Unrepaired ASD for cemented hip hemiarthroplasty83-year-old woman, 58 kg, for cemented hemiarthroplasty of a displaced femoral neck fracture

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • An 83-year-old with an unrepaired ASD and AF on apixaban, for urgent cemented hemiarthroplasty. Patient
   • At 83 with a broken hip, her delirium risk is high; I screen cognition before any sedation.
   • Today her flow is left to right; anything that raises PVR can reverse it. Disease
   • Once reversed, air, fat or cement debris can cross to her brain.
   • A cemented stem risks bone cement implantation syndrome, which loads her right heart. Surgery
   • Fixing her hip within 24 hours means less pain and a shorter stay.

2. Prepare

   Take me through her risk assessment and preparation.

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   • Urgency: hip fracture, best done within 24 hours; time to assess, not to delay. Stem trigger
   • Active cardiac conditions? None: her AF is rate-controlled and she isn't in failure. Disease
   • Risk score: none of the RCRI items, so RCRI 0.
   • Functional capacity: can't be judged with a broken hip, and at RCRI 0 it changes nothing.
   • Decision: proceed today without further cardiac testing.
   • Apixaban 30 hours ago rules out a spinal; it needs 72 hours off.
   • Every line de-aired with filters; cement technique agreed with the surgeon.

3. Plan

   What is your anaesthetic plan?

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   • General anaesthesia, arterial line placed before induction. Disease
   • Reduced propofol for her age; above 1.5 mg/kg causes severe hypotension in older adults.
   • No hypoxia, hypercarbia or acidosis, so her PVR stays down.
   • Surgeon lavages and vents the canal and warns me before cementing; uncemented if feasible. Surgery
   • At cementing: FiO2 up, pressure topped up, adrenaline drawn up. Crisis
   • HDU after; apixaban restarts once the surgeon is happy with haemostasis. After surgery

4. Crisis

   As the cemented stem goes in, BP falls to 70/40, SpO2 to 82%, and ETCO2 drops. What do you do?

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   • Bone cement implantation syndrome; her rising PVR may also be reversing her ASD shunt. (Crisis)
   • Help called, surgeon told, FiO2 to 1.0.
   • Phenylephrine 50–100 mcg, then adrenaline 0.05–0.2 mcg/kg/min to support her RV.
   • Fluid to keep her filled, without overloading her dilated RV.
   • Ventilation tuned against hypoxia, hypercarbia and acidosis; each pushes her PVR higher.
   • If she loses her pulse: adult arrest algorithm, CPR, adrenaline 1 mg every 3–5 minutes.

5. Crisis

   At the end she is slow to wake, with a new right hemiparesis. What do you do?

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   • Paradoxical embolism across her ASD until proven otherwise: a perioperative stroke. Crisis
   • Stroke team now, and emergent brain imaging.
   • Surgery today is a relative bar to thrombolysis; clot retrieval if bleeding risk is high.
   • Meanwhile oxygen, and her pressure held at her baseline.
   • Stroke unit or ICU; when apixaban restarts is decided with neurology. After surgery