Would you do further workup or proceed with this case?

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BDanes

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87 yo F presents sp hip fx

pmhx- CAD 3v 10 yrs prior, DM2, htn (uncontrolled- 212/87 yesterday, 180/110s today), severe dementia

IM sees patient yesterday and in the note writes: pt has poor funcional capacity, no current complaints of chest pain or sob
No cardiac workup since bypass
mod to high risk secondary to poor functional status-proceed to OR

EKG with one small block depression in leads v4,v5. A second ekg 6 hours later shows prolonged qt, 1 degree av block. Both EKG are from yesterday.

Pt is in no apparent distress on exam, but obviously demented.

So, do you proceed? If not, why not?

Case is non emergent, but should be done sooner rather than later. I'll let you guys reply a bit and then tell you what went down.:thumbup:
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We'll just assume something bad actually happened.

Not sure what you'd gain by delaying the case. Cardiology would seem quite unlikely to make any intervention to alter his risk. He's 87. He's not getting a CABG even if he had severe flow limiting CAD. I can't imagine he'd even get a stent for anything because you wouldn't want to delay his surgery for anticoagulation relating to a new stent, so I can't see him even getting a cath for any reason.

The only 2 things I'd like preoperatively are an Echo so I know what kind of heart function I'm dealing with and some better BP control.
 
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This is a typical case for us in Florida. I would not delay the case. I usually do GA with LMA for troch nails but sometimes spinals if the patient is calm and cooperative.
 
Hawaiian Bruin said:
I wouldn't, because I'd do it myself.:smuggrin:
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I can get the TTE tech in less than 30 min and look at the images with him/her. This gives me EF and any AS/AI quickly. I'll also look for any MR/MS if the tech gets good views.

By the way my partners don't bother wth the TTE and just do the case. They feel regardless of what the echo shows this patient needs the surgery and what exactly is cardiology going to do to improve quality of life?
 
Symptoms of dementia can be classified as either reversible or irreversible, depending upon the etiology of the disease. Fewer than 10% of cases of dementia are due to causes that may presently be reversed with treatment. Causes include many different specific disease processes, in the same way that symptoms of organ dysfunction such as shortness of breath, jaundice, or pain are attributable to many etiologies.
Without careful assessment of history, the short-term syndrome of delirium (often lasting days to weeks) can easily be confused with dementia, because they have all symptoms in common, except duration. Some mental illnesses, including depression and psychosis, may produce symptoms that must be differentiated from both delirium and dementia.[7]
There are many specific types (causes) of dementia, often showing slightly different symptoms. However, the symptom overlap is such that it is impossible to diagnose the type of dementia by symptomatology alone, and in only a few cases are symptoms enough to give a high probability of some specific cause. Diagnosis is therefore aided by nuclear medicine brain scanning techniques. Certainty cannot be attained except with brain biopsy during life, or at necropsy in death.
Some of the most common forms of dementia are: Alzheimer's disease, vascular dementia, frontotemporal dementia, semantic dementia and dementia with Lewy bodies. It is possible for a patient to exhibit two or more dementing processes at the same time, as none of the known types of dementia protects against the others. Indeed, about ten per cent of people with dementia have what is known as "mixed dementia", which may be a combination of Alzheimer's disease and multi-infarct dementia.[8][9]
 
With that kind of history, why not just assume that the patient has a ticking time bomb in his chest and proceed? If you do get an echo and it comes back normal, how is that going to change your management and acceptable blood pressure range in a patient with this history? It wouldn't change mine.

The longer you wait on this hip fracture the worse the prognosis gets. I say assume the worst and go for it.
 
HollywdAnesth said:
With that kind of history, why not just assume that the patient has a ticking time bomb in his chest and proceed? If you do get an echo and it comes back normal, how is that going to change your management and acceptable blood pressure range in a patient with this history? It wouldn't change mine.

The longer you wait on this hip fracture the worse the prognosis gets. I say assume the worst and go for it.
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agree 100%

This case is urgent, keep the patient "normal" as possible. regardless of what happens the chance of a successful lawsuit in these cases is tiny. These cases are truly ASA 5's. fixing the hip will only help with pain management, not much more than that and morphine would be just as good. If the patient survives a month i would be surprised.Sometimes i feel these cases are a place where we could be saving some healthcare resources. I love the ones i do where the patient is demented and hasn't walked in years, has a PEG.

I try and do spinals for most.
 
BDanes said:
87 yo F presents sp hip fx

pmhx- CAD 3v 10 yrs prior, DM2, htn (uncontrolled- 212/87 yesterday, 180/110s today), severe dementia

IM sees patient yesterday and in the note writes: pt has poor funcional capacity, no current complaints of chest pain or sob
No cardiac workup since bypass
mod to high risk secondary to poor functional status-proceed to OR

EKG with one small block depression in leads v4,v5. A second ekg 6 hours later shows prolonged qt, 1 degree av block. Both EKG are from yesterday.

Pt is in no apparent distress on exam, but obviously demented.

So, do you proceed? If not, why not?

Case is non emergent, but should be done sooner rather than later. I'll let you guys reply a bit and then tell you what went down.:thumbup:
Click to expand...

If the patient's been here since yesterday, I'm surprised they didn't get an echo already.

If the patient has evidence of failure or being volume overloaded, I'd wait because that can be optimized in a short time.

Otherwise, I'd proceed, even without an echo - just assuming the patient has a lousy EF and CAD. I might shy away from a spinal if there was a significant AS-suggestive murmur on exam, otherwise I don't think the anesthetic technique matters a bit so long as you take care to keep vitals in a tight box. To be honest I've come to prefer doing these cases under GA with a fascia iliaca block after they're asleep.
 
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This seems to be a perpetual crossroads as far as philosphy among practioners. Some will delay a few days and wait to stress him or get a baseline echo. Some will just assume he has a bum heart and proceed with the case. I prefer the ladder and like Blade's approach. I assume the worst, explain to the patient this he is at increased risk of morbidity and mortality with and without the surgery, and head to the OR exercising all precautions and base my care on assuming he has a bad heart.
 
Can J Anaesth. 2008 Mar;55(3):146-54.
Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression.

Shiga T, Wajima Z, Ohe Y.
Source

Second Department of Anesthesiology, Toho University School of Medicine, Tokyo, Japan. [email protected]

Abstract

PURPOSE:

Mortality associated with hip fracture is high in elderly patients. Surgical repair within 24 hr after admission is recommended by The Royal College of Physicians' guidelines; however, the effect of operative delay on mortality remains controversial. The objective of this study was to determine whether operative delay increases mortality in elderly patients with hip fracture.
METHODS:

Published English-language reports examining the effect of surgical delay on mortality in patients who underwent hip surgery were identified from electronic databases. The primary outcome was defined as all-cause mortality at 30 days and at one year. Effect sizes with corresponding 95% confidence intervals were calculated by using a DerSimonian-Laird randomeffects model.
RESULTS:

Sixteen prospective or retrospective observational studies (257,367 patients) on surgical timing and mortality in hip fracture patients were selected. When a cut-off of 48 hr from the time of admission was used to define operative delay, the odds ratio for 30-day mortality was 1.41 (95% CI = 1.29-1.54, P < 0.001), and that for one-year mortality was 1.32 (95% CI = 1.21-1.43, P < 0.001).
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.
 
CMAJ. 2010 Oct 19;182(15):1609-16. Epub 2010 Sep 13.
Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis.

Simunovic N, Devereaux PJ, Sprague S, Guyatt GH, Schemitsch E, Debeer J, Bhandari M.
Source

Department of Clinical Epidemiology and Biostatistics, McMasterUniversity, Hamilton, Ontario, Canada. [email protected]

Abstract

BACKGROUND:

Guidelines exist for the surgical treatment of hip fracture, but the effect of early surgery on mortality and other outcomes that are important for patients remains unclear. We conducted a systematic review and meta-analysis to determine the effect of early surgery on the risk of death and common postoperative complications among elderly patients with hip fracture.
METHODS:

We searched electronic databases (including MEDLINE and EMBASE), the archives of meetings of orthopedic associations and the bibliographies of relevant articles and questioned experts to identify prospective studies, published in any language, that evaluated the effects of early surgery in patients undergoing procedures for hip fracture. Two reviewers independently assessed methodologic quality and extracted relevant data. We pooled data by means of the DerSimonian and Laird random-effects model, which is based on the inverse variance method.
RESULTS:

We identified 1939 citations, of which 16 observational studies met our inclusion criteria. These studies had a total of 13 478 patients for whom mortality data were complete (1764 total deaths). Based on the five studies that reported adjusted risk of death (4208 patients, 721 deaths), irrespective of the cut-off for delay (24, 48 or 72 hours), earlier surgery (i.e., within the cut-off time) was associated with a significant reduction in mortality (relative risk [RR] 0.81, 95% confidence interval [CI] 0.68-0.96, p = 0.01). Unadjusted data indicated that earlier surgery also reduced in-hospital pneumonia (RR 0.59, 95% CI 0.37-0.93, p = 0.02) and pressure sores (RR 0.48, 95% CI 0.34-0.69, p < 0.001).
INTERPRETATION:

Earlier surgery was associated with a lower risk of death and lower rates of postoperative pneumonia and pressure sores among elderly patients with hip fracture. These results suggest that reducing delays may reduce mortality and complications.
 
Idiopathic said:
regardless of what ended up happening, an echo wont change your management, so dont delay.
Click to expand...

Great point idio.....As a resident I was always worried about these pts b/c they are so sick and I want to make sure I have all the tests but then you realize, what are you gonna do with the information and how is it going to change your plan? If you find severe disease, she's not gonna get bypassed and unlikely to be stented. The risk of delaying is greater than the risk of doing. Unless you suspect a tight aortic valve and you plan on a spinal then no need to worry about the echo.

2 of versed in the IV and 3cc of 0.5% marcaine in the CSF. Chart away

I'm batting a low percent of successful spinals in dementia pts.
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versed before hand makes em quit movin. Have you tried going paramedian? I find it really helps on pts w/a lot of osteophytes. I also use a 22g quinke in these pts to start with as they won't be getting a H/A anyway and it will make your life easier. Hope that helps improve your success rate
 
ssmallz said:
Unless you suspect a tight aortic valve and you plan on a spinal then no need to worry about the echo.
Click to expand...

And these patients are going to have an audible murmur ...

ssmallz said:
versed before hand makes em quit movin. Have you tried going paramedian? I find it really helps on pts w/a lot of osteophytes. I also use a 22g quinke in these pts to start with as they won't be getting a H/A anyway and it will make your life easier. Hope that helps improve your success rate
Click to expand...

A touch of ketamine helps too. +1000 on the big spinal needle too. I don't even try with the 25 g in the kit.
 
Personally, I would get the echo....

after the patient is asleep and tubed...

or not...

Anesthetic number 1

Agreed dime a dozen.

Next case.

- pod
 
BDanes said:
would you delay for the echo?
Click to expand...

Yes, the case is urgent, but not emergent. I want 2 pieces of information before proceeding. Is there myocardium at risk, and what is the heart function/degree of valvular disease. If there is valvular disease, I can at least know what is going on so I can make a treatment plan depending on what is going on.
 
Idiopathic said:
regardless of what ended up happening, an echo wont change your management, so dont delay.
Click to expand...

Sure it will. If the EF is 15% and/or they have severe AS I'm not considering a spinal. If the cardiac function is grossly normal, a spinal might be a great way to do this. Even if I do it under GA, the results of the Echo would influence my need for invasive lines.

So yes, the Echo changes the management of the case.
 
Mman said:
Sure it will. If the EF is 15% and/or they have severe AS I'm not considering a spinal. If the cardiac function is grossly normal, a spinal might be a great way to do this. Even if I do it under GA, the results of the Echo would influence my need for invasive lines.

So yes, the Echo changes the management of the case.
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Thank you. Somebody with some brains on this board. You get the echo because IT WILL ALTER YOUR MANAGEMENT!!!!!!!!!

EF-15% with critical AS will get the a line along with phenylephrine in line. EF -65% and no AS will not get an a line. severe MR will be fast full forward.

The echo changes management for the patient's benefit. I have this argument with the surgeons every day and I am sick and tired of having to expalin myself.
 
ill preface this with the caveat "im sure this patient did poorly because of the forum and the manner in which it is presented", but i feel like you can assess many conditions for severity with physical exam. no one has presented any physical exam findings suggestive of critical valvular lesions and no one has suggested EF 15%. technically any patient could have these conditions and therefore everybody needs an echo?

oh and myocardium at risk? are we getting a stress echo? id be on board for a formal/informal bedside echo for gross assessment of function, etc (delay for 1 hour) but would not delay this patient for stress.
 
cincincyreds said:
Thank you. Somebody with some brains on this board. You get the echo because IT WILL ALTER YOUR MANAGEMENT!!!!!!!!!

EF-15% with critical AS will get the a line along with phenylephrine in line. EF -65% and no AS will not get an a line. severe MR will be fast full forward.

The echo changes management for the patient's benefit. I have this argument with the surgeons every day and I am sick and tired of having to expalin myself.
Click to expand...

Have you ever encountered a patient with critical AS who didn't have a significant murmur? The kind of bad valvular disease or cardiac cripple EF that would make anesthesia sans invasive monitors a probable quick clean kill isn't subtle.

I'm not saying I would never delay a hip fx to get an echo, but not every one of them needs an echo, either. This patient is basically symptom free per the OP, presumably has no objective exam findings suggestive of failure or valvular disease ... it's always hard to get a good feel for the sickness of a patient based on a few lines of text over the internet, but this case didn't strike me as anything too unusual.

The choice here isn't just between
a) 15 mg spinal bupivacaine, NIBP cycling q5min, Scrabble on the iPhone
b) echo, a-line, phenylephrine pump on standby, intrathecal catheter vs LMA, epi-pen to anesthesiologist's right quad
 
agree w/Idio and PGG. Stethoscope is the first step in evaluating this pt. Let's do some real doctoring and figure out if she's got a high probability for the disease based on H&P before we order a test that's likely to be negative and more cya

Does she have a murmur? Does she have S/Sx consistent with severe AS (CP, DOE, Syncope)

Another point to consider is that she had a CABG 10 years ago. Presumably, her aortic valve was pretty good then or they would have replaced it. Did she suddenly develop severe AS in the last 10 year? Unlikely

Why do we think she has an EF of 15%? She has some risk factors but nothing suggestive. Furthermore, her uncontrolled HTN would seem to suggest that her myocardium is pretty strong and able to generate those pressures making it even less likely that she has an EF that low.

If you still feel like she's a cardiac cripple based on H&P, which is unlikely but possible, why do you need an echo to proceed? Just do an a-line, gentle LMA, and treat her as though she has an EF of 15% and a tight AV.

With a good surgeon this is a 45 minute case with 100cc of EBL, not a long drawn out case w/significant fluid shifts. You've also got an IM note saying proceed to the OR to fall back on in case the lawyers start asking questions which they won't because she's 87 y/o and sick. Proceed with case, she will do poorly b/c she's a sick 87 y/o pt w/multiple comorbities, not because she didn't have an echo and stress prior to the procedure.
 
ssmallz said:
agree w/Idio and PGG. Stethoscope is the first step in evaluating this pt. Let's do some real doctoring and figure out if she's got a high probability for the disease based on H&P before we order a test that's likely to be negative and more cya

Does she have a murmur? Does she have S/Sx consistent with severe AS (CP, DOE, Syncope)

Another point to consider is that she had a CABG 10 years ago. Presumably, her aortic valve was pretty good then or they would have replaced it. Did she suddenly develop severe AS in the last 10 year? Unlikely

Why do we think she has an EF of 15%? She has some risk factors but nothing suggestive. Furthermore, her uncontrolled HTN would seem to suggest that her myocardium is pretty strong and able to generate those pressures making it even less likely that she has an EF that low.

If you still feel like she's a cardiac cripple based on H&P, which is unlikely but possible, why do you need an echo to proceed? Just do an a-line, gentle LMA, and treat her as though she has an EF of 15% and a tight AV.

With a good surgeon this is a 45 minute case with 100cc of EBL, not a long drawn out case w/significant fluid shifts. You've also got an IM note saying proceed to the OR to fall back on in case the lawyers start asking questions which they won't because she's 87 y/o and sick. Proceed with case, she will do poorly b/c she's a sick 87 y/o pt w/multiple comorbities, not because she didn't have an echo and stress prior to the procedure.
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Getting the results of an Echo I order takes less than 60 minutes. It doesn't delay the case significantly. And it also provides useful information that impacts decision making. And since it's a demented old person I probably have zero idea of functional capacity because they have probably just been sitting around in a chair for years.

Crappy heart and she gets a preinduction a-line and good chance of a central line. If she has essentially normal cardiac function she gets nothing special and either a spinal or a simple GA.

There is a big difference between those 2 approaches.
 
pgg said:
This patient is basically symptom free per the OP
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How many symptoms does the average patient with severe dementia give you? She could be having crushing chest pain with even a teeny bit of exertion and we wouldn't know it.
 
Mman said:
How many symptoms does the average patient with severe dementia give you? She could be having crushing chest pain with even a teeny bit of exertion and we wouldn't know it.
Click to expand...

Your point here is well taken. She probably does have chest pain with exertion. Yesterday she had an ECG with some ST depression. I assume she has myocardium at risk. I don't need a stress echo to tell me that.

BDanes hasn't been back yet to tell us what happened, or what exam findings the patient had, or labs, or what meds the patient was taking, or even what the surgery is (troch nail vs arthroplasty). I assume there's no game-changing information there, else it would've been in the OP. While it's entirely possible that given a little more exam/history info I'd modify my approach, my EF15% fear flags aren't up. Maybe that means I'm setting myself up for a surprise.


If this patient came to me, I think I'd do the same thing I do for almost all of my old hips - NIBP set to q2min (at least initially), preoxygenate, put a phenylephrine drip in line, slow gentle induction with a couple ccs of propofol at a time, start the phenylephrine gtt at 25-50 mcg/min, a bit of roc, ETT, vent on, ~3% desflurane. Fascia iliaca block in. Move to OR table. Do case. Extubate, go to PACU.

If I had an echo showing critical AS, I'd do the same thing, with an a-line. This patient doesn't have critical AS though.
 
I would repeat the ECG and send cardiac markers. If either is positive, I would delay the case to request a cardiology consult. If cardiology don't want to do anything, they should document this and then I would proceed with an appropriate "cardiac cripple" anesthetic. If they want to make an intervention, then the case can go tomorrow or in a few days.

A preop echo will not change my "cardiac cripple" anesthetic since I am treating this guy as a cardiac cripple anyway. I would delay for a cardiology consult but if cardiology doesn't want to do anything I would not get an echo. (I used to request a lot more echos for these old hip fractures as a resident, but the reality is that all of these patients get the same gentle induction close BP monitoring HR control etc etc).
 
jennyboo said:
I would repeat the ECG and send cardiac markers. If either is positive, I would delay the case to request a cardiology consult. If cardiology don't want to do anything, they should document this and then I would proceed with an appropriate "cardiac cripple" anesthetic. If they want to make an intervention, then the case can go tomorrow or in a few days.

A preop echo will not change my "cardiac cripple" anesthetic since I am treating this guy as a cardiac cripple anyway. I would delay for a cardiology consult but if cardiology doesn't want to do anything I would not get an echo. (I used to request a lot more echos for these old hip fractures as a resident, but the reality is that all of these patients get the same gentle induction close BP monitoring HR control etc etc).
Click to expand...

So you would manage a severely stenotic valve the same as a regurgitant valve? Wouldn't make a difference if the patient had high PA pressures compared to normal?

To me, those things change how I manage the case.
 
Cases like this are why I think every residency program in the country should be teaching their trainees basic TTE. All the attention gets put on TEE, but whenever a pt like this shows up in holding, doing a quick scan yourself costs the system nothing, is risk free, and gives you valuable info.
 
Hawaiian Bruin said:
Cases like this are why I think every residency program in the country should be teaching their trainees basic TTE. All the attention gets put on TEE, but whenever a pt like this shows up in holding, doing a quick scan yourself costs the system nothing, is risk free, and gives you valuable info.
Click to expand...

:thumbup:
 
Mman said:
So you would manage a severely stenotic valve the same as a regurgitant valve? Wouldn't make a difference if the patient had high PA pressures compared to normal?
Click to expand...

This is a straw man argument. The goal of the anesthetic is to keep this old gomer in the range where he lives and is compensated, not to speed him up or slow him down to some number that makes the anesthetist happy. If he's not medically optimized (e.g. he has acute decompensated CHF, acute arrhythmia, active ischemia) then do that first, then fix his hip as soon as possible afterward.

You don't need an echo to do a standard "keep him close to his baseline" anesthetic for this patient to get a quick, palliative, not-truly-elective IM nail.
 
jennyboo said:
This is a straw man argument. The goal of the anesthetic is to keep this old gomer in the range where he lives and is compensated, not to speed him up or slow him down to some number that makes the anesthetist happy. If he's not medically optimized (e.g. he has acute decompensated CHF, acute arrhythmia, active ischemia) then do that first, then fix his hip as soon as possible afterward.

You don't need an echo to do a standard "keep him close to his baseline" anesthetic for this patient to get a quick, palliative, not-truly-elective IM nail.
Click to expand...

My group probably does about 200-250 of these cases a year (almost exactly as described by the OP). Out of the 250 I may get a TTE on about 1 of them if I am concerned about missing something; the rest get a LMA/GA if severely demented or an short SAB if mild Alzheimer's and no contraindications (Plavix, etc.).
 
Agreed. The vast majority of mine are prop-LMA or prop-sux-tube.
 
edelweiss said:
Agreed. The vast majority of mine are prop-LMA or prop-sux-tube.
Click to expand...

I agree that the vast majority of old broken hips fit into that mold. But this patient is a known diabetic with poorly controlled hypertension and a long history of coronary disease. I'm a little gun shy on just going for it with those patients. They have the potentially to spiral downhill quickly and can have disease processes (severe pulmonary hypertension or significantly valvular lesions) that can prevent your normal intraop rescues (phenylephrine) from helping.
 
This was only a hypothetical case. I was just curious to see what opinions are on this board. These, as you know, come in all the time. Some IM docs work them up w cards, others send them through without.

Most in my group elect to get the studies. I agree most do about as well as they can without cardiac workup, but no one on this board can tell me that moderate to severe pulmonary hypertension doesn't change their management.
 
BDanes said:
This was only a hypothetical case. I was just curious to see what opinions are on this board. These, as you know, come in all the time. Some IM docs work them up w cards, others send them through without.

Most in my group elect to get the studies. I agree most do about as well as they can without cardiac workup, but no one on this board can tell me that moderate to severe pulmonary hypertension doesn't change their management.
Click to expand...
:idea:

In an 87 Y/O demented patient with a broken hip NOTHING will change my management!
If they have a pulse they get a slow induction , LMA, GA and spontaneous vantilation with some pressure support.
Nothing else is needed.
 
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