on a broken hip for that long is no good either. The discussion would have to focus on the belief that the hemiarthroplasty is going to improve the quality of this pt's life, and that the risk of cardiac morbidity and mortality is accepted.
.

Remember that the mortality and morbidity goes up for hip fracture the longer you wait. Anything past 72 hours and it really jumps. Delaying in this case to 24-48 hours to optimize the patient wouldn't be an unreasonable choice either. If she's medically optimized, then you do the case at that point.

 

[radslooking]

I wish they would make it mandatory for cardiologists to spend a few months in the OR during fellowship so they could have some degree of basic understanding about what we do.

i agree, there really needs to be some standardized teaching and rules about what should be in preop consults and such. People sometimes will just recommend things to seem helpful, because it beats saying "no recommendations". So they include silly stuff that is either unnecessary or wrong.

 

[Noyac]

i agree, there really needs to be some standardized teaching and rules about what should be in preop consults and such. People sometimes will just recommend things to seem helpful, because it beats saying "no recommendations". So they include silly stuff that is either unnecessary or wrong.

YOur right, some are trying to be helpful. And we (or the person getting the consult) can help them by directing the consult. When you ask for a consult you should be clear as to what you are asking for (ie; cardiac status). You can do this by asking a few questions in your consult like would this pt benefit from better glucose control, would this pt warrant a change in medications, etc. You get the point.

In this case I would have asked things like, what's the AV area/gradient? Is the pt infarcting? Is the pt in CHF? Things like this.

Hopefully, they will get the message that I can manage the periop course without them telling me how to do my job, ie: swan.