Aortic stenosis and elective knee replacement

[huktonfonix]

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Hey, there will be a line of expert witnesses willing to hang you out to dry no matter what you do.

true enough

 

[joshmir]

hey plank-

you mentioned that the key to decision-making lies in the history and physical exam for pts with AS and elective surgery

the components of the history i believe we are aware of....(ie, syncope, angina)

what are the components of the physical exam you look for, and how do they change your management?

thanks.....

 

[joshmir]

would anybody want to do a preop spinal to put in a little astramorph?

how much would you use? 200mcg? 150mcg?

of course this also assumes placement of a fem catheter...

 

[Planktonmd]

hey plank-

you mentioned that the key to decision-making lies in the history and physical exam for pts with AS and elective surgery

the components of the history i believe we are aware of....(ie, syncope, angina)

what are the components of the physical exam you look for, and how do they change your management?

thanks.....

You should be able to recognize signs of heart failure:
Tachypnea, Rales on chest auscultation and jugular distension.
The systolic murmur although characteristic is not helpful in estimating the degree of AS, actually at advanced stages the murmur could decrease or even disappear.
Here is what we have in this case:
1- History negative for symptoms of severe AS: no angina, no syncope and no dyspnea at rest, and History of surgery under GA with no complications 4 months ago.
2- Physical exam not suggesting heart failure.
3- EKG not showing ST changes even with a heart rate of 110.
4- CXR showing only mild perihilar congestion.
5- Good SPO2 on room air and good BP.
6- Patient wants to proceed with surgery.
There are many things we don't have:
1- Echo showing the degree of aortic stenosis
2- Stress test showing adequate perfusion under stress
3- Input from a cardiologist
So this is why it is not wrong to say I want to wait and get these missing items although I doubt that any of them would have changed the plan.

 

[treasurefull2]

🙂
A line pre-op. Midazolam and 2.5 mg Lopressor preop brought the HR down to 70-80 BPM.
Femoral nerve catheter + GA using LMA.
Uneventful anesthetic and excellent post op course.
This does not mean that it was wrong to delay the case and ask for cardiac workup but there are many ways to do everything in this business and it is important to be flexible as well.

Hey Plank,

What did you use for induction, etomidate? And what did you use for maintenance, i'm assuming one of the gases?

 

[Planktonmd]

Hey Plank,

What did you use for induction, etomidate? And what did you use for maintenance, i'm assuming one of the gases?

I induced with Propofol with Phenylephrine running in the back ground.
Maintenance was the usual Sevo + O2 and Fentanyl.
Nothing exotic.

 

[aredoubleyou]

I induced with Propofol with Phenylephrine running in the back ground.
Maintenance was the usual Sevo + O2 and Fentanyl.
Nothing exotic.

You are saying pushing propofol on a phenyl drip?

 

[Leverage]

Isn't that what I said?
I didn't think "heart failure" is a symptom, is it?
You said AVR is decided based on symptoms:
If she has no symptoms does she still need an AVR?
Her quality of life does not seem to be affected by her Aortic disease, does she still need an AVR ?

other factors play into the indication for AVR regaurdless of symptoms. Class I evidence for EF less than 50 if severe AS and some class IIb evidence for asymptomatic folks looking at value area and gradients....

On a side note had aymptomatic patient this week with moderate to severe AS who had SBP in 160s....

 

[Planktonmd]

other factors play into the indication for AVR regaurdless of symptoms. Class I evidence for EF less than 50 if severe AS and some class IIb evidence for asymptomatic folks looking at value area and gradients....
On a side note had aymptomatic patient this week with moderate to severe AS who had SBP in 160s....

If a patient with severe AS, (not moderate) has a SYS BP of 160 I would question the accuracy of the diagnosis.
These are patients who are usually symptomatic at rest or at minimal effort and usually their LV is already working at maximum and simply can not produce the contractility needed to overcome the huge gradient and give you a high systolic pressure.
Let's say it is not impossible but highly unlikely to see such high systolic pressures in the presence of severe AS.

 

[Arch Guillotti]

You are saying pushing propofol on a phenyl drip?

Sounds like he is. If you are judicious about the propofol and keep a very close eye on the bp (aline) then this is a reasonable way to go. I have done this for pt.s w/cervical myelopathy for ACDF before w/good results.

 

[Planktonmd]

You are saying pushing propofol on a phenyl drip?

yes, sorry for the confusion.

 

[periopdoc]

There are many things we don't have:
1- Echo showing the degree of aortic stenosis
2- Stress test showing adequate perfusion under stress
3- Input from a cardiologist
So this is why it is not wrong to say I want to wait and get these missing items although I doubt that any of them would have changed the plan.

Just want to add a warning about input from subspecialists. We should know the guidelines put out by subspecialist societies regarding perioperative risk better than our subspecialists. We should solicit the opinion of our subspecialist colleagues to confirm what we already know, not to take the place of our own responsibility to stay current. Just because a subspecialist says it is safe to proceed does not make it so.

Case in point. A friend of mine was scheduled to anesthetize a gentleman for an elective, non-incarcerated, hernia repair. The cardiologist note mentioned that this gentleman had undergone PTCI with a drug eluting stent ~ 6 months prior to the scheduled surgery date, but "given the annoying nature of the hernia, the patient is cleared to proceed with the operation." The cardiologist went on to state that the patient should discontinue dual antiplatelet therapy 7 days prior to surgery, and that this therapy should be re-instituted within one week of surgery. He quoted a <1% risk of restenosis perioperatively.

After a brief discussion with the patient in which he was informed that he could suffer a catastrophic MI perioperatively, the patient wisely decided that the herniorrhapy could wait. Honestly, he had not even been advised of the potential for restenosis and MI with discontinuation of therapy and surgical stress.


Cardiac Risk of Noncardiac Surgery after Percutaneous Coronary Intervention with Drug-eluting Stents.

Stay current.

-pod

 

[Mman]

I know that this is what they are teaching you and I know that you have to learn what they teach you, but in medicine nothing is either black or white, everything we do is somewhere in between and I can tell you that I have done TKR numerous times under straight Femoral block + Sciatic block, provided you inject high volume in the femoral (30 cc) and did not need anything else other than 2 mg of Midazolam.
It is good to memorize all these things they tell you but you have to try things a few times before you discredit them.

I've done plenty of TKAs under femoral and sciatic block and I am aware that it can work. It's just an inferior technique to an LP/sciatic block. Often it will work well enough, but is that good enough in this patient? And if I am really trying to go for the gold on the regional technique with this patient, why settle for less?

I don't think anybody anywhere is still teaching that there is such a thing as a femoral "3 in 1" block. The terminology is hardly even used in the literature anymore.

I love femoral blocks. They take less than 2 minutes to do. It's just not the best bet if you really need complete anesthesia of the leg.

 

[Planktonmd]

I've done plenty of TKAs under femoral and sciatic block and I am aware that it can work. It's just an inferior technique to an LP/sciatic block. Often it will work well enough, but is that good enough in this patient? And if I am really trying to go for the gold on the regional technique with this patient, why settle for less?

I don't think anybody anywhere is still teaching that there is such a thing as a femoral "3 in 1" block. The terminology is hardly even used in the literature anymore.

I love femoral blocks. They take less than 2 minutes to do. It's just not the best bet if you really need complete anesthesia of the leg.

You are right, and you probably get a more certain anesthesia if you do a lumbar plexus block especially if you are a beginner, but a lumbar plexus block requires sitting the patient up or lateral decubitus then you need to do a sciatic block which requires another positioning and prep, I don't have that much time in my world and I do both blocks through an anterior approach so we are done with both blocks in 3 minutes.
It might sound too aggressive to you but time for me is very important and my blocks are usually successful.

 

[ncdoc1974]

I know that this is what they are teaching you and I know that you have to learn what they teach you, but in medicine nothing is either black or white, everything we do is somewhere in between and I can tell you that I have done TKR numerous times under straight Femoral block + Sciatic block, provided you inject high volume in the femoral (30 cc) and did not need anything else other than 2 mg of Midazolam.
It is good to memorize all these things they tell you but you have to try things a few times before you discredit them.

Planktonmd, I can't believe this resident (Mman) is running circles around you! C'mon...a femoral block is never a 3 in 1...A femoral block never covers the obturator nerve...However, the obturator nerve only provides innervation of the medial aspect of the knee in about 30% of people...everytime you have gotten away with doing a FNB+SNB alone for a TKA, your patients have been in the other 70% where the obturator nerve is not extending to the knee...thus taking it out of play, not because you blocked it...I completely agree with Mman-Lumbar plexus block (or catheter) + Sciatic nerve block...If you shy away from the LP block due to inexperience, then you could do the fem/sci and hope you are in the lucky 70%, add in some sedation for the tourniquet, or FNB/SNB, smooth inhalational induction and an LMA...However, if you have the expertise, LP/SNB is the regional anesthesiologists cadillac of choice...

 

[Noyac]

You are right, and you probably get a more certain anesthesia if you do a lumbar plexus block especially if you are a beginner, but a lumbar plexus block requires sitting the patient up or lateral decubitus then you need to do a sciatic block which requires another positioning and prep, I don't have that much time in my world and I do both blocks through an anterior approach so we are done with both blocks in 3 minutes.
It might sound too aggressive to you but time for me is very important and my blocks are usually successful.

THere is no way you can do both a FNB and a SNB in 3 minutes. Unless you are injecting 10cc in each, then maybe. You can't hardly blast 30 cc in each location in that amount of time not to mention the time it takes to locate the nerves which I know takes very little time.
I challenge you to look at the clock when you start the FNB and then again when you are finished with the SCN. I'll bet you its closer to 10 minutes, maybe 7 min. If you are doing the positioning, prep (I use etoh which is about as fast as it gets) and local, you are over 3 minutes almost before you start the blocks.

 

[ncdoc1974]

You are right, and you probably get a more certain anesthesia if you do a lumbar plexus block especially if you are a beginner, but a lumbar plexus block requires sitting the patient up or lateral decubitus then you need to do a sciatic block which requires another positioning and prep, I don't have that much time in my world and I do both blocks through an anterior approach so we are done with both blocks in 3 minutes.
It might sound too aggressive to you but time for me is very important and my blocks are usually successful.

1) you can do both a LP and Sciatic block from the lateral decubitus postition

2) I can slam blocks in just as fast as anyone else, but I have to agree that 3 minutes to do both blocks is unrealistic and if you really are going that fast it is probably unsafe. Prep solutions take time to dry...when using U/S the blocks might go a little faster than nerve stimulation, but the set up requires a extra minute or two to put the bag on to keep the probe sterile etc...and if you really are injecting a total of 60 cc of 0.5% as I do, you really don't want to slam all of that as fast as you can into anyone, especially this patient.

I am in the 7-10 minute range total for both blocks from the time I place monitors, O2, titrate sedation and place each block, assuming they both go smoothly. If you are cutting corners on either not placing monitors, poor prep, or injecting at light speed you are playing with fire and will get burned eventually

 

[Planktonmd]

Planktonmd, I can't believe this resident (Mman) is running circles around you! C'mon...a femoral block is never a 3 in 1...A femoral block never covers the obturator nerve...However, the obturator nerve only provides innervation of the medial aspect of the knee in about 30% of people...everytime you have gotten away with doing a FNB+SNB alone for a TKA, your patients have been in the other 70% where the obturator nerve is not extending to the knee...thus taking it out of play, not because you blocked it...I completely agree with Mman-Lumbar plexus block (or catheter) + Sciatic nerve block...If you shy away from the LP block due to inexperience, then you could do the fem/sci and hope you are in the lucky 70%, add in some sedation for the tourniquet, or FNB/SNB, smooth inhalational induction and an LMA...However, if you have the expertise, LP/SNB is the regional anesthesiologists cadillac of choice...

😕
Where did you see me say the the femoral nerve block provides an obturator nerve block???
I love it when people who started practicing yesterday show up here and want to teach us things we forgot many years ago!
All I said is that I have done many TKA's under straight Femoral Sciatic.
If you say it doesn't work (you or the resident that is running circles around me) then you are wrong.
Sometimes (maybe 10%) it might not work well enough and require something else, but that's not the point!

 

[ncdoc1974]

😕
Where did you see me say the the femoral nerve block provides an obturator nerve block???
I love it when people who started practicing yesterday show up here and want to teach us things we forgot many years ago!
All I said is that I have done many TKA's under straight Femoral Sciatic.
If you say it doesn't work (you or the resident that is running circles around me) then you are wrong.
Sometimes (maybe 10%) it might not work well enough and require something else, but that's not the point!

1) I did not start practicing yesterday, but close to a decade ago
2)You implied that you are able to get more "complete" anesthesia using a volume of 30cc, which (while it is an appropriate volume) will not spread to provide obturator nerve coverage
3)In this patient under these circumstances IF you want to do a straight regional anesthetic, with NO spinal, NO GA/LMA, then taking a chance with a Fem/Sci (with research showing a 30% chance of having an unblocked obturator nerve at the knee, NOT 10%) is suboptimal. In this patient, a lumbar plexus/sciatic block is the correct call. Period. Now since this is somewhat of an academic discussion, I just want accurate information here when people read the board...evidence based medicine, not "well I've gotten away with this in the past" type medicine. Know the risks and benefits EXACTLY.

 

[SleepIsGood]

1) I did not start practicing yesterday, but close to a decade ago
2)You implied that you are able to get more "complete" anesthesia using a volume of 30cc, which (while it is an appropriate volume) will not spread to provide obturator nerve coverage
3)In this patient under these circumstances IF you want to do a straight regional anesthetic, with NO spinal, NO GA/LMA, then taking a chance with a Fem/Sci (with research showing a 30% chance of having an unblocked obturator nerve at the knee, NOT 10%) is suboptimal. In this patient, a lumbar plexus/sciatic block is the correct call. Period. Now since this is somewhat of an academic discussion, I just want accurate information here when people read the board...evidence based medicine, not "well I've gotten away with this in the past" type medicine. Know the risks and benefits EXACTLY.

what concentration of drug and volume are you guys using?

Most ppl I've seen performing these blocks use 0.5% bupi with 1:200K of epi. usually need 40 ml for the sciatic block and 35 ml for the LP block.

Assuming an avg 60 kg lady or so, one could easily go over the "max dose of bupi".

It is usually recommended to perform these blocks 12-15 min apart d/t the POSSIBILITY of LA toxicity. Usually, bupi will peak around 12 or 20 min depending on what you read..

So I'm not sure how safe it is to do these blocks in 10 min, let alone 3 min...is this really what you guys are doing? Or are you using significantly lower volumes and/or using ultrasound?

Thanks

 

[Arch Guillotti]

what concentration of drug and volume are you guys using?

Most ppl I've seen performing these blocks use 0.5% bupi with 1:200K of epi. usually need 40 ml for the sciatic block and 35 ml for the LP block.

Assuming an avg 60 kg lady or so, one could easily go over the "max dose of bupi".

It is usually recommended to perform these blocks 12-15 min apart d/t the POSSIBILITY of LA toxicity. Usually, bupi will peak around 12 or 20 min depending on what you read..

So I'm not sure how safe it is to do these blocks in 10 min, let alone 3 min...is this really what you guys are doing? Or are you using significantly lower volumes and/or using ultrasound?

Thanks

Excellent points.

I would not go over 30 cc's on either block. If you are putting in a femoral catheter and are using a spinal for the case you can always wait to dose the catheter later. Some folks use ropi rather than bupi because the cardiac toxicity is less. The "max dose" of bupi is ill-defined, as far as I know the human data is extrapolated from animal models and there are many different variables to account for as far as a person's reaction to a particular dose.

I have seen local anesthetic toxicity from a peripheral nerve block injection and it is not pretty. Even with careful aspiration it is possible to deliver part or all of a dose intravascularly. I have also seen local injected into the vein under ultrasound.

 

[Planktonmd]

1) I did not start practicing yesterday, but close to a decade ago
2)You implied that you are able to get more "complete" anesthesia using a volume of 30cc, which (while it is an appropriate volume) will not spread to provide obturator nerve coverage
3)In this patient under these circumstances IF you want to do a straight regional anesthetic, with NO spinal, NO GA/LMA, then taking a chance with a Fem/Sci (with research showing a 30% chance of having an unblocked obturator nerve at the knee, NOT 10%) is suboptimal. In this patient, a lumbar plexus/sciatic block is the correct call. Period. Now since this is somewhat of an academic discussion, I just want accurate information here when people read the board...evidence based medicine, not "well I've gotten away with this in the past" type medicine. Know the risks and benefits EXACTLY.

If you read the thread(which I don't think you did), you would probably notice that I did not say I would do this specific case uder femoral+ sciatic, I was just saying that it can be done and that I have done it many times without a problem.
And since you are discussing what is appropriate and not appropriate, maybe you should think that a lumbar plexus block might not be great in aortic stenosis since we know now that there is a significant percentage of epidural spread and actually neuraxial blockade which is what we are trying to avoid here???
Also I am not sure why you keep talking about lumbar plexus blocks as such an advanved technique??
Do you really think that it's a difficult or advanced terchnique??

 

[ncdoc1974]

If you read the thread(which I don't think you did), you would probably notice that I did not say I would do this specific case uder femoral+ sciatic, I was just saying that it can be done and that I have done it many times without a problem.
And since you are discussing what is appropriate and not appropriate, maybe you should think that a lumbar plexus block might not be great in aortic stenosis since we know now that there is a significant percentage of epidural spread and actually neuraxial blockade which is what we are trying to avoid here???
Also I am not sure why you keep talking about lumbar plexus blocks as such an advanved technique??
Do you really think that it's a difficult or advanced terchnique??

1) Aortic stenosis is not an absolute contraindication to a lumbar plexus block. The resultant sympathectomy and decrease in preload is vastly different than a spinal.
2) I do not believe a lumbar plexus block is "such an advanced technique," however I do believe that the vast majority of anesthesiologists in private practice are less comfortable performing this block due to the fact it is a slightly higher risk block as compared to a femoral block...and due to the fact that it is a less commonly performed block as compared to a femoral block...For most total knees I usually do a continuous femoral catheter, single shot sciatic and then either a spinal or a GA with an LMA...I only switch the femoral block to a lumbar plexus block in a handful of patients a year based on comorbidities.
3) As far as dosing these blocks, I am curious what everyone is doing, as I know of many different things people do...As far as my usual dosing for a "typical" patient for a total knee:
In preop monitors, O2, sedation-Versed 2mg:
a)Femoral catheter placed under stimulation-then 30cc 0.5% Ropiv +/-clonidine through the catheter; catheter infused x48 hrs with 0.2% Ropiv +/- clonidine @6-8 cc/hour
b)Single shot sciatic block with 30cc 0.5% Bupiv + 1:300k epi fresh
c)To the OR, then spinal with 1cc 0.75% bupiv + 8.25% Dex, background propofol infusion for sedation (or GA with LMA)...Our tourniquet times for total knees averages 35-40 min with extremely consistent surgeons. Otherwise I would up the spinal dose.

I know these are high, bordering on "toxic" levels of local for a lot of patients. I dose slowly and methodically to make as sure as I can that there are no direct intravascular injections. Toxicity due to systemic absorption, while possible, is extremely uncommon. However, an intralipid infusion is in a box on top of the regional cart at all times ready to go. Knock on wood, I've yet to need it.

 

[huktonfonix]

If you are worried about your total doses, I would recommend dosing your femoral catheter later and with a lower dose. Typically we dose our fem caths about 30 minutes prior to finish with about 20 ml of 0.2 ropiv or 0.25 bupiv. There doesnt seem to be much intraop advantage to front loading your femoral catheter if youve already got a spinal in place.

 

[ncdoc1974]

If you are worried about your total doses, I would recommend dosing your femoral catheter later and with a lower dose. Typically we dose our fem caths about 30 minutes prior to finish with about 20 ml of 0.2 ropiv or 0.25 bupiv. There doesnt seem to be much intraop advantage to front loading your femoral catheter if youve already got a spinal in place.

The reason that I like to dose the femoral catheter initially is 1) I like to know it is going to work before I place the spinal, and 2) If I somehow placed the catheter intraneuraly, the patient should experience a significant amount of discomfort during the initial portion of the dosing, I would stop, and hopefully avoid any serious nerve injury...If the patient has a spinal block in place, the pain and potential nerve injury could be masked...kinda like the reason we don't do blocks under GA (Or at least I don't)

 

[huktonfonix]

The reason that I like to dose the femoral catheter initially is 1) I like to know it is going to work before I place the spinal, and 2) If I somehow placed the catheter intraneuraly, the patient should experience a significant amount of discomfort during the initial portion of the dosing, I would stop, and hopefully avoid any serious nerve injury...If the patient has a spinal block in place, the pain and potential nerve injury could be masked...kinda like the reason we don't do blocks under GA (Or at least I don't)

Usually, I'll shoot a few ccs of local in a cath up front just to 1)test patency of the catheter and 2) avoid intraneural injection. As far as testing if the catheter is working prior to the spinal, it would take too long to wait for the bupi/ropi to set in before placing the spinal. If the catheter doesnt work post op, I'll know about it soon enough when the spinal wears off and can redo it if neccesary.

 

[Planktonmd]

1) Aortic stenosis is not an absolute contraindication to a lumbar plexus block. The resultant sympathectomy and decrease in preload is vastly different than a spinal.

Nothing is an "absolute contraindication", not even a spinal.
But since you are advocating a lumbar plexus block for aortic stenosis it appears to me that you chose it over a neuraxial block because you are concerned about the hemodynamic effect, other wise we could just do an epidural couldn't we??
Now I am saying to you that a lumbar plexus block is in a significant percentage actually an epidural block especially when you inject under pressure (look it up), so what is the advantage of using it in aortic stenosis over an epidural?????

 

[Planktonmd]

Here is my anesthetic plan for the average TKA currently:
Spinal + Sedation then Post op continuous femoral nerve block (yes, while the spinal is still working).
I inject 20cc of Bupivacaine 0.25% through the needle then we run Bupivacaine 0.125% PCA after that.
We also use Cox2 inhibitors and intraop Ketamine.
Most patients require minimal narcotics with this regimen.

 

[ncdoc1974]

Usually, I'll shoot a few ccs of local in a cath up front just to 1)test patency of the catheter and 2) avoid intraneural injection. As far as testing if the catheter is working prior to the spinal, it would take too long to wait for the bupi/ropi to set in before placing the spinal. If the catheter doesnt work post op, I'll know about it soon enough when the spinal wears off and can redo it if neccesary.

I usually do my femoral catheter before my sciatic block, then roll to the room, monitors, sit the patient up for a spinal etc...usually 8-10minutes has elapsed since the dosing of the fem cath with Ropiv & the block is starting to set up...I usually like to know early on if the block is going to work or not b/c I am in an MD only practice and if the spinal is wearing off and I am stuck in a heart, it may be hours before I can replace it.

 

[ncdoc1974]

Here is my anesthetic plan for the average TKA currently:
Spinal + Sedation then Post op continuous femoral nerve block (yes, while the spinal is still working).
I inject 20cc of Bupivacaine 0.25% through the needle then we run Bupivacaine 0.125% PCA after that.
We also use Cox2 inhibitors and intraop Ketamine.
Most patients require minimal narcotics with this regimen.

You are a brave man (or woman, whichever) for doing the block post op, knee wrapped with the dressing and spinal in place...Can't say I'd do that personally. We do use celebrex preop, and also 10mg oxycontin preop...I am not currently using ketamine, although I think it is a good move...My problem with the ketamine is that our pharmacy only stocks the 500mg vials...Why don't you use Ropiv in your infusion? (less motor block than bupiv which helps during physical therapy)

 

[Planktonmd]

You are a brave man (or woman, whichever) for doing the block post op, knee wrapped with the dressing and spinal in place...Can't say I'd do that personally. We do use celebrex preop, and also 10mg oxycontin preop...I am not currently using ketamine, although I think it is a good move...My problem with the ketamine is that our pharmacy only stocks the 500mg vials...Why don't you use Ropiv in your infusion? (less motor block than bupiv which helps during physical therapy)

Honestly I think that the difference between Ropivacaine and Bupivacaine is insignificant when it comes to motor blockade.
I do agree though that Ropivacaine is actually a weaker local anesthetic which might create the illusion that it causes less motor block.

 

[Noyac]

Honestly I think that the difference between Ropivacaine and Bupivacaine is insignificant when it comes to motor blockade.
I do agree though that Ropivacaine is actually a weaker local anesthetic which might create the illusion that it causes less motor block.

I have to disagree. Its not an illusion. It is weaker however O.2 % vs 0.25%.

 

[Tenesma]

planktonmd --- i take issue w/ comment re: BP and severe AS - i have seen many severe (even a few critical ASers) with very high BPs...

also, i am not worried about doing a severe AS or critical AS case... but the key is knowing that there may be some AS issue to begin with... we put severe/critical AS folk to sleep all the time for cardiac surgery... so just treat the anesthetic as if it were a critical AS, and you will probably do fine.

HOWEVER, i have seen many of these patients do just FINE with the surgery only to crump in the PAC or on Post-op Day 2... they either get a bit hypotensive (usually due to volume or blood or a very generous RN with a lot of pain meds) and they then crump without having an anesthesiologist present to catch the falling knife...

so it isn't the surgery that will kill them, it is possibly the post-op course

hence the reason to get cardiac re-eval of valve...

and re: surgery 4 months ago--- i would just tell ortho dude that my partner is a lucky son of a gun.

when it comes to cancelling cases, i find it a LOT more succesful w/ surgeons to look like you'd love to do the case because it would a fun/tough anesthetic to do, but you are VERY concerned about the post-operative course.... that way they NEVER blame me for the cancellation, they just don't want to be hasseled post-operatively on their patients...

 

[ncdoc1974]

I have to disagree. Its not an illusion. It is weaker however O.2 % vs 0.25%.

I agree with Noyac. It is not an illusion.

 

[Noyac]

planktonmd --- i take issue w/ comment re: BP and severe AS - i have seen many severe (even a few critical ASers) with very high BPs...

also, i am not worried about doing a severe AS or critical AS case... but the key is knowing that there may be some AS issue to begin with... we put severe/critical AS folk to sleep all the time for cardiac surgery... so just treat the anesthetic as if it were a critical AS, and you will probably do fine.

HOWEVER, i have seen many of these patients do just FINE with the surgery only to crump in the PAC or on Post-op Day 2... they either get a bit hypotensive (usually due to volume or blood or a very generous RN with a lot of pain meds) and they then crump without having an anesthesiologist present to catch the falling knife...

so it isn't the surgery that will kill them, it is possibly the post-op course

hence the reason to get cardiac re-eval of valve...

and re: surgery 4 months ago--- i would just tell ortho dude that my partner is a lucky son of a gun.

when it comes to cancelling cases, i find it a LOT more succesful w/ surgeons to look like you'd love to do the case because it would a fun/tough anesthetic to do, but you are VERY concerned about the post-operative course.... that way they NEVER blame me for the cancellation, they just don't want to be hasseled post-operatively on their patients...

You just touched on something I have always had a problem with. I will start a new thread on this so as not to hijack this one.

 

[Planktonmd]

I agree with Noyac. It is not an illusion.

I think it is an illusion.

 

[Planktonmd]

planktonmd --- i take issue w/ comment re: BP and severe AS - i have seen many severe (even a few critical ASers) with very high BPs...

also, i am not worried about doing a severe AS or critical AS case... but the key is knowing that there may be some AS issue to begin with... we put severe/critical AS folk to sleep all the time for cardiac surgery... so just treat the anesthetic as if it were a critical AS, and you will probably do fine.

HOWEVER, i have seen many of these patients do just FINE with the surgery only to crump in the PAC or on Post-op Day 2... they either get a bit hypotensive (usually due to volume or blood or a very generous RN with a lot of pain meds) and they then crump without having an anesthesiologist present to catch the falling knife...

so it isn't the surgery that will kill them, it is possibly the post-op course

hence the reason to get cardiac re-eval of valve...

and re: surgery 4 months ago--- i would just tell ortho dude that my partner is a lucky son of a gun.

when it comes to cancelling cases, i find it a LOT more succesful w/ surgeons to look like you'd love to do the case because it would a fun/tough anesthetic to do, but you are VERY concerned about the post-operative course.... that way they NEVER blame me for the cancellation, they just don't want to be hasseled post-operatively on their patients...

In my experience (and it is considerable if you count my years in internal medicine before anesthesia), I have not seen a patient with Aortic stenosis that is severe enough to cause the classic symptoms: (Angina, syncope and heart failure) that was also still able to produce high systolic pressure.
I am not talking about someone diagnosed with severe or critical aortic stenosis on Echo, I am specifically talking about Symptomatic aortic stenosis.
And although I agree with you about the importance of approaching aortic stenosis with caution and thinking about the whole perioperative experience not only the intraoperative time, my point from posting this case was to stimulate thought and to emphasize the idea that things are not always clear cut and that there are many factors involved in your decision to proceed or to not with a certain case.
As I mentioned previously, I certainly would not blame anyone for not proceeding with this case, but I don't think that going ahead is wrong either.

 

[Noyac]

In my experience (and it is considerable if you count my years in internal medicine before anesthesia), I have not seen a patient with Aortic stenosis that is severe enough to cause the classic symptoms: (Angina, syncope and heart failure) that was also still able to produce high systolic pressure.
I am not talking about someone diagnosed with severe or critical aortic stenosis on Echo, I am specifically talking about Symptomatic aortic stenosis.

I just had one. Pt with syncope and BP in the hospital
during my pre-op 190/110. Echo determined critical AS.

 

[Planktonmd]

I just had one. Pt with syncope and BP in the hospital
during my pre-op 190/110. Echo determined critical AS.

🙂
Well, I have never seen it.
Are you sue that the syncope was caused by cerebral hypoperfusion due to the AS and not an arrhythmia??

 

[Noyac]

🙂
Well, I have never seen it.
Are you sue that the syncope was caused by cerebral hypoperfusion due to the AS and not an arrhythmia??

Are we really sure of anything in a 92 yo? She stood up and passed out. I wasn't there when it happened.

 

[Noyac]

If a patient with severe AS, (not moderate) has a SYS BP of 160 I would question the accuracy of the diagnosis.
These are patients who are usually symptomatic at rest or at minimal effort and usually their LV is already working at maximum and simply can not produce the contractility needed to overcome the huge gradient and give you a high systolic pressure.
Let's say it is not impossible but highly unlikely to see such high systolic pressures in the presence of severe AS.

Really?

 

[Planktonmd]

Are we really sure of anything in a 92 yo? She stood up and passed out. I wasn't there when it happened.

Correct!
We don't know, but I still think that people with aortic stenosis that is severe enough to produce hypoperfusion symptoms to the heart or the brain it would be highly unlikely that they could produce high systemic blood pressure.

 

[Planktonmd]

Really?

Yes.

 

[Tenesma]

go to the cardiac anesthesia pre-ops who are going for an AVR, and look at those BPs... they tend to be hypertensive and not so normotensive.

 

[Planktonmd]

go to the cardiac anesthesia pre-ops who are going for an AVR, and look at those BPs... they tend to be hypertensive and not so normotensive.

Because people are getting AVR now before they reach the point where the pump bocomes unable to produce high pressure.