What would you do?

[urge]

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Little old lady had a syncope and broke her hip. Echo has severe AS, mod MS. Booked for orif.

A- Screw (as in f..ck, not as "put a screw in") the hip. Fix the heart first. Wheelchairs come in nice colors

B- Fix the hip since mortality is quite high if not repaired. Might die on the table.

C- Fix both at the same time. Will bleed like stink.

 

[Jeff05]

current aha/aca recommendations are to fix the valve before noncardiac surgery. but, in patients with severe aortic stenosis who refuse cardiac
surgery or are otherwise not candidates for aortic
valve replacement, noncardiac surgery can be performed with a mortality of about 10%.

Torsher LC, Shub C, Rettke SR, Brown DL. Risk of patients with
severe aortic stenosis undergoing noncardiac surgery. Am J Car-
diol. 1998;81:448 –52.




provided she refuses a new valve:
a line.
place epidural.
bring up level slowly and counter decrease in svr with phenylephrine.

i have also done mepiv spinals with a touch of fent (2.2ml 1.5% mepiv with 12.5mcg fent) in patients with pretty tight as (valve 1cm sq) with completely stable hemodynamics.

 

[VentdependenT]

Nice paper by the ACCP 2005 concerning non-cardiac surgery in pts with Aortic Stenosis.
http://www.chestjournal.org/cgi/reprint/128/4/2944.pdf?ck=nck

If they can just pin the neck then I'd slap in an LMA and an a-line and call it a day.

 

[Planktonmd]

Fascia iliaca block + GA + LMA, Fix the hip.
They can later think about what they want to do to the valve.

 

[nociceptor]

Little old lady had a syncope and broke her hip. Echo has severe AS, mod MS. Booked for orif.

A- Screw (as in f..ck, not as "put a screw in") the hip. Fix the heart first. Wheelchairs come in nice colors

B- Fix the hip since mortality is quite high if not repaired. Might die on the table.

C- Fix both at the same time. Will bleed like stink.

How about

D- Call the attending and return to my usual clueless position

 

[VentdependenT]

Cards dude may wanna float a cath in there and do a quickie balloon valvuloplasty....or not.

 

[urge]

Nice paper by the ACCP 2005 concerning non-cardiac surgery in pts with Aortic Stenosis.
http://www.chestjournal.org/cgi/reprint/128/4/2944.pdf?ck=nck

If they can just pin the neck then I'd slap in an LMA and an a-line and call it a day.

Good paper, but it leaves a lot of room for you to pull either way. This is not really an elective case. Most people would classify as urgent. But,
How urgent is a hip fracture? People could argue very urgent. If she doesn't get fixed she'll probably die in a few weeks or months. People may argue not so urgent, she'll take a few months to die. Who is right, who is wrong?

What about the mod MS?

 

[Noyac]

If they can just pin the neck then I'd slap in an LMA and an a-line and call it a day.

you are on your way son. 👍

Have you learned this from your academic attendings or from our internet attendings? LOL

 

[Noyac]

Fascia iliaca block + GA + LMA, Fix the hip.
They can later think about what they want to do to the valve.

Exactly what I'd do +/- the block. These pts don't really hurt after surgery and the intraop coarse is very stable. I block almost everyone I can (I like regional) but I don't usually block these geezers. It won't hurt though.

Piece of cake. We do 1-3 of these every weekend.

 

[militarymd]

Nice paper by the ACCP 2005 concerning non-cardiac surgery in pts with Aortic Stenosis.
http://www.chestjournal.org/cgi/reprint/128/4/2944.pdf?ck=nck

If they can just pin the neck then I'd slap in an LMA and an a-line and call it a day.

Nice paper...gave me data to support what I believe already.