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[yogenbhatt1]

    This young lady is 94 admitted with a fracture neck femur. She is totally fit on paper. But she has a clot in the left atrium, calcified aortic and mitral valve, giving Aortic stenosis and Mitral Regurg, ejection fraction 50%. Admited with Hb of 5.6 and irrelevant talk and behaviour. She was given pack cell with a central line and Hb was brought to 10.5 over 3 days.
    On table the patient was deeply drowsy. awakened only if the fracture leg was lifted. I did not like the patient and postponed the surgery. I  asked for a repeat work up and electrolytes. Sodium turned out to be 119. We explained a very high risk of surgery till all corrections were made. Relatives did not want to take risk and took her home.
    Next day, I get a call from another hospital, now a very small clinic, with hardly any facility, no ICU and not properly equipped. It turned out to be the same patient, with a surgeon now very keen on doing surgery. I am asked to give anaesthesia as the relatives are now willing to take risk.( Remember that in Mumbai we have hundreds of tiny clinics of 12 to 20  beds each, managed privately by surgeon alone.)
   I have given her fitness once, then made her unfit once, and now without any improvement in the condition of the patient, will it ever be right to give fitness and do surgery? The previous hopspital was much better with all departments, and an ICU managed by anaesthesiologists of my team and cardiologist.
What is my status, if I give anaesthesia to this patient in countries where you practice?

[jafo1964]

So typically a case of SIADH

Geriatric
Trauma, pain & stress
Altered sensorium
before you know she is slipping away
Sodiums way too low

I have a share of similar cases too but mostly develping in the post-op after an apparently no problem lower limb surgery under neuraxial block that was absolutely problem free
They are tough to treat even with hypertonic saline coz  they very easily slip into multisystem problems. You start with one and end up else where

regarding decision making
I beleive better defensive than dead
If i said no first and then said a yes then my credibility is severly dented.
That is the reason why doctors across our country are losing their respect and standing.
If the patient attenders dont take the risk i never force them
In this situation I would have referred it to a better set up and left it there
Definite NO to doing it in a centre that is less equipped to take care of your patient

This patient requires
MAXIMAL ANESTHESIA CAUTION and not MINIMAL ANESTHESIA CARE

regs

[yogenbhatt1]

Great. Actually I missed you guys, so put a case just for the sake of it. Use the site guys!!!
I sent the pt to a higher centre and may be operated in a day or two. I promised the surgeon that I will give him a live pt at the end of surgery, but she will die for sure over next few days.
But these elderly patients do give us jitters.
Best is, at times, despite us telling about high risk and table death concent, nothing happens to them and even they laugh at us.
Thanks and regards.

[yogenbhatt1]

Just for information:
She was shifted to a multi specialty hospital, was safely operated, shifted to ICU but died over next 4 days.
Regards

[dhanvantri]

i would like  to know how u anaesthetised this old lady.
did u have a plan A,a plan B in case plan A fails.what all are the problems u anticipated and what all were ur preparations to deal with them.

[yogenbhatt1]

Hi,
I did not give anaesthesia to the patient.
She went away before I planned anything.
They had called me in other hospital to give anaesthesia, but since I had declined once, I refused to go.

[yogenbhatt1]

Sorry, but she was operated in a larger hospital, where I do not go for Anaesthesia. I do not know what they did. If her general condition is bad, the anaesthesia plans will not alter her situation and morbidity.
She died anyway with MultiSystem failure.