63-year-old lady presenting for ORIF of a periprosthetic hip fracture
- No significant past medical history. Current smoker.
- Elective total hip replacement 2 weeks prior to presentation
- Procedure performed as ‘Public in Private’
- Simple fall on discharge resulting in periprosthetic fracture
- Initial THR – Postoperative hypotension resulting in type 2 MI.
- Troponin rise to 900
- Required 5-day admission to ICU for vasopressor support, had profound vasoplegia
- Commenced on Aspirin and Beta-blocker
- Developed wound haematoma and had drop in haemoglobin, requiring transfusion
- Cardiologist review as inpatient, Echo unremarkable with normal LV function and no regional wall motion abnormalities
- For CTCA, not yet performed
- Patient experienced multiple issues due to being a public patient in the private hospital, clinical governance concerns
- Uneventful intraoperative course with minimal blood loss
- On revisiting the history, patient stated she had a similar issue many years ago
- Uncertain cause – discussed possibility of undiagnosed pulmonary hypertension (not seen on echo), anaphylaxis unlikely, possibility it was a type 1 MI should be considered.
- Likely COPD, required bronchodilators during ICU admission.
- Current smoker, has cardiac risk factors.
Management of Current Procedure
- Emergent procedure, little value in CTCA preoperatively. Cardiologist in agreement.
- Postoperative troponin measurement – cardiologist opinion that it would be prudent in this case.
- Expectation that troponin will rise to around 800-900 but any further increases would warrant a cardiologist review
- CCU not an ideal location for post-surgical care, ICU bed more appropriate due to potential vasopressor requirement
- See above table from Canadian CV Guidelines
‘Public in private’ patients
- General opinion that patient selection for this criterion is complex and may not be being performed optimally at present
- Anaesthetists report they are encountering cases that are not suitable to be performed in some private hospitals due to complex comorbidities, lack of postoperative monitoring etc
- Suggestion that it is important that we provide feedback on this issue, it may not be apparent to the relevant department.
- Concerns expressed regarding the movement of the patient between 3 different hospitals and subsequent discharge before completion of investigations
- Decision to discuss at M&M regarding clinical governance issues