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cchoukal

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You're called by Ortho for a washout of infected knee hardware. They warn you the guy is a little sick. You review the record...

90 yo M with a PMHx of CHF (EF 25%), AFib, and 3rd degree AV block (all presumed due to amyloidosis) and COPD. He was admitted to an OSH a month ago for infected knee hardware and underwent arthroscopy x 3 and grew out pseudomonas. Went to SNF on cefepime, but redeveloped infected knee and got admitted to your hospital. He now has fluid overload with pulmonary edema and effusions, AKI with a creatinine of 3 (baseline 1-ish), an INR of 2.2 (not on anticoagulants and LFTs are NL), and plts of 90K.

What's your move?

Defer pending optimization of his CHF? Will he get septic in the meantime?

Nerve blocks and a strap of leather to bite down on?

Retrograde wire?
 
Unfortunately this guy's chance at making it are slim to none.
The safest way not to kill him would be to start a norepi infusion and do a 1cc isobaric spinal at L2L3.
 
dhb said:
Unfortunately this guy's chance at making it are slim to none.
The safest way not to kill him would be to start a norepi infusion and do a 1cc isobaric spinal at L2L3.
Click to expand...

Lmao
 
cchoukal said:
You're called by Ortho for a washout of infected knee hardware. They warn you the guy is a little sick. You review the record...

90 yo M with a PMHx of CHF (EF 25%), AFib, and 3rd degree AV block (all presumed due to amyloidosis) and COPD. He was admitted to an OSH a month ago for infected knee hardware and underwent arthroscopy x 3 and grew out pseudomonas. Went to SNF on cefepime, but redeveloped infected knee and got admitted to your hospital. He now has fluid overload with pulmonary edema and effusions, AKI with a creatinine of 3 (baseline 1-ish), an INR of 2.2 (not on anticoagulants and LFTs are NL), and plts of 90K.

What's your move?

Defer pending optimization of his CHF? Will he get septic in the meantime?

Nerve blocks and a strap of leather to bite down on?

Retrograde wire?
Click to expand...

Hemodynamically ok?
In AF? Or CHB? Has a pacemaker or AICD?
Any of these cardiac conditions new? Presumably pt would have had some interventions performed since his last anesthetic was only a month ago.

I would have a long and detailed discussion with surgeon and patient about risks of delaying vs. Proceeding. It is a risk benefit analysis and not a decision you can make by yourself.

What is clear is that this patient is high risk. End organ injury can worsen. Pt is fluid overloaded, in acute heart failure exacerbation, with presumably significant liver dysfunction but unclear if this is related to the heart failure or separate problem. If it was deemed necessary to proceed, I would plan for arterial line with cardiac stable induction, have pressers and inotropes on the ready, place a central line, and plan to go to the ICU intubated postop. I would consider gently diuresing during the case if patient remains reasonably stable.

Fem-sci block isnt going to cover everything, and may cause you to do an emergent conversion during the cade which would be messy and potentially more unstable for the patient.

I'm fairly certain you can get the patient alive through the surgery. The postop course however is another story, and you want as many trained eyes on the patient as possible. ID, nephrology, hepatology, cardiology should all be on this case.
 
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Vitals? Were you able to examine the patient? Is the patient “really” septic?

I am more worried about 3rd heart block. Are you putting pacing pads on this dude?

Pre-op block. Fumes, pray.

If option, defer to be optimized.
 
eikenhein said:
You would do a spinal in a patient with INR 2.2?
Click to expand...
Is he necessarily coagulopathic, just because his INR is >2? Given his CHF and volume overload with AKI, I would not be surprised if he had some degree of hepatic dysfunction (even in the absence of significant transaminitis). As a result, both procoagulant and anticoagulant substances (proteins C and S) are deficient. INR may be elevated, but net clotting function is not depressed (normal TEG/ROTEM, no clinically increased bleeding). I saw this all the time in the MICU, and would have the talk with residents and surgeons that we can't just defer anticoagulation or DVT prophylaxis simply because of an elevated INR.
 
psychbender said:
Is he necessarily coagulopathic, just because his INR is >2? Given his CHF and volume overload with AKI, I would not be surprised if he had some degree of hepatic dysfunction (even in the absence of significant transaminitis). As a result, both procoagulant and anticoagulant substances (proteins C and S) are deficient. INR may be elevated, but net clotting function is not depressed (normal TEG/ROTEM, no clinically increased bleeding). I saw this all the time in the MICU, and would have the talk with residents and surgeons that we can't just defer anticoagulation or DVT prophylaxis simply because of an elevated INR.
Click to expand...

I think the answer is you don't know if the patient is truly coagulopathic. But the number is there. Is it nutritional? Is it hepatic dysfunction? in this situation the prudent thing is to not do a spinal or take the risk. Imagine having to do this knee case, and then coming back to the OR to do an emergent decompression due to epidural hematoma.

You would have to have a pretty strong argument against all the other options for anesthesia to persuade someone that spinal is the correct course of action.
 
Okay, so at the bedside, he is elderly, cachectic, and asleep. Arouses with difficulty, says, "Son, can we do this on monday or Tuesday?"

VS:
Afebrile.
HR 80s, regular; he has a dual-chamber pacer, but does not appear to be pacer dependent. BP 100/50. He is not diaphoretic.
His extremities are warm, but cap refill sluggish. There is no pitting.
He has a wet cough and brings up pink, frothy sputum. He has crackles at both bases.
His knee is swollen and hot, but not red.

His INR is now down to 1.8, WBC 11.
 
eikenhein said:
I think the answer is you don't know if the patient is truly coagulopathic. But the number is there. Is it nutritional? Is it hepatic dysfunction? in this situation the prudent thing is to not do a spinal or take the risk. Imagine having to do this knee case, and then coming back to the OR to do an emergent decompression due to epidural hematoma.
Click to expand...
Agreed, just pointing out to the residents and students here that an elevated INR does not always mean an actual clinical coagulopathy. If you have time, and can confirm normal clotting function, then having a frank discussion of risks, benefits, alternatives, and possibly proceeding with neuraxial may be prudent. In an emergency, though, just take it at face value, and decline neuraxial interventions.
 
psychbender said:
Is he necessarily coagulopathic, just because his INR is >2? Given his CHF and volume overload with AKI, I would not be surprised if he had some degree of hepatic dysfunction (even in the absence of significant transaminitis). As a result, both procoagulant and anticoagulant substances (proteins C and S) are deficient. INR may be elevated, but net clotting function is not depressed (normal TEG/ROTEM, no clinically increased bleeding). I saw this all the time in the MICU, and would have the talk with residents and surgeons that we can't just defer anticoagulation or DVT prophylaxis simply because of an elevated INR.
Click to expand...

Totally agree that INR in liver disease does not accurately reflect coagulation status. Used to think it was dumb that surgeons/proceduralists would ask to correct INR with FFP and vitamin K, but then again I dont think I’d do neuraxial with an INR of 2.2 in this patient...
 
MoMoGesiologist said:
Totally agree that INR in liver disease does not accurately reflect coagulation status. Used to think it was dumb that surgeons/proceduralists would ask to correct INR with FFP and vitamin K, but then again I dont think I’d do neuraxial with an INR of 2.2 in this patient...
Click to expand...

Does ASRA have anything to say about all this? I dont recall use of ROTEM or TEG to assess coagulation function when INR abnormal. I dont think they even mention anything about vit K and FFP correction in the guidelines
 
cchoukal said:
Okay, so at the bedside, he is elderly, cachectic, and asleep. Arouses with difficulty, says, "Son, can we do this on monday or Tuesday?"

VS:
Afebrile.
HR 80s, regular; he has a dual-chamber pacer, but does not appear to be pacer dependent. BP 100/50. He is not diaphoretic.
His extremities are warm, but cap refill sluggish. There is no pitting.
He has a wet cough and brings up pink, frothy sputum. He has crackles at both bases.
His knee is swollen and hot, but not red.

His INR is now down to 1.8, WBC 11.
Click to expand...

Patient refusal! Monday it is!

He doesn’t “appear” as sick as I have in my head. No spinal. Prayer still needed.
 
cchoukal said:
You're called by Ortho for a washout of infected knee hardware. They warn you the guy is a little sick. You review the record...

90 yo M with a PMHx of CHF (EF 25%), AFib, and 3rd degree AV block (all presumed due to amyloidosis) and COPD. He was admitted to an OSH a month ago for infected knee hardware and underwent arthroscopy x 3 and grew out pseudomonas. Went to SNF on cefepime, but redeveloped infected knee and got admitted to your hospital. He now has fluid overload with pulmonary edema and effusions, AKI with a creatinine of 3 (baseline 1-ish), an INR of 2.2 (not on anticoagulants and LFTs are NL), and plts of 90K.

What's your move?

Defer pending optimization of his CHF? Will he get septic in the meantime?

Nerve blocks and a strap of leather to bite down on?

Retrograde wire?
Click to expand...

Aline
Albuterol Neb
Pace maker vs pads and cardiac clearance
Neo gtt
Inhalational Induction, LMA,
Keep breathing spontaneously
Blood as needed
 
cchoukal said:
Okay, so at the bedside, he is elderly, cachectic, and asleep. Arouses with difficulty, says, "Son, can we do this on monday or Tuesday?"

VS:
Afebrile.
HR 80s, regular; he has a dual-chamber pacer, but does not appear to be pacer dependent. BP 100/50. He is not diaphoretic.
His extremities are warm, but cap refill sluggish. There is no pitting.
He has a wet cough and brings up pink, frothy sputum. He has crackles at both bases.
His knee is swollen and hot, but not red.

His INR is now down to 1.8, WBC 11.
Click to expand...

lasix 80 iv, prop, sux, tube, extubate to bipap
 
Bad case for the weekend unless you’re at a tertiary center that runs well staffed on the weekends.

Spinal is a hard no for me. You can talk about the coagulation cascade all you want but it won’t hold up in court when the lawyer asks why you decided to stick a needle in an infected patients back in the setting of INR 2.2. Of course I understand you might actually be acting in the patient’s best interest but you never know when a greedy family member will suddenly start looking for a payday. I just don’t see enough upside to justify that kind of risk.

Nerve blocks sound good in theory but not practical and won’t work well enough. Conversion would be messy

I would insist on optimizing this guy before I proceeded, unless he actually does have sepsis. Obviously a hard call and you need to discussed with the surgeon and the family. Gonna be hard to use diuretics with his aki but I would at least try. Going into a case with active CHF is very suboptimal.

I can get this guy through a case but he’s going to the unit intubated and no promises on where he goes from there. Patient and family need to know that.
 
This is not an emergency, hence CHF optimization takes priority. Put in a dialysis catheter, put him on CVVH (or HD if tolerated), we'll talk after that.

Seriously, why would anybody even consider doing this case? This guy's infection is chronic. WBC of 11, HR of 80, BP of 100/50, this ain't sepsis yet (despite the AMS). Fix the heart, especially an amyloid heart with a lot of diastolic dysfunction (not just systolic).
 
Last edited by a moderator:
FFP said:
This is not an emergency, hence CHF optimization takes priority. Put in a dialysis catheter, put him on CVVH, we'll talk after that.

Seriously, why would anybody even consider doing this case? This guy's infection is chronic. WBC of 11, HR of 80, BP of 100/50, this ain't sepsis yet (despite the AMS). Fix the heart.
Click to expand...

Because it’s the weekend. Ortho has a few families to feed.... maybe? Or few extra spouses, girlfriends, new cars?
 
Echo33 said:
Spinal is a hard no for me. You can talk about the coagulation cascade all you want but it won’t hold up in court when the lawyer asks why you decided to stick a needle in an infected patients back in the setting of INR 2.2. Of course I understand you might actually be acting in the patient’s best interest but you never know when a greedy family member will suddenly start looking for a payday. I just don’t see enough upside to justify that kind of risk.
Click to expand...


In real life, no lawyer will accept a malpractice case on this 90yo patient.
 
IMGASMD said:
Because it’s the weekend. Ortho has a few families to feed.... maybe? Or few extra spouses, girlfriends, new cars?
Click to expand...
This is the kind of case where I make ortho document that this is an emergent case, or it won't happen, but I can see a number of people bending over backwards for the client, the surgeon.
 
Last edited by a moderator:
FFP said:
This is not an emergency, hence CHF optimization takes priority. Put in a dialysis catheter, put him on CVVH (or HD if tolerated), we'll talk after that.

Seriously, why would anybody even consider doing this case? This guy's infection is chronic. WBC of 11, HR of 80, BP of 100/50, this ain't sepsis yet (despite the AMS). Fix the heart, especially an amyloid heart with a lot of diastolic dysfunction (not just systolic).
Click to expand...

I like this approach as well in light of the vitals and exam data we got. Hell, I bet ortho doesn’t wanna do the case all that badly anyway.
 
nimbus said:
In real life, no lawyer will accept a malpractice case on this 90yo patient.
Click to expand...

Don't be so sure. Know of a case that was settled for a decent amount that sounds very similar to this, patient was 85.
 
FFP said:
This is the kind of case where I make ortho document that this is an emergent case, or it won't happen, but I can see a number of people bending over backwards for the client, the surgeon.
Click to expand...

I agree. Sometimes we need to remind everyone that we are not technicians. Unless the surgeon insists the guy is going to lose a limb or die of sepsis if we don't operate in the next few hours, this guy needs to be optimized first.
 
FFP said:
This is not an emergency, hence CHF optimization takes priority. Put in a dialysis catheter, put him on CVVH (or HD if tolerated), we'll talk after that.

Seriously, why would anybody even consider doing this case? This guy's infection is chronic. WBC of 11, HR of 80, BP of 100/50, this ain't sepsis yet (despite the AMS). Fix the heart, especially an amyloid heart with a lot of diastolic dysfunction (not just systolic).
Click to expand...


How do you fix an amyloid heart?
 
Echo33 said:
Don't be so sure. Know of a case that was settled for a decent amount that sounds very similar to this, patient was 85.
Click to expand...

You’re right. Anything is possible if there is flagrant malpractice. But in this case one is trying to make a decision about a legitimate clinical dilemma. I should have stated that medicolegal action is unlikely.
 
I assume this amyloid heart guy is afterload dependent?
Would you guys be cranking the PEEP?
 
eikenhein said:
I don't necessarily agree that this keeping pt spontaneously breathing is light and simple. I would opt to intubate and muscle relax, so you can use a balanced anesthetic with less sevo
Click to expand...

personally i regard an anesthetic with an ETT "heavier" than one with an LMA. this person needs 1% sevo and 25 of fentanyl, i feel adding the intubation and roc and reversal is more of a process for his body to go through
 
Case should be delayed for optimization ( diuretics). That being said if ortho insists that it is an emergency (and documents). Then anesthesia is simple. Etomidate, roc, tube. Then send to CCU intubated and let cardiology diurese and wean. Warn patients family that he is staying tubed. Next case.
 
Hoya11 said:
personally i regard an anesthetic with an ETT "heavier" than one with an LMA. this person needs 1% sevo and 25 of fentanyl, i feel adding the intubation and roc and reversal is more of a process for his body to go through
Click to expand...


1% sevo is approaching a full MAC in this patient. You can likely get by with a lot less. That’s easier to do if they’re intubated and paralyzed.
 
nimbus said:
1% sevo is approaching a full MAC in this patient. You can likely get by with a lot less. That’s easier to do if they’re intubated and paralyzed.
Click to expand...

Its easier to intubate and paralyze him and dump him in the unit intubated, ill give you that.

you dont need to paralyze everyone you want to run light, your concerned about this 90 yo barely living guy moving? benadryl would probably be enough. An LMA and minimalistic approach can spare this guy the ICU trip is what im thinking.

And in the end the difference between the ETT and LMA may not make a difference either way. The key is its a straight forward general, pressors, aline.
 
Last edited:
Hoya11 said:
Its easier to intubate and paralyze him and dump him in the unit intubated, ill give you that.

you dont need to paralyze everyone you want to run light, your concerned about this 90 yo barely living guy moving? benadryl would probably be enough. An LMA and minimalistic approach can spare this guy the ICU trip is what im thinking.

And in the end the difference between the ETT and LMA may not make a difference either way. The key is its a straight forward general, pressors, aline.
Click to expand...


I really don’t expect this patient to remain intubated postop. We have similar patients for bivent icd all the time. My recipe is preinduction Aline/prop/roc/tube/low dose sevo/suga/extubate. Haven’t needed to keep one intubated ever.
 
I’m with plank- assuming emergent and that infection is driving clinical presentation- what not fem/sci blocks? (Assuming risk of GA or neuraxial exceeds risk of theoretical bacterial seeding around injection sites)
 
He has an acute HF exacerbation. Hit him with as much diuretics as you can. The good thing is he doesn't seem to have an O2 requirement currently so somebody actually paying attention to him could get him in a better spot by tomorrow. The CHB doesn't matter since he has a PPM. Seems fairly straightforward.

If you did have to proceed for whatever reason (declared an "emergency") then just take it easy with the IVF and diurese him during the case. His creatinine will come down once his venous congestion is fixed. Otherwise, prop/sux/tube.
 
Hoya11 said:
Its easier to intubate and paralyze him and dump him in the unit intubated, ill give you that.

you dont need to paralyze everyone you want to run light, your concerned about this 90 yo barely living guy moving? benadryl would probably be enough. An LMA and minimalistic approach can spare this guy the ICU trip is what im thinking.

And in the end the difference between the ETT and LMA may not make a difference either way. The key is its a straight forward general, pressors, aline.
Click to expand...
Surprised people are considering LMA. This patient has acute CHF exacerbation, crackles in lungs and is coughing up pink froth. He needs diuresis. You lay this guy flat and give him any anesthetic you will affect his respiration, even if you do inhalation induction ect. He will need real ventilation and that is best done through an ETT. Probably a slight aspiration risk as well.....
 
nimbus said:
I really don’t expect this patient to remain intubated postop. We have similar patients for bivent icd all the time. My recipe is preinduction Aline/prop/roc/tube/low dose sevo/suga/extubate. Haven’t needed to keep one intubated ever.
Click to expand...

Keeping this guy intubated postop isnt a big deal. He is going to the unit postop one way or another.
 
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