Another purely hypothetical scenario

[Beeftenderloin]

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60ish male needs cysto w/ biopsies for staging of bladder cancer. 6.4cm ascending thoracic aortic aneurysm found incidentally on CT as part of work-up. 40 pack year smoker, no features that scream Marfan, ehlers danlos, etc. Patient seen by medicine who says “patient is optimized for surgery”. Seen by thoracic who says, patient can proceed under anesthesia and will consider repair if prognosis from cancer is reasonable based on staging, biopsies, etc. You’re assigned the case and despite having not used your stethoscope since residency you for some reason decide to listen to this patients heart and lungs and hear a reasonably loud murmur. Patient has never been told they have a murmur and there is no murmur documented anywhere in this patients chart including recent interactions with thoracic and medicine. Has never seen a cardiologist. No echo. You doing this case today?

 

[dchz]

Let me ask you this, if you have all the time in the world, what would you see on TTE or TEE that would make you do your anesthetic differently?

If the pt had an ascending replacement and came back, would it change your anesthetic management?

 

[dchz]

Very complex case from different perspectives:

Thoracic surgeon perspective: the mortality/morbidity of ascending replacement is not 0. Replacement is not an emergency. Keep in mind, an aneurysm is very different from a dissection. Depending on the stage of the cancer, the cancer might legit kill him before the aneurysm. Aneurysm has spontaneous rupture rate of 3.7% per year. 11% death rate : Source. Giving the patient complete information to make decisions is the right thing to do.

Uro Onc surgeon: The cancer is the patients major complaint and it's not a major surgery with high mortality and morbidity. But it gives the doctors and the patient major prognostic information. This will take 10 mins.

Patient's perspective: I just want as much good quality life as possible. And I want to keep smoking.

My perspective: this patient needs this procedure, any cardiac intervention will most likely increase his mortality/morbidity more than a cysto. The changes in BP through my anesthetic isn't that much different than the stress when the patient coughs for 5 mins when he wakes up in the morning. I would aim my best to give this guy as much good quality life as possible and that's not sending him through 3 more cardiology visits and 2 weeks of running around to say "low risk surgery with medium risk patient, maintain normotension and normocardia during surgery."

 

[Hork Bajir]

Is the murmur diastolic? Holodiastolic? Easy enough to put a probe on the chest and look at the aortic valve. If there’s wide open AI, might change your hemodynamic goals (esp if it’s acute in the setting of a rapidly expanding aneurysm). But if he’s asymptomatic with a good fxnl status, unlikely to have severe acute hemodynamically significant AI (or contained rupture, or any other catastrophic complication related to the aneurysm).

Bottom line is I’d still probably do the case, but no harm in looking first. If you’re cardiac trained and want to be slick you can drop a TEE probe when he’s asleep- just don’t bust the aneurysm when you put it in...

 

[pjl]

Very complex case from different perspectives:

Thoracic surgeon perspective: the mortality/morbidity of ascending replacement is not 0. Replacement is not an emergency. Keep in mind, an aneurysm is very different from a dissection. Depending on the stage of the cancer, the cancer might legit kill him before the aneurysm. Aneurysm has spontaneous rupture rate of 3.7% per year. 11% death rate : Source. Giving the patient complete information to make decisions is the right thing to do.

Uro Onc surgeon: The cancer is the patients major complaint and it's not a major surgery with high mortality and morbidity. But it gives the doctors and the patient major prognostic information. This will take 10 mins.

Patient's perspective: I just want as much good quality life as possible. And I want to keep smoking.

My perspective: this patient needs this procedure, any cardiac intervention will most likely increase his mortality/morbidity more than a cysto. The changes in BP through my anesthetic isn't that much different than the stress when the patient coughs for 5 mins when he wakes up in the morning. I would aim my best to give this guy as much good quality life as possible and that's not sending him through 3 more cardiology visits and 2 weeks of running around to say "low risk surgery with medium risk patient, maintain normotension and normocardia during surgery."

Great, well thought out answer.
For me, this is a fairly minor, low risk case and we would likely proceed given all the complex discussion above.
Any finding on the ECHO will likely be unlikely to make me do anything other than “proceed with caution” which I would be planning for him anyways.

I may be motivated enough to throw a probe in intraop, purely for diagnostic purposes, but it is doubtful.

 

[vector2]

Very complex case from different perspectives:

Thoracic surgeon perspective: the mortality/morbidity of ascending replacement is not 0. Replacement is not an emergency. Keep in mind, an aneurysm is very different from a dissection. Depending on the stage of the cancer, the cancer might legit kill him before the aneurysm. Aneurysm has spontaneous rupture rate of 3.7% per year. 11% death rate : Source. Giving the patient complete information to make decisions is the right thing to do.

Uro Onc surgeon: The cancer is the patients major complaint and it's not a major surgery with high mortality and morbidity. But it gives the doctors and the patient major prognostic information. This will take 10 mins.

Patient's perspective: I just want as much good quality life as possible. And I want to keep smoking.

My perspective: this patient needs this procedure, any cardiac intervention will most likely increase his mortality/morbidity more than a cysto. The changes in BP through my anesthetic isn't that much different than the stress when the patient coughs for 5 mins when he wakes up in the morning. I would aim my best to give this guy as much good quality life as possible and that's not sending him through 3 more cardiology visits and 2 weeks of running around to say "low risk surgery with medium risk patient, maintain normotension and normocardia during surgery."

The pt needs the cysto but I’m not doing the case that day if I’m literally the first person to document a murmur loud enough to hear with auscultation on the day of surgery. I’m also assuming he got a regular CT chest/abd/p with contrast and not a properly gated CTA which is indicated in this patient so the aorta is thoroughly evaluated for harder to see pathology.

Once you get an echo and send to cards, it’s still reasonable to proceed (by RCRI) even if he has severe AI assuming his LVEF is normal and he’s relatively euvolemic.

I’m sure everyone here can *assume* chronic moderate to severe AI and just proceed with caution and watch the blood pressure and fluids, but if there’s any sort of decompensation (or if he also had concomitant severe AS which is possible in 60yo with 40PY smoking hx) and you didn’t have further assessment, treatment, and stratification documented it’s really not gonna go well for anyone involved.

 

[deleted875186]

Assess functional status. If low METS, and if he can get an echo in a reasonable amount of time, would delay the case to see how bad his valvular disease is.

 

[Hoya11]

60ish male needs cysto w/ biopsies for staging of bladder cancer. 6.4cm ascending thoracic aortic aneurysm found incidentally on CT as part of work-up. 40 pack year smoker, no features that scream Marfan, ehlers danlos, etc. Patient seen by medicine who says “patient is optimized for surgery”. Seen by thoracic who says, patient can proceed under anesthesia and will consider repair if prognosis from cancer is reasonable based on staging, biopsies, etc. You’re assigned the case and despite having not used your stethoscope since residency you for some reason decide to listen to this patients heart and lungs and hear a reasonably loud murmur. Patient has never been told they have a murmur and there is no murmur documented anywhere in this patients chart including recent interactions with thoracic and medicine. Has never seen a cardiologist. No echo. You doing this case today?

if he has decent exercise tolerance i would do it, but ideally you would want an echo first. if this guy goes for cystectomy he is going to have to have his heart investigated further anyways

 

[sethco]

This all boils down to one question (From both a CT surgeon and Cardiac Anesthesiologist perspective)...

Is the patient symptomatic from the Thoracic Aneurysm and/or Valvular issue? If the answer is No, then no workup is indicated at this time

 

[dchz]

but no harm in looking first...

This scenario is why i spent 2 months in fellowship working on TTEs. Now i just need someone to buy me a butterfly or a mobile phased array probe.

 

[Beeftenderloin]

Let me ask you this, if you have all the time in the world, what would you see on TTE or TEE that would make you do your anesthetic differently?

If the pt had an ascending replacement and came back, would it change your anesthetic management?

The murmur in question is systolic. This essentially takes AI off the table. It’s entirely possible that medicine didn’t hear the murmur and thoracic didn’t even listen. Bicuspid aortic stenosis is very much on the table in the setting of an aneurysm. Just prove to me on echo that the patient doesn’t have a mean gradient of 40 and I’ll happily do this with a spinal. This is the value I get from the echo. Cards seeing the patient and writing “high risk patient for low risk procedure” is only helpful from a medico-legal standpoint.

 

[deleted697535]

it's a cysto! carry on...
leave the guessing tubes at home! ;-)

dchz great answer.

 

[sethco]

The murmur in question is systolic. This essentially takes AI off the table. It’s entirely possible that medicine didn’t hear the murmur and thoracic didn’t even listen. Bicuspid aortic stenosis is very much on the table in the setting of an aneurysm. Just prove to me on echo that the patient doesn’t have a mean gradient of 40 and I’ll happily do this with a spinal. This is the value I get from the echo. Cards seeing the patient and writing “high risk patient for low risk procedure” is only helpful from a medico-legal standpoint.

I'm confused, did you want to do a Cystoscopy under Spinal?

 

[Beeftenderloin]

I'm confused, did you want to do a Cystoscopy under Spinal?

Why not? Typically, no. But in this patient in the setting of a very large thoracic aortic aneurysm, as long as no clinically significant AS is present, spinal seems like a good way to keep this guy comfortable while avoiding hypertension and tachycardia which could be fatal in this guy.

Yes, I recognize this dude is still straining with bowel movements and getting his heart rate above 100 from time to time. But this thing is a ticking time bomb at that size, and I’m going to taylor my anesthetic to avoid contributing to it’s rupture.

 

[vector2]

Man, I really don’t know if I’ve ever disagreed so strongly with what seems like a quite wrong but growing consensus to just say “ahh fck it he can go up two flights of stairs just do the case,” especially among the generalists out there who don’t have the ability to do a relatively comprehensive and quantitative TTE like @dchz.

Functional status is not the end-all-be-all of perioperative risk stratification, especially when there are known diagnoses on the table that have not been adequately worked up. There was not a lot of information in the original stem, but per the RCRI if this pt has severe valvular lesion, particularly severe AI with an EF less than 35%, then you should not be doing this case unless it’s emergent. If he has severe AS then that also needs to be taken into account. This thing is a potential ticking time bomb, and again, he has not gotten a high resolution CTA (afaik). To belabor the point with another scenario, there are plenty people with a Mobitz type II who can go up two flights of stairs, but you’re an idiot if you would take one to surgery without them seeing cards first.

At the very least, beyond a garbage “clearance” note from medicine, what comorbidities does he have and is he being treated? Is he on a beta blocker? Anti hypertensives? How bad was the coronary calcification on his CT? What’s his volume status? How’s the pulse pressure? Does he need diuretics? How bad is his presumed COPD?

 

[dchz]

The murmur in question is systolic. This essentially takes AI off the table. It’s entirely possible that medicine didn’t hear the murmur and thoracic didn’t even listen. Bicuspid aortic stenosis is very much on the table in the setting of an aneurysm. Just prove to me on echo that the patient doesn’t have a mean gradient of 40 and I’ll happily do this with a spinal. This is the value I get from the echo. Cards seeing the patient and writing “high risk patient for low risk procedure” is only helpful from a medico-legal standpoint.

First of all, we all know ribeye is the best cut of steak. 😛

I hear you and I agree AS is high on the DDx. But what if the gradient is 42?!??! you're all of a sudden going to change your entire plan and then if its' 38 you're going to still do the spinal? How many TTEs have you done to look for the AS gradient? it's essentially a crapshoot and totally dependent on how hard the echo tech tries to find the highest gradient. The same person with 42 can easily have a gradient of 38 if another echo tech did it. It's not an exact science and they don't always line up the flow with the doppler.

Why not? Typically, no. But in this patient in the setting of a very large thoracic aortic aneurysm, as long as no clinically significant AS is present, spinal seems like a good way to keep this guy comfortable while avoiding hypertension and tachycardia which could be fatal in this guy.

Yes, I recognize this dude is still straining with bowel movements and getting his heart rate above 100 from time to time. But this thing is a ticking time bomb at that size, and I’m going to taylor my anesthetic to avoid contributing to it’s rupture.

Tailor*, as in the person that measures your clothes.

I applaud your thought process and logical reasoning. But we disagree on some of your fundamental assumptions:

-Mean gradient of 35mmhg is clinically significant AS, 25mmhg can be for some others. there isn't some magical switch that goes above 40mmhg that causes all the sudden is "clinically significant". 40mmhg is classified as "severe" when a bunch of experts came together and wrote a paper. I think you're viewing it way strictly than it is meant to be.

-There isn't a type of anesthetic that makes this safer than the others, as long as they meet the anesthetic goals of keeping the pt normotensive and good forward flow. what do you think happens when they do a TAVR? SAVR? all of those are GAs with significant AS.

-You're saying you normally wouldn't do a spinal for a cysto, but you would do it for this case because you think it will magically compensate for his AS simply because you changed the type of anesthetic. This is exactly the wrong kind of thinking. The best anesthetic you are most adept at delivering is the safest (unless you do OB full time, for most of us it is still GA) for the patient because you're most used to adjusting and treating anything that comes up.

You normally don't do a spinal for a cysto but now you're gonna suddenly do it on possibly the sickest patient you've had in a while? step back and think about that for a second.

 

[vector2]

First of all, we all know ribeye is the best cut of steak. 😛

I hear you and I agree AS is high on the DDx. But what if the gradient is 42?!??! you're all of a sudden going to change your entire plan and then if its' 38 you're going to still do the spinal? How many TTEs have you done to look for the AS gradient? it's essentially a crapshoot and totally dependent on how hard the echo tech tries to find the highest gradient. The same person with 42 can easily have a gradient of 38 if another echo tech did it. It's not an exact science and they don't always line up the flow with the doppler.



Tailor*, as in the person that measures your clothes.

I applaud your thought process and logical reasoning. But we disagree on some of your fundamental assumptions:

-Mean gradient of 35mmhg is clinically significant AS, 25mmhg can be for some others. there isn't some magical switch that goes above 40mmhg that causes all the sudden is "clinically significant". 40mmhg is classified as "severe" when a bunch of experts came together and wrote a paper. I think you're viewing it way strictly than it is meant to be.

-There isn't a type of anesthetic that makes this safer than the others, as long as they meet the anesthetic goals of keeping the pt normotensive and good forward flow. what do you think happens when they do a TAVR? SAVR? all of those are GAs with significant AS.

-You're saying you normally wouldn't do a spinal for a cysto, but you would do it for this case because you think it will magically compensate for his AS simply because you changed the type of anesthetic. This is exactly the wrong kind of thinking. The best anesthetic you are most adept at delivering is the safest (unless you do OB full time, for most of us it is still GA) for the patient because you're most used to adjusting and treating anything that comes up.

You normally don't do a spinal for a cysto but now you're gonna suddenly do it on possibly the sickest patient you've had in a while? step back and think about that for a second.

Wow, that’s a lot to think about there. It’s almost as if those among us who don’t have such detailed knowledge might benefit from sending this pt with a 6.4 cm thoracic aortic aneurysm, 40 pack year smoking history, and an unknown murmur to someone who specializes in evaluating and treating diseases of the cardiovascular system.

 

[dchz]

Man, I really don’t know if I’ve ever disagreed so strongly with what seems like a quite wrong but growing consensus to just say “ahh fck it he can go up two flights of stairs just do the case,” especially among the generalists out there who don’t have the ability to do a relatively comprehensive and quantitative TTE like @dchz.

Functional status is not the end-all-be-all of perioperative risk stratification, especially when there are known diagnoses on the table that have not been adequately worked up. There was not a lot of information in the original stem, but per the RCRI if this pt has severe valvular lesion, particularly severe AI with an EF less than 35%, then you should not be doing this case unless it’s emergent. This thing is a potential ticking time bomb, and again, he has not gotten a high resolution CTA (afaik). To belabor the point with another scenario, there are plenty people with a Mobitz type II who can go up two flights of stairs, but you’re an idiot if you would take one to surgery without them seeing cards first.

At the very least, beyond a garbage “clearance” note from medicine, what comorbidities does he have and is he being treated? Is he on a beta blocker? Anti hypertensives? What’s his volume status? How’s the pulse pressure? Does he need diuretics? How bad is his presumed COPD?

First of all, you're much too kind, if you go back far enough, you'll find enough of my posts that are amateur at best. I understand the heart nowhere near as good as some of the cardiologists and CT anesthesiologists that taught me. I only see far because I stood on the shoulders of giants.

Second, I understand the impetus to want to cancel. I would have done the same 2 years ago. Throwing out some answer like "the patient is not cardiac optimized". So let's throw the agree/disagree out of the window. Simply do the best thing with the patient's interest in mind, and work through some of the scenarios (these are some of the ones that come up when I think about it, feel free to bring up other scenarios):

- TTE performed. Severe AS with mean gradient of 42. TAVR workup takes 3 weeks. TAVR itself wont be done for 4 weeks. Is the anesthetic that the patient receives for the TAVR less risky than the GA for the cysto? (it is less risky for one's medical license though)

Wow, that’s a lot to think about there. It’s almost as if those among us who don’t have such detailed knowledge might benefit from sending this pt with a 6.4 cm thoracic aortic aneurysm, 40 pack year smoking history, and an unknown murmur to someone who specializes in evaluating and treating diseases of the cardiovascular system.

Or we could just go through the thought experiment to be once step closer to that kind of expert 😛. The line between expert and novice is really discussion like the ones we are doing in this thread. I've been around enough to know a cysto is not a CT case, it should be within in the realm of any general anesthesiologist.

 

[deleted697535]

im not sure i understand either.
monday i got 4 mitral clips with a combined ef a little over 80. they're all elective. most optimized but some not possible to optimise crap.
there really isnt much of any preop tests that predict post op outcome especially echo, especially ef. maybe ntprobnp. i agree definitely not self reported exercise tolerance, it's almost always wrong.

at the end of the day its a 20min procedure, with an lma, low bleeding risk. hey it can even be done under local and often is...

 

[vector2]

First of all, you're much too kind, if you go back far enough, you'll find enough of my posts that are amateur at best. I understand the heart nowhere near as good as some of the cardiologists and CT anesthesiologists that taught me. I only see far because I stood on the shoulders of giants.

Second, I understand the impetus to want to cancel. I would have done the same 2 years ago. Throwing out some answer like "the patient is not cardiac optimized". So let's throw the agree/disagree out of the window. Simply do the best thing with the patient's interest in mind, and work through some of the scenarios (these are some of the ones that come up when I think about it, feel free to bring up other scenarios):

- TTE performed. Severe AS with mean gradient of 42. TAVR workup takes 3 weeks. TAVR itself wont be done for 4 weeks. Is the anesthetic that the patient receives for the TAVR less risky than the GA for the cysto? (it is less risky for one's medical license though)


Or we could just go through the thought experiment to be once step closer to that kind of expert 😛

I think you know me (or at least my posts) better than to assume that I’m sending this guy to cards just for the sake of sending this guy to cards.

Ignoring the medicolegal implications, it is very clearly not in this patient’s best interest to undergo this procedure without further workup. A first year vascular surgery resident could tell you that a guy with an incidental 6.4 cm aneurysm needs a CTA to better evaluate the anatomy and to more definitively rule out any pseudoaneurysm, small rupture, or small dissections. Secondly, an echo, one way or another, needs to be done before he undergoes surgery. If you can do expert level TTE and document your findings, great. If not, get cards involved. You’ve heard a murmur and he’s got a big smoking history and a big aneurysm which significantly increases the risk of him having a severe valvular lesion and possibly abnormal ventricular function with or without ischemia. Assuming things just based on your stethoscope and then making anesthetic induction and maintenance decisions based on those assumptions is malpractice in this day and age. Thirdly, taking into account urology’s opinion of the acuity as well, medication optimization over the course of a week may be in the best interest of this patient, especially if he’s a poorly controlled hypertensive or is volume overloaded or if he has indications for being on ASA, statin, beta blocker or if he has very reactive COPD, etc

 

[Beeftenderloin]

First of all, we all know ribeye is the best cut of steak. 😛

I hear you and I agree AS is high on the DDx. But what if the gradient is 42?!??! you're all of a sudden going to change your entire plan and then if its' 38 you're going to still do the spinal? How many TTEs have you done to look for the AS gradient? it's essentially a crapshoot and totally dependent on how hard the echo tech tries to find the highest gradient. The same person with 42 can easily have a gradient of 38 if another echo tech did it. It's not an exact science and they don't always line up the flow with the doppler.



Tailor*, as in the person that measures your clothes.

I applaud your thought process and logical reasoning. But we disagree on some of your fundamental assumptions:

-Mean gradient of 35mmhg is clinically significant AS, 25mmhg can be for some others. there isn't some magical switch that goes above 40mmhg that causes all the sudden is "clinically significant". 40mmhg is classified as "severe" when a bunch of experts came together and wrote a paper. I think you're viewing it way strictly than it is meant to be.

-There isn't a type of anesthetic that makes this safer than the others, as long as they meet the anesthetic goals of keeping the pt normotensive and good forward flow. what do you think happens when they do a TAVR? SAVR? all of those are GAs with significant AS.

-You're saying you normally wouldn't do a spinal for a cysto, but you would do it for this case because you think it will magically compensate for his AS simply because you changed the type of anesthetic. This is exactly the wrong kind of thinking. The best anesthetic you are most adept at delivering is the safest (unless you do OB full time, for most of us it is still GA) for the patient because you're most used to adjusting and treating anything that comes up.

You normally don't do a spinal for a cysto but now you're gonna suddenly do it on possibly the sickest patient you've had in a while? step back and think about that for a second.

We agree on almost everything you just said. I just threw the number 40 out because it’s high and everyone knows what it means. If it’s 38 I treat it the same way I treat 40 and probably don’t do a spinal because that would be completely counter to the hemodynamic goals of aortic stenosis, which further supports my point for why getting the echo would be beneficial in the first place.

Your right, I don’t typically do spinals for cystos, but I do plenty of spinals for OB and ortho. And if the gradient is on the milder side and the patient is asymptomatic then a spinal seems like a good choice for keeping his aneurysm from rupturing perioperatively.

Regardless of whether you choose GA or regional, you still need that echo to know what you’re managing and what your Hemodynamic goals are going to be perioperatively. That’s great that you are facile enough with TTE to get that info by yourself. My guess is most aren’t.

 

[deleted697535]

I think you know me (or at least my posts) better than to assume that I’m sending this guy to cards just for the sake of sending this guy to cards.

Ignoring the medicolegal implications, it is very clearly not in this patient’s best interest to undergo this procedure without further workup. A first year vascular surgery resident could tell you that a guy with an incidental 6.4 cm aneurysm needs a CTA to better evaluate the anatomy and to more definitively rule out any pseudoaneurysm, small rupture, or small dissections. Secondly, an echo, one way or another, needs to be done before he undergoes surgery. If you can do expert level TTE and document your findings, great. If not, get cards involved. You’ve heard a murmur and he’s got a big smoking history and a big aneurysm which significantly increases the risk of him having a severe valvular lesion and possibly abnormal ventricular function with or without ischemia. Assuming things just based on your stethoscope and then making anesthetic induction and maintenance decisions based on those assumptions is malpractice in this day and age. Thirdly, taking into account urology’s opinion of the acuity as well, medication optimization over the course of a week may be in the best interest of this patient, especially if he’s a poorly controlled hypertensive or is volume overloaded or if he has indications for being on ASA, statin, beta blocker or if he has very reactive COPD, etc

didnt he say the dude with the knife said carry on, and the smart people who know anesthesia better than us also said carry on. so why not carry on?

hes been seen by both med and surg, why not assume theyre doing their job?
Honestly this is a thing that could be yarned on about forwards and back for years so it doesnt really matter. it happens all the time. usually i end up inheriting ****e like this

 

[dchz]

I think you know me (or at least my posts) better than to assume that I’m sending this guy to cards just for the sake of sending this guy to cards.

Ignoring the medicolegal implications, it is very clearly not in this patient’s best interest to undergo this procedure without further workup. A first year vascular surgery resident could tell you that a guy with an incidental 6.4 cm aneurysm needs a CTA to better evaluate the anatomy and to more definitively rule out any pseudoaneurysm, small rupture, or small dissections. Secondly, an echo, one way or another, needs to be done before he undergoes surgery.

I agree with your thought process. I know you're not sending them to cards for fun. But cards is going to send this guy to a CT surgeon, which have already gave his input. We have been down this road. You're wanting to get a second opinion?

That’s great that you are facile enough with TTE to get that info by yourself. My guess is most aren’t.

Sorry that's not my point. The statement I made earlier is to say even if i have the TTE skills, i don't have the probe handy in most places to do it.

My point is that the anesthestic management won't change much if i did find out the severity of the AS or MR. I'm going to have phenylephrine ready and by the time i find out he might benefit from 10 mcgs of epi the case is over.

And if the gradient is on the milder side and the patient is asymptomatic then a spinal seems like a good choice for keeping his aneurysm from rupturing perioperatively.

I think you also missed my point here. Spinal is not a better choice to keep his aneurysm from rupturing perioperatively, no better than any other modality and you shouldn't change your most comfortable modality because you think it's some magic bullet. It is a misconception to think a spinal is the magic bullet that is going to do that.

 

[vector2]

I agree with your thought process. I know you're not sending them to cards for fun. But cards is going to send this guy to a CT surgeon, which have already gave his input. We have been down this road. You're wanting to get a second opinion?

The referral to cards is not for definitive management of his aneurysm. It’s mostly because I expect to get a pertinent positive when I put the probe on his chest and it makes more sense to leave it to the people who are gonna follow him for the next ten years to actually optimize him (unlike the medicine goobers who couldn’t even pick up a murmur before “clearing” him) and start his lasix or coreg or lipitor or whatever. Now, I suppose if a CTA is done and it reveals nothing but the aneurysm, he doesn’t have other significant comorbidities, and I get a pretty good quality bedside study showing his valves aren’t severely diseased, his function is fine, and the only findings are diastolic dysfnx and a dilated Ao annulus.. then I think the cards referral could wait.

 

[dchz]

The referral to cards is not for definitive management of his aneurysm. It’s mostly because I expect to get a pertinent positive when I put the probe on his chest and it makes more sense to leave it to the people who are gonna follow him for the next ten years to start his lasix or coreg or lipitor or whatever. Now, I suppose if a CTA is done and it reveals nothing but the aneurysm, he doesn’t have other significant comorbidities, and I get a pretty good quality bedside study showing his valves aren’t severely diseased, his function is fine, and the only findings are diastolic dysfnx and a dilated Ao annulus.. then I think the cards referral could wait.

K, I will walk down this road with you. Let's say worst case scenario. The pt has severe AS and mod MR.

Are you going to make the asymptomatic pt get an aortic valve operation before he has a cysto to prognosticate his cancer?

Will knowing the AS ahead of time change your intraop anesthetic management??

 

[vector2]

K, I will walk down this road with you. Let's say worst case scenario. The pt has severe AS and mod MR.

Are you going to make the asymptomatic pt get an aortic valve operation before he has a cysto to prognosticate his cancer?

Will knowing the AS ahead of time change your intraop anesthetic management??

Lol, to answer the last question first- uhhhhh obviously yes, knowing that a patient with an incidental large TAA also has severe AS would absolutely alter the anesthetic management. If you don’t know the pt has severe AS you’re likely to kill them with all the aggressive BP control that comes with tiptoeing around the TAA that has a 14% annualized risk of rupture just from the pt performing their ADLs.

If the pt is asymptomatic from the AS (no signs of ischemia, syncope, HF etc) I would not delay the cysto to get an AV operation

 

[Beeftenderloin]

I agree with your thought process. I know you're not sending them to cards for fun. But cards is going to send this guy to a CT surgeon, which have already gave his input. We have been down this road. You're wanting to get a second opinion?




Sorry that's not my point. The statement I made earlier is to say even if i have the TTE skills, i don't have the probe handy in most places to do it.

My point is that the anesthestic management won't change much if i did find out the severity of the AS or MR. I'm going to have phenylephrine ready and by the time i find out he might benefit from 10 mcgs of epi the case is over.



I think you also missed my point here. Spinal is not a better choice to keep his aneurysm from rupturing perioperatively, no better than any other modality and you shouldn't change your most comfortable modality because you think it's some magic bullet. It is a misconception to think a spinal is the magic bullet that is going to do that.

The only person who ever said magic bullet was you (over and over for some reason). I’m well aware that you can do this case many different ways. I’m also well aware of the hemodynamic goals of an unsecured aneurysm as well as the hemodynamic consequences of a spinal. There is nothing magic about either of those things. If you aren’t comfortable doing a spinal for this case then it would be a pretty poor choice of anesthetic for you. I’m comfortable with it and think it would be a safe management choice for this patient, (going back to the beginning now) assuming they’ve had an echo that proves they don’t have any clinically significant aortic stenosis. But that goes for GA also. I’d want to know regurgitate vs stenotic and severity either way so I could make more informed choices regarding management.

 

[Iso4ane]

K, I will walk down this road with you. Let's say worst case scenario. The pt has severe AS and mod MR.

Are you going to make the asymptomatic pt get an aortic valve operation before he has a cysto to prognosticate his cancer?

Will knowing the AS ahead of time change your intraop anesthetic management??

I’ve seen this scenario. Cards will come back to the table with ‘patient will likely need TAVR and/or MitraClip, however would like to get definitive cancer prognosis before proceeding.’ And now we’re back where we started.

 

[Southpaw]

kinda shocking some of you here are wondering if a board certified anesthesiologist is comfortable with the hemodynamic effects of a spinal, and yet you're totally okay with inducing general anesthesia with a 6.4cm TAA and undiagnosed, but clearly audible, murmur. I agree with @sethco and @dchz giving the thoughts of CT surgeon, but the care given on the medicine side here is poor. Very poor. Unacceptably poor. 'patient optimized for surgery'? Really? Did you not put a stethoscope on the chest? How difficult is it really to diagnose and give information to the anesthesiologist regarding this murmur? No cardiology input but only because the medicine physician didn't properly do their job. The needed information isn't absurdly complex and it doesn't take forever to acquire. Once we have all the needed information then we can make a decent plan for what will surely be a quick procedure.

What if we do a short acting spinal, or induce GA and place LMA, and find ourselves giving epi/vaso for the next 20 minutes and continuing to support BP in the PACU? Is that likely to happen? No. Has it happened? Yes. What if we place the LMA, patient coughs/reacts, or whatever, and you look up and your next BP is 210/110. Is that likely to happen? No. Has it happened? Yes.

I'm not totally uncomfortable doing this case without all the information I'd like. Spinal or LMA, I'm comfortable. Certainly, for me, spinal is overall a more hemodynamically stable option. But that's me. However, I am frustrated at a service (medicine) doing an awful half-assed job and putting it all back on me with surgeons staring at me like 'when can we go?'.

 

[Southpaw]

Also, if you can perform and do a full diagnostic TTE, that's great. But let's apply this scenario across the scope of anesthesia care in this country and anesthesiologists routinely doing TURBT. The extreme large majority of them aren't doing much as far as diagnostic TTE goes. That's not a question of where could this specialty go, or what should we be doing, merely a reflection and my opinion of where I believe we are currently.

 

[BLADEMDA]

I can always tell those who have no idea about real malpractice risks in this society. Those who have never seen a routine case go badly. Those who haven’t had enough codes or periop deaths to see the full spectrum of what can go wrong.

But I know that people’s practice patterns change over time once they realize the true morbidity out there or they get a notice of intention to litigate from a large TV law firm.

 

[dhb]

Pent sux tube

 

[BLADEMDA]

Also, if you can perform and do a full diagnostic TTE, that's great. But let's apply this scenario across the scope of anesthesia care in this country and anesthesiologists routinely doing TURBT. The extreme large majority of them aren't doing much as far as diagnostic TTE goes. That's not a question of where could this specialty go, or what should we be doing, merely a reflection and my opinion of where I believe we are currently.

On more than one occasion I have gotten a TTE in the holding area prior to surgery. This may delay the case, or may not, up to about 1 hour but if the situation arises such as new systolic murmur in a patient who already is at high I risk I tend to be cautious and obtain the limited TTE. Patient safety comes first and elective surgery is just that, elective, which means there is no urgency to go to the O.R. But, if the case is urgent or emergent I note that on the record and treat the patient as if they have severe aortic stenosis until the proper evaluation can be performed at a later date.

I have personally participated in cases where patients experienced codes in the O.R. due to undiagnosed severe Aortic stenosis. These were routine, elective cases on elderly patients over the age of 70. While I was not the primary provider in these cases I would testify that the diagnosis of severe A.S. was the main reason for the arrest and the team was fortunate the patient did not die. This has happened more than once and other patients with severe morbidity have died at my institution undergoing routine procedures in the O.R.

There is no such thing as a simple case for many ASA 4 patients.

 

[Arch Guillotti]

I have personally participated in cases where patients experienced codes in the O.R. due to undiagnosed severe Aortic stenosis. These were routine, elective cases on elderly patients over the age of 70. While I was not the primary provider in these cases I would testify that the diagnosis of severe A.S. was the main reason for the arrest and the team was fortunate the patient did not die. This has happened more than once and other patients with severe morbidity have died at my institution undergoing routine procedures in the O.R.

Listen for a murmur. If you are that concerned then give them an anesthetic with minimal hemodynamic perturbation.

 

[anbuitachi]

we not uncommonly do cystos under spinal... our cystos are regularly over 1hr long. id vote for TTE of some form.

 

[Arch Guillotti]

we not uncommonly do cystos under spinal...

Inpatient or outpatient?

 

[GassYous]

On more than one occasion I have gotten a TTE in the holding area prior to surgery. This may delay the case, or may not, up to about 1 hour but if the situation arises such as new systolic murmur in a patient who already is at high I risk I tend to be cautious and obtain the limited TTE. Patient safety comes first and elective surgery is just that, elective, which means there is no urgency to go to the O.R. But, if the case is urgent or emergent I note that on the record and treat the patient as if they have severe aortic stenosis until the proper evaluation can be performed at a later date.

I have personally participated in cases where patients experienced codes in the O.R. due to undiagnosed severe Aortic stenosis. These were routine, elective cases on elderly patients over the age of 70. While I was not the primary provider in these cases I would testify that the diagnosis of severe A.S. was the main reason for the arrest and the team was fortunate the patient did not die. This has happened more than once and other patients with severe morbidity have died at my institution undergoing routine procedures in the O.R.

There is no such thing as a simple case for many ASA 4 patients.

Know of a patient who died 2/2 undiagnosed severe AS in the periop period. They were in their 40s or 50s

 

[vector2]

Listen for a murmur. If you are that concerned then give them an anesthetic with minimal hemodynamic perturbation.

Say the AS murmur isn’t strong enough to radiate to the carotids. How many people here know the correct auscultation anatomy and have listened to enough MR and AS murmurs to tell them apart? You’re gonna bet this pt’s life on your ability to auscultate a soft S1?

Good lord, just get the echo. Especially when severe AS and the aneurysm have totally different hemodynamic goals.

 

[anbuitachi]

Inpatient or outpatient?

either