Case: 73 yo ASA 3 w/ CAD for R TKA

cchoukal · Aug 29, 2006

Pt shows up in pre-op. She's 73, w/ DM2, HTN, previous CVA w/ residual weakness to R UE/LE, and CAD "positive" stress test 1 month ago (reversible perfusion defect involving 24% of the LV; total perfusion defect score 6/100, all reversible; EF 80%)

Do you proceed?

Do you use a regional technique w/ co-existing neurologic defecit?

Intra-op monitoring?

(this is probably fairly basic for many on here, but it was interesting for me, a newly minted CA1)

toughlife · Aug 29, 2006

cchoukal said:
Pt shows up in pre-op. She's 73, w/ DM2, HTN, previous CVA w/ residual weakness to R UE/LE, and CAD "positive" stress test 1 month ago (reversible perfusion defect involving 24% of the LV; total perfusion defect score 6/100, all reversible; EF 80%)

Do you proceed?

Do you use a regional technique w/ co-existing neurologic defecit?

Intra-op monitoring?

(this is probably fairly basic for many on here, but it was interesting for me, a newly minted CA1)

What's the surgery?

I'd go with GA since any exacerbation of her neurologic deficit could be attributed to regional anesthesia. If you choose regional make sure you document prior deficits thoroughly. Concerns I have would be possibility of hyperkalemia with sux given prior hx of CVA 2/2 proliferation of motor end plates. BP has to be addressed intraop to decrease afterload and avoid any increase in cardiac work and run risk of causing demand ischemia. Not sure whether reversible perfusion defect is an issue.
I go with a-line for intraop monitoring. I haven't done any anesthesia yet so I could be way off. (Just an intern).

toughlife · Aug 29, 2006

duplicate

toughlife · Aug 29, 2006

duplicate

The_Sensei · Aug 29, 2006

Throw in an LMA.....case done in 90 minutes if surgeon is on the slow side.

Laryngospasm · Aug 30, 2006

cchoukal said:
Pt shows up in pre-op. She's 73, w/ DM2, HTN, previous CVA w/ residual weakness to R UE/LE, and CAD "positive" stress test 1 month ago (reversible perfusion defect involving 24% of the LV; total perfusion defect score 6/100, all reversible; EF 80%)

Do you proceed?

Do you use a regional technique w/ co-existing neurologic defecit?

Intra-op monitoring?

(this is probably fairly basic for many on here, but it was interesting for me, a newly minted CA1)

What is the reason for the surgery? Cardiology clearance? If something goes wrong in an elective case in a patient with a positive stress test and no cardiology clearance you will be in deep sh..

deleted87051 · Aug 30, 2006

This patient raises more questions.

Why does she want a new knee? Is she currently active and ambulatory? If not, is it because of stroke or knee pain? Does she want to return to golf?

Does she recognize that rehab after TKR is both very stenuous and affects the outcome of the surgery?? Will her rehab be limited by angina or dyspnea?

Why no cath after a grossly positive stress test? She has preserved myocardial function so she has a lot to lose. She may actually benefit from a stent and waiting a couple of months.

That said, I don't think anesthetic technique (GA vs. Regional) will matter much. Just make sure she is beta blocked.

Noyac · Aug 30, 2006

nimbus said:
This patient raises more questions.

Why does she want a new knee? Is she currently active and ambulatory? If not, is it because of stroke or knee pain? Does she want to return to golf?

Does she recognize that rehab after TKR is both very stenuous and affects the outcome of the surgery?? Will her rehab be limited by angina or dyspnea?

Why no cath after a grossly positive stress test? She has preserved myocardial function so she has a lot to lose. She may actually benefit from a stent and waiting a couple of months.

That said, I don't think anesthetic technique (GA vs. Regional) will matter much. Just make sure she is beta blocked.

You are right about some of these points but I disagree with other points. Firstly, we can and do successfully replace joints in this pt population all the time. While rehab is not easy, she will most likely be able to complete it safely. Even if she can't, are we (anesthesia) to cancel her case b/c she may not do well in rehab?
With regards to stents. It was not too long ago that I quoted the current thinking of the Cardiovascular Society of Anesthesiologists. It stated that pts with drug eluting stents must be 1 year out of stent placement b/4 elective surgery. Non drug eluting, 3-6 months. You will have to stop their anticoagulants and the surgery will increase their stress response which will increase the chance of clotting off the stent.
I agree that hthis is a tough case to be involved in b/c the best management is not clear. But personally, I'd place an LMA in for a fast to average surgeon with some intrathecal narcotics.

cchoukal · Aug 30, 2006

cchoukal · Aug 30, 2006

Pt takes a beta-blocker. TKA for knee pain, known osteoarthritis, has h/o contralateral TKA with good results. My attending feels the stress increases her risk for peri-operative events, but only to a small degree. The point about the downside of stents was a good one. Here's a typical scenario:

pt has chest pain, gets worked up with a borderline stress test, and, thus, onto angiogram. There's a 50% lesion somewhere, maybe it's in the distribtion consistent with the perfusion defect on the stress test; maybe it's not. Some of the interventionalists at our institution will admit that, "since we're in there and there's a lesion, let's stent it, but it might not be the culprit lesion." A stent then buys you at least 6 months on clopidogrel, during which time surgery is a no-no. Imagine someone has cancer and needs an operation, but has a so-so story for angina. Do you stress/cath, knowing they're likely to get a stent which, if not in the culprit lesion, will not change their peri-operative risk, thereby delaying a cancer surgery?

Anyway, for this lady, we did a femoral nerve block and a GA with proseal LMA. She was very comfortable on 0.5 mac of des and a little fentanyl until they started drilling on the tibia (not covered by the block). HR into the 80s, SBP to 170s for about 5 minutes. ST segments start to sag.

What next?

Noyac · Aug 30, 2006

cchoukal said:
Pt takes a beta-blocker. TKA for knee pain, known osteoarthritis, has h/o contralateral TKA with good results. My attending feels the stress increases her risk for peri-operative events, but only to a small degree. The point about the downside of stents was a good one. Here's a typical scenario:

pt has chest pain, gets worked up with a borderline stress test, and, thus, onto angiogram. There's a 50% lesion somewhere, maybe it's in the distribtion consistent with the perfusion defect on the stress test; maybe it's not. Some of the interventionalists at our institution will admit that, "since we're in there and there's a lesion, let's stent it, but it might not be the culprit lesion." A stent then buys you at least 6 months on clopidogrel, during which time surgery is a no-no. Imagine someone has cancer and needs an operation, but has a so-so story for angina. Do you stress/cath, knowing they're likely to get a stent which, if not in the culprit lesion, will not change their peri-operative risk, thereby delaying a cancer surgery?

Anyway, for this lady, we did a femoral nerve block and a GA with proseal LMA. She was very comfortable on 0.5 mac of des and a little fentanyl until they started drilling on the tibia (not covered by the block). HR into the 80s, SBP to 170s for about 5 minutes. ST segments start to sag.

What next?

Get her pressure down. This is one reason that I put 8-15mg bupiv in my spinals when all I really want is the narcotics for post-op pain management. I also like their HR in the 60's.

ReefTiger · Aug 30, 2006

I'd explain to her the options with getting a cath and possible stent and the delay it would have on her elective case. The case itself is not even intermediate risk for a cardiac event. I'd do the case with the patient informed, and keep BP and HR under tight control. You could do a regional, but a general is just as easy to manage.

jwk · Aug 30, 2006

cchoukal said:
Anyway, for this lady, we did a femoral nerve block and a GA with proseal LMA. She was very comfortable on 0.5 mac of des and a little fentanyl until they started drilling on the tibia (not covered by the block). HR into the 80s, SBP to 170s for about 5 minutes. ST segments start to sag.

What next?

Narcs, esmolol or labetalol.

Or, as one of my old docs would have put it, "put her to sleep son". 😉

IN2B8R · Aug 31, 2006

LMA unless your surgeon demands paralysis; B-blockers and narcs. Doubt I'd find many anesthesiologists who would still do regional blocks in patients who have had neurological insults (and that's mainly due to medico-legal reasons). Continue to make sure that she's adequately analgesiatized post-op (otherwise she'll tachy and infarct when you are not watching....)

Noyac · Aug 31, 2006

IN2B8R said:
LMA unless your surgeon demands paralysis; B-blockers and narcs. Doubt I'd find many anesthesiologists who would still do regional blocks in patients who have had neurological insults (and that's mainly due to medico-legal reasons). Continue to make sure that she's adequately analgesiatized post-op (otherwise she'll tachy and infarct when you are not watching....)

No problem with regional in this case due to residual weakness. Just document the weakness well b/4 the block.

hokie · Aug 31, 2006

cchoukal said:
Pt takes a beta-blocker. TKA for knee pain, known osteoarthritis, has h/o contralateral TKA with good results. My attending feels the stress increases her risk for peri-operative events, but only to a small degree. The point about the downside of stents was a good one. Here's a typical scenario:

pt has chest pain, gets worked up with a borderline stress test, and, thus, onto angiogram. There's a 50% lesion somewhere, maybe it's in the distribtion consistent with the perfusion defect on the stress test; maybe it's not. Some of the interventionalists at our institution will admit that, "since we're in there and there's a lesion, let's stent it, but it might not be the culprit lesion." A stent then buys you at least 6 months on clopidogrel, during which time surgery is a no-no. Imagine someone has cancer and needs an operation, but has a so-so story for angina. Do you stress/cath, knowing they're likely to get a stent which, if not in the culprit lesion, will not change their peri-operative risk, thereby delaying a cancer surgery?

Anyway, for this lady, we did a femoral nerve block and a GA with proseal LMA. She was very comfortable on 0.5 mac of des and a little fentanyl until they started drilling on the tibia (not covered by the block). HR into the 80s, SBP to 170s for about 5 minutes. ST segments start to sag.

What next?

Did you consider doing a sciatic block in addition to the femoral?

VentdependenT · Aug 31, 2006

Any reason to choose Gen Vs Regional from a cardiac standpoint?

Literature seems to provide no support for benifits of one approach over the other as long as proper monitoring and a tight anesthetic (Example: lower sevo higher narcs intra op, emergence:titrate nitro drip and have some esmolol on hand....this for the LOW EF'ers) is run.

As for the whole decreased thromboembolic events and regional I was told the studies which had favored the regional approach were done before widespread DVT prophylaxis with our buddy lovenox was instututed.

Perhaps MMD is dead on with his "regional blows" approach.

VentdependenT · Aug 31, 2006

Noyac said:
You are right about some of these points but I disagree with other points. Firstly, we can and do successfully replace joints in this pt population all the time. While rehab is not easy, she will most likely be able to complete it safely. Even if she can't, are we (anesthesia) to cancel her case b/c she may not do well in rehab?
With regards to stents. It was not too long ago that I quoted the current thinking of the Cardiovascular Society of Anesthesiologists. It stated that pts with drug eluting stents must be 1 year out of stent placement b/4 elective surgery. Non drug eluting, 3-6 months. You will have to stop their anticoagulants and the surgery will increase their stress response which will increase the chance of clotting off the stent.
I agree that hthis is a tough case to be involved in b/c the best management is not clear. But personally, I'd place an LMA in for a fast to average surgeon with some intrathecal narcotics.

She is 73 and getting a new knee and now has a reversible defect on stress test....What is her functional status like? Unstable angina or angina at all? METs?

What is the risk of having an angio with stent placement vs the risk for an epidural and a total knee surgery? What is the benefit of having the knee replaced first before having a stent placed? Can/should her CAD just be medically managed?

My poopy opinion: Can of Worms has been opened so now you have to deal with it. Follow the ACC/AHA guideline for periop cardiovascular evaluation for noncardiac surgery.

CLinical Predictors: CAD, DM, HTN (controlled?), advanced age
SURGERY RISK: Intermediate

Now weigh risk vs benefit of preop angio with stenting and its complications vs replacing the knee with an intermediate risk patient/intermediate risk procedure AND a positive stress test.

Well you can either:

Manage medically with betablocker go for surgery with an epidural and LMA backup. Throw in an A-line. (my choice of MET's >4 with a RELIABLE history).

Subject the woman to interventional cards and postpone the ELECTIVE SURGERY (MET's <4).

I don't think you would be faulted either way. IR cards can seriously mess somebody up and its not without major complications. If she has been cardiac stable up to now then I'd manage medically and have her f/u with cards post op. If she has been having symptoms of CAD/recent change in fuctional status/declining health then its IR time.

Vent

jetproppilot · Aug 31, 2006

cchoukal said:
Pt shows up in pre-op. She's 73, w/ DM2, HTN, previous CVA w/ residual weakness to R UE/LE, and CAD "positive" stress test 1 month ago (reversible perfusion defect involving 24% of the LV; total perfusion defect score 6/100, all reversible; EF 80%)

Do you proceed?

Do you use a regional technique w/ co-existing neurologic defecit?

Intra-op monitoring?

(this is probably fairly basic for many on here, but it was interesting for me, a newly minted CA1)

Man, I know I've been hittin' the Don Julio-enriched margaritas lately, but after reading this thread, did I miss something?

REVERSIBLE perfusion defect would be a big red-flag for me, and I'm pretty fearless.

Myocardium at risk.

Something that can be optimized before the patient undergoes a huge elective procedure.

When it comes to consults, all I care about is....is the patient optimized?

Don't really know one can argue a patient with a reversible perfusion defect has been optimized, unless interventional-cardiology-dude says so.

About the regional vs general....a no brainer in my book. Regional all the way and like Noy said, pre-op neurologic deficit isnt a contraindication. Document it, sedate the patient, and put a needle in their back.

22" spinal or 17" Tuohy.

Your choice.

Noyac · Sep 1, 2006

jetproppilot said:
Man, I know I've been hittin' the Don Julio-enriched margaritas lately, but after reading this thread, did I miss something?

REVERSIBLE perfusion defect would be a big red-flag for me, and I'm pretty fearless.

Myocardium at risk.

Something that can be optimized before the patient undergoes a huge elective procedure.

When it comes to consults, all I care about is....is the patient optimized?

Don't really know one can argue a patient with a reversible perfusion defect has been optimized, unless interventional-cardiology-dude says so.

About the regional vs general....a no brainer in my book. Regional all the way and like Noy said, pre-op neurologic deficit isnt a contraindication. Document it, sedate the patient, and put a needle in their back.

22" spinal or 17" Tuohy.

Your choice.

Reversible ischemia is now something I would rather deal with than a newly place stent and taking the pt off their plavix or whatever. I was impressed with the data regarding these stents and surgery. Maybe I am wrong but I'll bet we know more in the future with regards to these stents and surgery.
Hell, I may even say do the knee then take her to the cath lab for a stent afterwards and start the plavix postop/stent.

jetproppilot · Sep 1, 2006

Noyac said:
Reversible ischemia is now something I would rather deal with than a newly place stent and taking the pt off their plavix or whatever. I was impressed with the data regarding these stents and surgery. Maybe I am wrong but I'll bet we know more in the future with regards to these stents and surgery.
Hell, I may even say do the knee then take her to the cath lab for a stent afterwards and start the plavix postop/stent.

or maybe we should elect to NOT deal with it.

"Uhhh, Mrs Jones, your heart may take a hit during this ELECTIVE procedure that we may not be able to bring you back from..."

Again, I'm (pretty) fearless.

But identifiable preoperative-myocardial issues make me stop and think....especially reversible ischemia issues....

....I wouldnt've done this case.

Yeah, that doesnt sound like the "Your patient is ready in room ten, Mr Ortho Stud..." Jet that you're used to.

But again, reversible myocardial defects.....

deleted87051 · Sep 1, 2006

Agree with Jet.

Doesn't everybody assume that a 73 yo with DM+Htn also has CAD? What was the point of getting the stress test if a positive result does not affect your decision making?? Maybe if the Stress test was negative (or false negative), you could give this patient a sloppier anesthetic. Most of the proposed anesthetics look identical to what we do for patients with negative stress tests. Beta block, RA or GA, control hemodynamics, control pain. Doesn't every 73 year old total knee get this?

This lady is at high risk for periop troponin leak. Maybe the risk of a cath lab disaster is even higher. But I would also want a cardiologist to state she is medically optimized and does not want or need a cath+-PCI before proceeding.

Noyac · Sep 1, 2006

jetproppilot said:
or maybe we should elect to NOT deal with it.

"Uhhh, Mrs Jones, your heart may take a hit during this ELECTIVE procedure that we may not be able to bring you back from..."

Again, I'm (pretty) fearless.

But identifiable preoperative-myocardial issues make me stop and think....especially reversible ischemia issues....

....I wouldnt've done this case.

Yeah, that doesnt sound like the "Your patient is ready in room ten, Mr Ortho Stud..." Jet that you're used to.

But again, reversible myocardial defects.....

I can't disagree with you Jet. And wouldn't fault anyone who wouldn't have done this case. However, I have stated my concerns with the case.

Case: 73 yo ASA 3 w/ CAD for R TKA

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