We made too many wrong mistakes'

1

• We made too many wrong mistakes.

2
Case Presentation

• An 89 year old male with history of two failed
  left total hip arthroplasties presenting for
  revision of failed left hip arthroplasty.

3
History

• Cardiac Atrial fibrillation.
• Stable angina, relief with NTG.
• No history of myocardial infarction, or
  congestive heart failure.
• Thallium stress test in 11/99 negative.

4
History

• Pulmonary Sleep apnea, uses nasal CPAP at home.
  Remote history of bronchitis.
• Renal Baseline chronic renal insufficiency.
• Endocrine Hypothyroid.
• Neurologic No history of weakness, stroke.
• On glaucoma medication.

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Past Surgeries

• 1999 Cataract extractions MAC
• 1993 Inguinal hernia repair MAC
• 1986 R hip replacement GA
• 1983 L hip revision GA
• 1981 L hip replacement GA
• 1979 TURP GA

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Medications

• Digoxin
• Atrovent
• Synthroid
• Lasix, Triamterene
• Isoptocarpine, betagan, xalatan
• Nasonex, claritin,
• Vioxx, feldene, naproxen, trental

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Physical Exam

• Vitals BP 152/82, HR 88, RR 22, O2 Sat 96, T
  36.5, Wt 79 kg
• General Elderly, well developed gentleman.
  Bed-bound. Conversant.
• Airway MP Class I. Missing teeth. Limited neck
  extension.
• Neck No bruits.

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Physical Exam

• Chest Clear
• Cardiovascular Normal S1, S2. Irregular rhythm.
  No murmurs.
• Extremities Trace edema in legs.
• Neurologic Non-focal. Alert.
• Skin Normal.

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Laboratory Studies

• WBC 4.8, Hgb 12.9, Hct 37.1, Plts 209
• PT 13.7, INR 1.2, PTT 34.8
• Na 140, K 5.1, Cl 104, CO2 29, Glu 102
• Digoxin 0.6
• BUN 42, Cr 2.1
• AST 20

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Pre-Operative Labs

• EKG Atrial fibrillation, low voltage QRS.

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Pre-Operative instructions

• Stop ecotrin, vioxx, trental, feldene, naproxen
  (4 days until surgery).
• Take digoxin, lasix, synthroid on AM of surgery.
• Bring own nasal CPAP for post-op recovery.

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Assessment

• This is an 89 year old gentleman with atrial
  fibrillation and sleep apnea scheduled for
  revision of failed left total hip replacement.

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Plan

• Monitoring Standard monitors. Arterial line.
  Additional large-bore IV.
• Anesthesia Combined anesthesia General
  endotracheal anesthesia with epidural infusion.
• Post-op plan Extubate, to recovery room. Pain
  management to follow epidural.

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Day of Surgery Pre-Op

• PIV start.
• Premedication
• Epidural Sitting position. Usual prep. Tuohy 8.5
  cm 17g needle midline approach at L3-4. LOR at
  6.5 cm. Catheter taped at 12 cm. No paresthesias
  reported by patient.
• Informed of intraop MEP monitoring.

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Intra-op

• IV induction. A-line start. PIV start. Test dose
  negative for heart rate or BP change.
• Maintenance Desflurane initially, slowly weaned
  off. Propofol gtt started.
• Epidural dosed with MSO4 2.5 mg two hours into
  the case.
• Motor evoked potentials intact througout.

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Intraop Labs

• ABG 1 (60 min after incision)
• 7.39 / 36.8 / 44 1/ -1.3 / 100 FIO2 80
• ABG 2 (160 min after incision)
• 7.34 / 40 / 223 / 22 / -2.9 / 99 FIO2 60
• Hgb 7.6, Hct 24, Plt 155

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Fluids

• In Crystalloid 3000 cc
• Hextend 1000 cc
• Cell saver 750 cc
• Out EBL 1,500 cc
• Urine 300 cc

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Post-op

• Extubated with oral airway in place. Epidural
  left in place.
• Transport to PACU with spontaneous respirations.
• Epidural infusion started in PACU per Pain
  Service Ropivacaine 0.125 Fentanyl 3 mcg/cc _at_
  7 cc.

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POD 1

• AM rounds Left lower extremity with sensory
  deficit to light touch, able to DF/PF toes 2/5
  strength.
• Epidural removed at 12 noon.
• Enoxaparin injection 8 pm.

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POD 2

• Hematocrit drops 4 points to 24 overnight.
  Hemodynamically stable. INR 1.3.
• Patient unable to move or feel any part of left
  leg. Right leg with decreased strength and
  sensation. Positive Babinski bilaterally.
• Emergent MRI shows epidural hematoma T4 L2.

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POD 2

• Pt to OR for surgical decompression of epidural
  hematoma.
• EBL 2500, PRBC 5 units, FFP 2 Units, Plts 6 pack
  x 2.
• Dopamine gtt 2.5 mcg/kg/min.
• Pt to ICU with endotracheal tube in place.

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Post Op course

• ICU D1 Self extubated without complications.
• Follow up MRI Nearly complete evacuation of
  epidural hematoma.
• Residual left lower extremity weakness.
• High DVT and PE risk IVC filter placed under IR.
  
• Acute renal failure slowly resolved.

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Discharge

• Discharged to rehabilitation facility 5 days
  after epidural hematoma evacuation.
• Residual left lower extremity weakness.
• Tingling sensation in left lower extremity.

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ASRA Consensus Statement

• Patients with postoperative initiation of LMWH
  thromboprophylaxis may safely undergo single-dose
  and continuous catheter techniques. The first
  dose of LMWH should be administered no earlier
  than 24 hours postoperatively and only in the
  presence of adequate hemostasis. In addition, it
  is recommended that indwelling catheters be
  removed prior to initiation of LMWH
  thromboprophylaxis. If a continuous technique is
  selected, the epidural catheter may be left
  indwelling overnight and removed the following
  day, with the first dose of LMWH administered two
  hours after catheter removal.