Case 10: Delay in surgery for a high-risk patient

Orthopaedic Surgery

CASE SUMMARY A woman in her mid-70s was admitted to hospital with bilateral pleural effusions, chronic right rib fractures and right fractured neck of femur (NOF) following a witnessed fall at her nursing home. Medical history included ischaemic heart disease, a recent ST-elevation myocardial infarction (STEMI), atrial fibrillation, apical thrombus, recent cerebrovascular accident and alcoholism. She was entered into the fractured NOF pathway and underwent anaesthetic and medical review within 24 hours. Upon admission, the patient was found to be over-anticoagulated secondary to warfarin, with an international normalised ratio (INR) of 3.2, which increased to 4.2 the following day. She was also on clopidogrel and aspirin. It was decided to delay surgery until the INR was corrected, although the patient was given bridging enoxaparin for the first 48 hours. She was deemed ready for surgery 48 hours after admission when the INR had reversed; however, no theatres were available for the next 2 days. On day 4 of admission the patient had a MET call for decreasing oxygen saturation (71%) and reduced state of consciousness after being given fentanyl and oxycodone for pain relief. She was also charted for a buprenorphine patch, but it is unclear whether the patient had this patch applied. (Of note, the patient had significant renal impairment which may reduce opiate metabolism). The patient was assessed as being narcotised. She had 7 doses of IV naloxone, prompting an initial rally; however, by that evening she had deteriorated. A further MET call was instituted when the patient was found unresponsive with no pulse and agonal breathing. She was pronounced dead that evening.

DISCUSSION This was an unwell, high-risk anaesthetic patient, which was identified on admission following medical and anaesthetic review. This was discussed with the family on admission and the patient was deemed not for code blue. There were several issues with this patient’s care: • The decision to consider surgery rather than palliation for a frail nursing-home patient with pleural effusions, rib fractures, recent STEMI and coagulation disorder who was thus highly unlikely to survive the fractured NOF, let alone any operation.

• The provision of bridging anticoagulation (enoxaparin) to a patient with an INR of 3.2 who had been on clopidogrel and aspirin. • The advisability of treating a patient with known alcohol dependency (and therefore a likely disordered coagulation profile) with 3 different anticoagulants. • The wisdom of initiating multiple MET calls for this patient, given that the family discussion concluded that the patient was not for code blue, and the risk of death from the combination of premorbid pathology, chest trauma and skeletal trauma was extreme.

CLINICAL LESSONS A multidisciplinary team would have greatly improved decision-making in this clinical care pathway, particularly regarding pain management and the decision to operate at all on an elderly, compromised patient. Additionally, withholding further anticoagulants until all clotting profile studies were complete should have been considered, particularly given the impaired renal function of the patient.