How low a Na+ for Elective Surgery?

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nimbus said:
Like hypotension, hyponatremia is another marker for sick patients who will have worse perioperative outcomes. Of course a population of patients with serum sodium of 140 will do better than a population with a sodium of 125. The more important question to ask is, “Does intervention to correct preop serum sodium improve outcomes?” That has not been answered.
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Resolution of hyponatremia during hospitalization attenuated the increased mortality risk conferred by hyponatremia.

Mortality after hospitalization with mild, moderate, and severe hyponatremia. - PubMed - NCBI

In multivariable-adjusted models, patients with hyponatremia had an increased risk of death in hospital (odds ratio 1.47, 95% confidence interval [CI], 1.33-1.62), at 1 year (hazard ratio 1.38, 95% CI, 1.32-1.46), and at 5 years (hazard ratio 1.25, 95% CI, 1.21-1.30). The increased risk of death was evident even in those with mild hyponatremia (130-134 mEq/L; odds ratio 1.37, 95% CI, 1.23-1.52). The relationship between hyponatremia and mortality was pronounced in patients admitted with cardiovascular disease, metastatic cancer, and those admitted for procedures related to the musculoskeletal system
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BLADEMDA said:
Another question that needs to be asked is "should I proceed with this elective case knowing the Na+ is 125 based upon the available evidence?" For me, the answer is a clear "NO" and I'm going to cancel the case. For FFP and you, feel free to proceed knowing that any bad outcome may be linked to your decision.
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I think the key thing is the urgency of the case. ICU patients very rarely have "elective" procedures. But in this case, despite cancer, the patient probably benefits from correction even if it delays the procedure a few days.
 
I think threatening people who disagree with one's opinions and illusions with litigation and trial lawyers is a little bit childish and tasteless.
The practice of medicine still relies heavily on the physician's judgement, and no matter how hard we try to quantify risk factors and turn everything into a binary 0 or 1 question, we still have to look at the whole picture and use clinical judgement to decide the best approach to each individual case. This is why we are consultants and scientists because if everything was concrete numbers and algorithms then it would be easy and anyone could do it.
For the record: I have never seen one case of immediate post op mortality or morbidity that was directly attributed to hyponatremia , that doesn't mean it does not exist, but I have never seen or heard of one FWIW!
 
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Thank you, @Planktonmd. I guess Blade's opinion is that, if something goes wrong, malpractice lawyers will also point to the hyponatremia to "prove" the substandard care the patient had received. I think he posted with good intentions, he just wanted to make the lesson memorable. I hope all of us will have more discussions like this in the future; it's what makes the place great, to quote @jetproppilot.

From my standpoint, the main concern with asymptomatic (relatively) chronic moderate hyponatremia (i.e. above 120-125, depending on the source) is edema. It matters most in closed spaces (e.g. cerebral or ocular) or if it involves the airway. We tend to hear more about the complications of rapid Na correction than of hyponatremia itself, probably because the former are more frequent.

In the end, everything in medicine is a matter of risks vs benefits, both for the patient and (especially in America) for the doctor.
 
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This thread is old, but bumping it up since I have case that's relevant. I have 61 y/o cirrhotic (from alcohol but hasn't drank in 11 years) with osteoporosis coming in for ORIF intertrochanteric fracture. She broke hip falling out of bed. She came in with Na 121 2 days ago. Case was canceled then due to Na, and again today by me with Na 123. Na is now 124 and patient is assigned to my room tomorrow. I spoke to hospitalist about need to correct Na to 130 before going to OR. Patient doesn't appear to have any neurological symptoms, and the surgeon is very good and fast. On the other hand, INR is also 1.66 and at this rate, Na will probably be 125-126 tomorrow morning. Would you do the case, or risk pissing off surgeon for a 3rd day in a row?
 
just do the case. excess delay aint a free lunch either

if surgeons a dick, piss em off too. you can do both
 
Do the case. I have done a number of liver transplants on cirrhotic patients with lower sodium... If you can get a patient through a 15L blood loss case without over-correcting, then this should be nothing. As said above, the risk of waiting is not trivial... This isn’t a knee scope or a facelift. Every day spent in bed for this patient is more dangerous than the last (deconditioning is no joke). Document a good discussion of risks vs benefits. If you want to be hyper-nervous, place an art line for frequent labs and go to a monitored setting for 24h postop (imo this is overkill, but it’s the defensive move here)
 
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To my knowledge, no study has ever shown increased risk of periop arrhythmias in hypoK patients if the patient was not already having them before surgery. I don’t know that a study has looked at morbidity more generally though, from edema or whatever else.
 
Hork Bajir said:
Do the case. I have done a number of liver transplants on cirrhotic patients with lower sodium... If you can get a patient through a 15L blood loss case without over-correcting, then this should be nothing. As said above, the risk of waiting is not trivial... This isn’t a knee scope or a facelift. Every day spent in bed for this patient is more dangerous than the last (deconditioning is no joke). Document a good discussion of risks vs benefits. If you want to be hyper-nervous, place an art line for frequent labs and go to a monitored setting for 24h postop (imo this is overkill, but it’s the defensive move here)
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I disagree with your initial logic, but not the statement. I've done a moderate number (30 or 40) liver txs with hyponatremia, some went fine and some not. Just because no one had a complication that was directly attributable to the sodium does it mean it was safe - it means you got away with it (or didn't study the post op outcomes closely enough).

That being said you are absolutely right, hip fx (or liver tx for high meld) are non elective surgeries. Unless you are going to tell the patient to go palliative and comfort care I would do the case.
 
There's some interesting conclusions in this thread 🤔
 
Lashler9054 said:
This thread is old, but bumping it up since I have case that's relevant. I have 61 y/o cirrhotic (from alcohol but hasn't drank in 11 years) with osteoporosis coming in for ORIF intertrochanteric fracture. She broke hip falling out of bed. She came in with Na 121 2 days ago. Case was canceled then due to Na, and again today by me with Na 123. Na is now 124 and patient is assigned to my room tomorrow. I spoke to hospitalist about need to correct Na to 130 before going to OR. Patient doesn't appear to have any neurological symptoms, and the surgeon is very good and fast. On the other hand, INR is also 1.66 and at this rate, Na will probably be 125-126 tomorrow morning. Would you do the case, or risk pissing off surgeon for a 3rd day in a row?
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i dont get it. why would the surgeon be pissed. did you mention Na has to be 130+? if you did, then the surgeon should know that 125 is < 130.
 
Airway said:
I disagree with your initial logic, but not the statement. I've done a moderate number (30 or 40) liver txs with hyponatremia, some went fine and some not. Just because no one had a complication that was directly attributable to the sodium does it mean it was safe - it means you got away with it (or didn't study the post op outcomes closely enough).

That being said you are absolutely right, hip fx (or liver tx for high meld) are non elective surgeries. Unless you are going to tell the patient to go palliative and comfort care I would do the case.
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define elective surgery. because when covid happened, and elective surgeries got postponed, the hospital released definitions of whats elective and the conclusion was made that pretty much only some cosmetic surgeries are elective.

i think sodium is a gray zone. you can go either way. recently had a case for inpatient egd, had recent drop in crit with melena, but then stable, but sodium of 125. primary team consulted nephrology who then wrote 'Na of 125 not deterrent for surgery'. case proceeded. and i doubt anyone from my department will follow the patient for 30 days to find out outcome of these patients
 
Well, I did it, and the patient took FOREVER to wake up. Barely ran fluids. Gave 2mg versed, 100mcg fentanyl, and 0.5mg dilaudid for whole case. I was able to extubate her, but she was barely arousable for hours in the PACU. Probably could have given less opioid for cirrhotic, but hip surgery can be quite painful.
 
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Lashler9054 said:
Well, I did it, and the patient took FOREVER to wake up. Barely ran fluids. Gave 2mg versed, 100mcg fentanyl, and 0.5mg dilaudid for whole case. I was able to extubate her, but she was barely arousable for hours in the PACU. Probably could have given less opioid for cirrhotic, but hip surgery can be quite painful.
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I would have done a ficb and given 2mg less versed, 100mcg less fentanyl, and 0.5mg less dilaudid. If I couldn’t do a ficb, I’d have given 100mcg fentanyl but no versed or dilaudid. That’s my recipe for these cases irrespective of sodium level.
 
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nimbus said:
I would have done a ficb and given 2mg less versed, 100mcg less fentanyl, and 0.5mg less dilaudid. If I couldn’t do a ficb, I’d have given 100mcg fentanyl but no versed or dilaudid. That’s my recipe for these cases irrespective of sodium level.
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Ironically, I usually only give Versed when I don't want the patients waking up at the end!
 
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nimbus said:
I would have done a ficb and given 2mg less versed, 100mcg less fentanyl, and 0.5mg less dilaudid. If I couldn’t do a ficb, I’d have given 100mcg fentanyl but no versed or dilaudid. That’s my recipe for these cases irrespective of sodium level.
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Patients must wake up in pain. Not that much. Not doing ficb with that INR
 
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Lashler9054 said:
Patients must wake up in pain. Not that much. Not doing ficb with that INR
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Disagree. Fascia iliaca is a totally safe block to do. INR 1.6 is nothing. You're nowhere near the artery and you have an ultrasound. It is very superficial.

I wouldn't have canceled in the first place. No versed. Give some prop, 50 of fentanyl, slide the lma in, fascia iliaca with ropi 0.5 30 cc. Patient is happy with pain score 0-2 in pacu. I only give the fentanyl because it lets me give less prop for placing lma but I have done these cases without fentanyl just like nimbus.
 
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GassYous said:
Disagree. Fascia iliaca is a totally safe block to do. INR 1.6 is nothing. You're nowhere near the artery and you have an ultrasound. It is very superficial.

I wouldn't have canceled in the first place. No versed. Give some prop, 50 of fentanyl, slide the lma in, fascia iliaca with ropi 0.5 30 cc. Patient is happy with pain score 0-2 in pacu. I only give the fentanyl because it lets me give less prop for placing lma but I have done these cases without fentanyl just like nimbus.
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why would you not cancel this case? sodium of 121 pretty bad. would you cancel the case if lets say the potassium is 6.3?
 
SaltyDog said:
Yes immediately.




I don’t think FIBs do jack.
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They definitely do work. You’re probably missing them. Ever since I’ve done the suprainguinal approach, they’ve been highly effective
 
Lashler9054 said:
They definitely do work. You’re probably missing them. Ever since I’ve done the suprainguinal approach, they’ve been highly effective
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why is the suprainguinal appraoch more effective than infrainguinal? what is your approach? i just find the fem nerve, then the fascia iliaca, and inject 40ml of bupi. seems to be okay
 
Lashler9054 said:
I wish I had your patients. Most of mine feel pain unless I do a fascia iliaca block beforehand
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they’re hip fractures. My average age patient is like 90. They don’t feel much of anything. They’re often demented. I don’t do blocks for those cases. It’s a spinal or a LMA w a touch of fentanyl. They’re fine post op.
 
If I were to do a block I wouldn’t care about anticoag because it’s a superficial block so I’d do it. I feel the same w any brachial plexus approach block.
 
anbuitachi said:
why is the suprainguinal appraoch more effective than infrainguinal? what is your approach? i just find the fem nerve, then the fascia iliaca, and inject 40ml of bupi. seems to be okay
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The anatomy is easier for me to figure out and the local anesthetic gets trapped above the inguinal ligament, which tends to make it more effective
 
Southpaw said:
they’re hip fractures. My average age patient is like 90. They don’t feel much of anything. They’re often demented. I don’t do blocks for those cases. It’s a spinal or a LMA w a touch of fentanyl. They’re fine post op.
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Sure. My patient was 61 and lucid though
 
Lashler9054 said:
The anatomy is easier for me to figure out and the local anesthetic gets trapped above the inguinal ligament, which tends to make it more effective
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i guess im outdated. :cryi:

how many of you do PENG blocks instead? i'm planning on trying this out in my hips instead of FI block. wonder if i'll see any difference..
 
anbuitachi said:
i guess im outdated. :cryi:

how many of you do PENG blocks instead? i'm planning on trying this out in my hips instead of FI block. wonder if i'll see any difference..
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I have some partners that do it and swear by it. But I don't think it's necessary.
 
Delaying a hip fx is not without its own set of risks. The risk from laying around with a broken hip for a few days is probably much greater than the risk of a Na that's chronically in the 120s.

Old people don't need benzodiazepines. 61 with those comorbidities is old.

Perfectly OK to do a FICB in a person with an INR of 1.66, unless your approach is trans-spinal, trans-cranial, or trans-cardiac. I mean, it's a compartment block done far away from the femoral vessels, it's probably one of the lowest risk blocks we do. I'd do one with an INR of double that, a morning dose of Plavix, and sclera just this side of yellow, if I thought it would help the patient's pain.

FICBs are like the Panther, 60% of the time they work every time. I do them often for hip fractures that don't get spinals for whatever reason. I think they help, some. If nothing else they cover incisional pain by way of getting the LFC nerve.
 
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pgg said:
Delaying a hip fx is not without its own set of risks. The risk from laying around with a broken hip for a few days is probably much greater than the risk of a Na that's chronically in the 120s.

Old people don't need benzodiazepines. 61 with those comorbidities is old.

Perfectly OK to do a FICB in a person with an INR of 1.66, unless your approach is trans-spinal, trans-cranial, or trans-cardiac. I mean, it's a compartment block done far away from the femoral vessels, it's probably one of the lowest risk blocks we do. I'd do one with an INR of double that, a morning dose of Plavix, and sclera just this side of yellow, if I thought it would help the patient's pain.

FICBs are like the Panther, 60% of the time they work every time. I do them often for hip fractures that don't get spinals for whatever reason. I think they help, some. If nothing else they cover incisional pain by way of getting the LFC nerve.
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i wouuld say majority of these old traumatic patients are still laying on their hips after the surgery.... especially if they are demented or confused.

i could be wrong since its been a while since i read the studies.... but fix hip fractures earlier is recommended because it helps with bone healing, but traumatic hip fractures are events with high % of M&M, not due to fracture but other comorbidities..

from uptodate

"two large studies that also controlled for comorbid conditions suggest that the time to surgery is primarily a marker of comorbidity [56,59]. In a retrospective study of 8383 patients, mortality rates were not different among patients who had surgery more than 96 hours after admission compared with patients who had surgery 24 to 48 hours after admission after adjusting for demographic characteristics and underlying medical problems [56]. The risk of decubitus (pressure) ulcer was associated with delayed surgery (odds ratio [OR] 2.2, 95% CI 1.6-3.1). A subsequent prospective cohort study of 2250 patients also found no association of in-hospital mortality or complications with surgical delays of ≤120 hours after adjusting for demographic characteristics and comorbid conditions [59]. However, higher rates of mortality and medical complications were associated with surgical delays >120 hours, despite adjustment for these factors."
 
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Lashler9054 said:
This thread is old, but bumping it up since I have case that's relevant. I have 61 y/o cirrhotic (from alcohol but hasn't drank in 11 years) with osteoporosis coming in for ORIF intertrochanteric fracture. She broke hip falling out of bed. She came in with Na 121 2 days ago. Case was canceled then due to Na, and again today by me with Na 123. Na is now 124 and patient is assigned to my room tomorrow. I spoke to hospitalist about need to correct Na to 130 before going to OR. Patient doesn't appear to have any neurological symptoms, and the surgeon is very good and fast. On the other hand, INR is also 1.66 and at this rate, Na will probably be 125-126 tomorrow morning. Would you do the case, or risk pissing off surgeon for a 3rd day in a row?
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This IS NOT an elective case. So, you must balance the risk of delaying the case vs proceeding with the low Na. The longer the patient stays in the hospital the greater the chance of a complication. I would do the case. Also, an INR of 1.6 isn't a big deal as long as the platelet count is reasonable. I get more concerned if the INR is over 2.0 and at that point would discuss the possibility of needing FFP intraop.
 
Lashler9054 said:
This thread is old, but bumping it up since I have case that's relevant. I have 61 y/o cirrhotic (from alcohol but hasn't drank in 11 years) with osteoporosis coming in for ORIF intertrochanteric fracture. She broke hip falling out of bed. She came in with Na 121 2 days ago. Case was canceled then due to Na, and again today by me with Na 123. Na is now 124 and patient is assigned to my room tomorrow. I spoke to hospitalist about need to correct Na to 130 before going to OR. Patient doesn't appear to have any neurological symptoms, and the surgeon is very good and fast. On the other hand, INR is also 1.66 and at this rate, Na will probably be 125-126 tomorrow morning. Would you do the case, or risk pissing off surgeon for a 3rd day in a row?
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Chronic hyponatremia is very common in cirrhotic patients and you will not be able to fix it. Just do the case.
 
BLADEMDA said:
This IS NOT an elective case. So, you must balance the risk of delaying the case vs proceeding with the low Na. The longer the patient stays in the hospital the greater the chance of a complication. I would do the case. Also, an INR of 1.6 isn't a big deal as long as the platelet count is reasonable. I get more concerned if the INR is over 2.0 and at that point would discuss the possibility of needing FFP intraop.
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Eh a high inr could either be too much or too little coagulation in that population. I'm not sure I'd reach for the ffp unless they started bleeding like a stuck pig. And I'd probably ask for 4 factor pcc instead.
 
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