63-year-old lady presenting for ORIF of a periprosthetic hip fracture

Background

• 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

Issues

• 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

Discussion

Perioperative hypotension

• 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