EF 25% for Knee Scope.

[sevoflurane]

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2ppd smoker, CAD, CABG x5 5 years ago. Optimized. Dilated Cardiomyopathy with EF of 20-25%. For Knee scope that is to last 40 minutes. Chart comes to you for outpatient surgery.

Do you say OK?
Nerve Block?
Move him to inpatient?
A-line on induction?

 

[Planktonmd]

Single shot femoral block (if you like but not necessary).
LMA GA like everyone else just on induction go slow with the Propofol.

2ppd smoker, CAD, CABG x5 5 years ago. Optimized. Dilated Cardiomyopathy with EF of 20-25%. For Knee scope that is to last 40 minutes. Chart comes to you for outpatient surgery.

Do you say OK?
Nerve Block?
Move him to inpatient?
A-line on induction?

 

[sevoflurane]

Single shot femoral block (if you like but not necessary).
LMA GA like everyone else just on induction go slow with the Propofol.

Move to inpatient or keep as outpatient?

Nay on the induction A-line?

 

[2win]

2ppd smoker, CAD, CABG x5 5 years ago. Optimized. Dilated Cardiomyopathy with EF of 20-25%. For Knee scope that is to last 40 minutes. Chart comes to you for outpatient surgery.

Do you say OK?
Nerve Block?
Move him to inpatient?
A-line on induction?

I say OK, OK....Let's do it...
I agree with Plank - be gentle.
I would try a Bier block - just because I didn't use it for knee procedures and if doesn't work go with the GA.
http://www.springerlink.com/content/3514uj5233779721/
Give it a try and let us now.
2win

 

[Noyac]

If ambulatory center is detached from main hospital then you may want to move to hospital setting. Otherwise, LMA case with or without block, I prefer without.

Definitely no A-line necessary but many would place one.

 

[aredoubleyou]

Pt is stated as Optimized, so its a go. LMA or spinal. Outpatient is fine, no reason you have to monitor someone for 24 hours for a knee scope! If you NEED an A-line to induce this patient for a surgery with no fluid shifts, which is quick, minimal blood loss, then you are doing something very wrong. No nerve block, but I dont think its neccessarily wrong, just not needed.

 

[sevoflurane]

Patient did fine. No problems. As stated above simple case:

LMA, no block, kept on the outpatient side, no A-line. Home after 4 hours in recovery.

I've done many ASA III and IV's in the attached ASC. I would not do this one at one of our other sites where I am the only anesthesiologists in the building.

As far as block... as much as I love regional I don't like them on sick cardiac patients. You only need a small amount of local to piss off a sick heart. That is my approach. Risk/Benefit.

Optimized means that... as best as they can be... so it's always a go for me, but not necessarily on the outpatient side.

A-line... well some would say "how about if this guy was having a redo CABG?" Just because your patient is in the ortho room doesn't mean his heart disease is any better.

What do the ASA guidelines say regarding ASA IV and ambulatory surgery?

 

[sevoflurane]

I don't know about a spinal... and an ef of 20-25%. I don't think I would do one unless I had an intrathecal catheter and titrated my local... too much effort for a short case.

 

[bullard]

I'd try to talk this guy into a spinal, but if discussion was going nowhere fast, I'd do LMA, no art-line like everybody else, assuming he's been asymptomatic in the 5 years since revascularization.

My question: what do people like for short-acting, "outpatient" spinals? I ask because in this situation I would probably just do 8 mg of hyperbaric bupiv, but am told chlorprocaine is the way to go...what dose of that would you use?

 

[sevoflurane]

I'd try to talk this guy into a spinal, but if discussion was going nowhere fast, I'd do LMA, no art-line like everybody else, assuming he's been asymptomatic in the 5 years since revascularization.

My question: what do people like for short-acting, "outpatient" spinals? I ask because in this situation I would probably just do 8 mg of hyperbaric bupiv, but am told chlorprocaine is the way to go...what dose of that would you use?

Adhesive arachnoiditis?

 

[nap$ter]

2ppd smoker, CAD, CABG x5 5 years ago. Optimized. Dilated Cardiomyopathy with EF of 20-25%. For Knee scope that is to last 40 minutes. Chart comes to you for outpatient surgery.

Do you say OK?
Nerve Block?
Move him to inpatient?
A-line on induction?

nobody cares what his functional status is like? BMI? big fat guy that lives in a Lazy-Boy and gets chest pain and SOB puttin the foot rest up? or is he a skinny dude out rakin leaves?

i also disagree with spinal, agree with LMA +/- block - could also consider epidural single shot..

 

[Planktonmd]

Adhesive arachnoiditis?

The guys at Virginia Mason published a study on 2 choloroprocaine for ambulatory surgery with excellent results.
http://www.anesthesia-analgesia.org/cgi/content/full/100/2/553

I don't like doing spinals for out patients for many reasons though.

 

[tucker27705]

A touch of fentanyl. Inhalational induction with Sevo. LMA. Change to Des. I would not do a spinal, prolongs recovery.
Tuck

 

[Arch Guillotti]

could also consider epidural single shot..

Of what and how much?

 

[Arch Guillotti]

My plan:

No a line
slow with the propofol
LMA
stick of neo handy
know where the epi is

I probably wouldn't do a spinal just because it is out patient. if I were going to do a spinal I would use chloroprocaine. I have always wanted to do a demerol spinal but probably wouldn't with this guy.

i don't consider his EF to be a problem with the spinal.

 

[2ndyear]

I wouldn't do a spinal. Once you've put it in, you have to deal with hypotension likely. No great way to do this with poor ventricular function without either increasing afterload, increasing preload, or raising the heart rate. That being said, isobaric chloroprocaine is very stable hemodynamically. That would be my choice if I did feel strongly about it. I use it all the time for urology cases. Stable, but the geriatric population still gets hypotensive.

He's not intubated now, so chances are good he doesn't need to be after a knee scope. Go slow with induction, plan on an LMA, and do the case. I'd prefer not to do this one at a detached ASC, and hopefully the chart would have been flagged by someone prior to surgery. Our ASC is miles away from the hospital. Nobody likes an ambulance ride.

 

[IN2B8R]

Would do an LMA +/- nerve block (it's a knee scope, so not terribly painful, especially if orthopod injects the knee). Had this case been a TKA, then I would have done an isobaric 0.75% bupiv spinal + a-line (or peripherally blocked the knee fem/sciatic/obturator--more work!). Isobaric spinals work well with these trashed pumps.

I don't know about a spinal... and an ef of 20-25%. I don't think I would do one unless I had an intrathecal catheter and titrated my local... too much effort for a short case.

 

[bullard]

How much chloroprocaine?

My plan:

No a line
slow with the propofol
LMA
stick of neo handy
know where the epi is

I probably wouldn't do a spinal just because it is out patient. if I were going to do a spinal I would use chloroprocaine. I have always wanted to do a demerol spinal but probably wouldn't with this guy.

i don't consider his EF to be a problem with the spinal.

 

[sevoflurane]

Based on Planks excellent citation, I would have to say 30-40 mg. Thanks for the link Plank. I've yet to use chloroprocaine for a spinal. I'll have to check it out based on what I've read here today.

 

[bullard]

Thanks, I somehow missed Plank's post.

 

[BLADEMDA]

Common scenario in my practice. I wouldn't do an A-line and induce with Propofol 60-80 mg I.V. then mask assist with propofol. Check BP one or twice (makes me feel better) and insert LMA. I would probably place a BIS to keep the SEVO or inhalational agent of your choice at a minimum.


If asked to do a Regional by the patient I would do an old fashioned saddle block (patient in sitting position) with a non-cutting needle.
Due to my familiarity and proven safety record I woulg go with Heavy Bupivicaine (about 7 mg). Alternatively, you could consider 15 mg of Isobaric Bupivicaine in the lateral position. Both should minimize spinal induced hypotension. IMHO, the Spinal will dealy this patient's discharge compared to the LMA technique; but, it isn't like he doesn't have the extra hour to spare.😉

What do you all think about N20 in this patient? Forget about the N/V and focus on the positives/negatives of N20 in this scenario. Would you use 50% N20 with the inhalational agent? For this 40 minute case would you get better hemodynamics?

 

[Arch Guillotti]

15 mg of iso bupi seems like a lot for a knee scope

Common scenario in my practice. I wouldn't do an A-line and induce with Propofol 60-80 mg I.V. then mask assist with propofol. Check BP one or twice (makes me feel better) and insert LMA. I would probably place a BIS to keep the SEVO or inhalational agent of your choice at a minimum.


If asked to do a Regional by the patient I would do an old fashioned saddle block (patient in sitting position) with a non-cutting needle.
Due to my familiarity and proven safety record I woulg go with Heavy Bupivicaine (about 7 mg). Alternatively, you could consider 15 mg of Isobaric Bupivicaine in the lateral position. Both should minimize spinal induced hypotension. IMHO, the Spinal will dealy this patient's discharge compared to the LMA technique; but, it isn't like he doesn't have the extra hour to spare.😉

What do you all think about N20 in this patient? Forget about the N/V and focus on the positives/negatives of N20 in this scenario. Would you use 50% N20 with the inhalational agent? For this 40 minute case would you get better hemodynamics?

 

[BLADEMDA]

15 mg of iso bupi seems like a lot for a knee scope

Arch, it is a significant dose. Since I use the 0.5% Bupivicaine bottle for my Isobaric Bup despite what the label says I am very familiar with that dose. Perhaps, 2 mls of the 0.5% would be sufficient although my experience is limited here (use ISOBARIC on sick inpatients mostly). In the patient described above I would go with the reliable, predictable saddle block if spinal anesthesia was chosen.

 

[BLADEMDA]

Nitrous Oxide- You either are a lover or a hater; regardless, you should be able to defend your answer whether or not to use it on this patient.



http://www.ncbi.nlm.nih.gov/pubmed/...ed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=20



http://journals.lww.com/anesthesiol...fects_of_Nitrous_Oxide__A_Mechanistic.20.aspx

 

[Arch Guillotti]

Arch, it is a significant dose. Since I use the 0.5% Bupivicaine bottle for my Isobaric Bup despite what the label says I am very familiar with that dose. Perhaps, 2 mls of the 0.5% would be sufficient although my experience is limited here (use ISOBARIC on sick inpatients mostly). In the patient described above I would go with the reliable, predictable saddle block if spinal anesthesia was chosen.

I think 10 would work fine and I would be interested to try and push it lower but I have never gone below this amount that I can recall. I agree that the iso bupi seems to be pretty stable hemodynamically.

 

[nap$ter]

Of what and how much?

20mL 3% chloroprocaine

Anesth Analg 2000;91:860-864 outta the chloroprocaine lovas at VM

i've only done this twice (2yrs ago) but remember that i was surprised at how smooth it was... think i'd like to try it again..

 

[periopdoc]

20mL 3% chloroprocaine

Anesth Analg 2000;91:860-864 outta the chloroprocaine lovas at VM

I think you mixed up a unit there.

I spent 2 months at VM and learned to LOVE the chlorprocaine spinal. My weapon of choice for outpatient lower extremity ortho. But this guy is getting an LMA unless he is insistent on being awake for surgery. Nothing worse than taking a sick heart s/p spinal into the grey zone between sedation and anesthesia because surgery went just a little longer than expected or the torniquet pain isn't quite covered.

- pod

 

[Narcotized]

Why mess with Propofol and not use Etomidate? Also, although not a big case, but a femoral block may allow you to use less anesthetic. With a pretty sick heart why not take all the help you can get?

 

[sevoflurane]

Why mess with Propofol and not use Etomidate? Also, although not a big case, but a femoral block may allow you to use less anesthetic. With a pretty sick heart why not take all the help you can get?

It's all in how you use the drug. I am not a big fan of etomidate despite it's "cardiac stability". If I use it... I'll mix it with propofol.

 

[Arch Guillotti]

I think you mixed up a unit there.

I spent 2 months at VM and learned to LOVE the chlorprocaine spinal. My weapon of choice for outpatient lower extremity ortho. But this guy is getting an LMA unless he is insistent on being awake for surgery. Nothing worse than taking a sick heart s/p spinal into the grey zone between sedation and anesthesia because surgery went just a little longer than expected or the torniquet pain isn't quite covered.

- pod

he was referring to a single shot epidural.

 

[Noyac]

What do you all think about N20 in this patient? Forget about the N/V and focus on the positives/negatives of N20 in this scenario. Would you use 50% N20 with the inhalational agent? For this 40 minute case would you get better hemodynamics?

I don't use N2O very often but in this case it can be useful. Since MAC values of volatiles are additive one can add 0.5 MAC N2O to the sevo cutting it down to 0.5-0.75 MAC sevo and therefore diminishing the myocardial depression of sevo.

 

[Noyac]

Why mess with Propofol and not use Etomidate? Also, although not a big case, but a femoral block may allow you to use less anesthetic. With a pretty sick heart why not take all the help you can get?

You can sure use etomidate but IMO it's a nasty drug. Having seen a dramatic case of adrenal suppression from a single dose of etomidate I now rarely use it. I prefer to use propofol and a little neo if needed to counteract the vasodilation.

 

[Dejavu]

I do this all the time, works great for short knee scopes....

Isobaric bupiv spinal 5-6mg with 15 mcg Fent mixed in.

Minimal cardiovasc disturbance, plenty of coverage, pretty fast offset of block. No aline.

Did two of these today already. Just as described. Better have an efficient surgeon though.

 

[Noyac]

I do this all the time, works great for short knee scopes....

Isobaric bupiv spinal 5-6mg with 15 mcg Fent mixed in.

Minimal cardiovasc disturbance, plenty of coverage, pretty fast offset of block. No aline.

Did two of these today already. Just as described. Better have an efficient surgeon though.

Lateral or upright placement?

how long does it last?

when are they ready for D/C?

 

[tucker27705]

I'm surprised with all the Prop, and lately the Etomidate comments. Haven't you guys all been doing inhalational inductions for the last month (with the prop shortage)? Its smooth. Do one on a guy with an a-line. Minimal drop in BP. Don't need to be very deep to insert an LMA.
N2O? where's the upside?
Spinal? why?
Maybe I'm missing something, but an optimized EF of 25% isn't all that bad unless there is some valvular dz.
Tuck

 

[Dejavu]

Lateral or upright placement?

how long does it last?

when are they ready for D/C?

Either sitting or lateral, although most of my colleagues do them lateral, I sit them up and immediately get them supine after the needle is out. I guess they last long enough for about 60-75 minutes of operating time , give or take a few. Maybe you can get lucky after that but I don't count on it.

Usually up walking about 3 hrs or so after removing the needle (or a couple of hours postop for the average one hour case), mostly without much deficit. Still have to worry about a little increased chance of urinary retention compared to general, IMHO. I think there are studies that address that.

 

[nap$ter]

I think you mixed up a unit there.

I spent 2 months at VM and learned to LOVE the chlorprocaine spinal. My weapon of choice for outpatient lower extremity ortho. But this guy is getting an LMA unless he is insistent on being awake for surgery. Nothing worse than taking a sick heart s/p spinal into the grey zone between sedation and anesthesia because surgery went just a little longer than expected or the torniquet pain isn't quite covered.

- pod

nope - i meant it - 20mL 3% chloroprocaine for single shot epidural for knee scope. the reference i quoted is a nice one from VM re single shot epidural vs general c LMA vs spinal for knee scopes.

single shot chloroprocaine epidural and GA c LMA were equally superior to chloroprocaine spinal in regards to discharge time, validating the hesitation of everyone on here to pop a spinal for a knee scope. the three techniques were equivalent in all other measures.

 

[dhb]

I do this all the time, works great for short knee scopes....

Isobaric bupiv spinal 5-6mg with 15 mcg Fent mixed in.

Minimal cardiovasc disturbance, plenty of coverage, pretty fast offset of block. No aline.

Did two of these today already. Just as described. Better have an efficient surgeon though.

I do pretty much the same with good results

 

[Noyac]

Either sitting or lateral, although most of my colleagues do them lateral, I sit them up and immediately get them supine after the needle is out. I guess they last long enough for about 60-75 minutes of operating time , give or take a few. Maybe you can get lucky after that but I don't count on it.

Usually up walking about 3 hrs or so after removing the needle (or a couple of hours postop for the average one hour case), mostly without much deficit. Still have to worry about a little increased chance of urinary retention compared to general, IMHO. I think there are studies that address that.

Way too long IMO. Knee scopes are leaving our ASC at around 1 hr post-op. With this technique they will need to remain at least another 1.5 hrs.

And if this case is the last one of the day and you have to be around until the last pt is d/c'd then this 1.5 hrs is huge.

 

[Dejavu]

Way too long IMO. Knee scopes are leaving our ASC at around 1 hr post-op. With this technique they will need to remain at least another 1.5 hrs.

And if this case is the last one of the day and you have to be around until the last pt is d/c'd then this 1.5 hrs is huge.

Believe me, I tell the pt that the fastest way out of the building is a General anesthetic. I agree with you totally, Noyac. We use General Anesth way more often than spinals for this type of case in our ASC, but I was just saying that this is an option for a low EF kind of guy.

 

[Noyac]

Believe me, I tell the pt that the fastest way out of the building is a General anesthetic. I agree with you totally, Noyac. We use General Anesth way more often than spinals for this type of case in our ASC, but I was just saying that this is an option for a low EF kind of guy.

👍

 

[hokie]

For the (pretty rare) patient who really wants a neuraxial technique for a short procedure like a knee scope or inguinal hernia I will often do a 3% chloroprocaine epidural. I do put a catheter in and give 10-15cc then titrate more if necessary. Their time to discharge is a little bit longer but nothing like bupi spinal times.
I did a few chloroprocaine spinals in residency but have not done any as an attending.... may look into that again.

 

[amyl]

i love spinals, but not in this pt. he will likely need fluid after and i don't like overloading a poopy heart... will probably be okay but why deal with it.
i like etomidate and think it would be good here. sure propofol will probably be okay, but again, why deal with it.
i love nitrous, but not in this pt. in general try to avoid in signif COPDers like i suspect he is at 2ppd, probably didn't start smoking yesterday. probably a short surgery so again would likely be okay, but i wouldn't....

 

[Noyac]

i love spinals, but not in this pt. he will likely need fluid after and i don't like overloading a poopy heart... will probably be okay but why deal with it.
i like etomidate and think it would be good here. sure propofol will probably be okay, but again, why deal with it.
i love nitrous, but not in this pt. in general try to avoid in signif COPDers like i suspect he is at 2ppd, probably didn't start smoking yesterday. probably a short surgery so again would likely be okay, but i wouldn't....

YOur comments are supportable but I'd like to hear your reasoning on why avoid N2O in this pt (COPD'ers). I'm sure others are interested as well.

 

[amyl]

theoretical risk of undiagnosed pleural bleb rupture. again admittedly small risk in short surgery but....
please correct me if i am wrong.... but be nice to a ca-1 🙂

 

[amyl]

yeah, theroretical risk, questionable clinical significance but i personally am not gonna do it. sorry re-reading what i wrote it wasn't clear... undiagnosed is not the right word...
those were my general sentiments -- thanks for putting it more eloquently for me 🙂

 

[amyl]

i know i have to really brush up on those skills before orals...sometimes when im pimped i technically have the right answer but it comes out wrong.... like i know what i mean and my brain goes faster than my mouth, or in this case typing hand...

 

[aredoubleyou]

OK, so i get that many people here wont do a spinal because of recovery time...but people REALLY think a spinal in this patient is UNSAFE. OPTIMIZED non-symptomatic CHF with an EF of 25%. Unsafe, seriously??

 

[Noyac]

OK, so i get that many people here wont do a spinal because of recovery time...but people REALLY think a spinal in this patient is UNSAFE. OPTIMIZED non-symptomatic CHF with an EF of 25%. Unsafe, seriously??

I don't think so.

 

[Arch Guillotti]

OK, so i get that many people here wont do a spinal because of recovery time...but people REALLY think a spinal in this patient is UNSAFE. OPTIMIZED non-symptomatic CHF with an EF of 25%. Unsafe, seriously??

I don't think so

i don't consider his EF to be a problem with the spinal.