Recent stroke and elective surgery

[anes121508]

Hey all,

Case came through for preop evalaution at outpatient center

75 yo Elective shoulder scope Beach chair

Admit for 2.5 months ago. Acute infarct on top of old lacunar stuff on mri.

Bp controlled 120-130 per office notes. On an aspirin and statin.

Thoughts on timing? Any good data? I did a prelim search....

Would embolic vs ischemic origin make a difference in your decision to proceed?

Would size of infarct or region involved make a difference?

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[Arch Guillotti]

Hey all,

Case came through for preop evalaution at outpatient center

75 yo Elective shoulder scope Beach chair

Admit for 2.5 months ago. Acute infarct on top of old lacunar stuff on mri.

Bp controlled 120-130 per office notes. On an aspirin and statin.

Thoughts on timing? Any good data? I did a prelim search....

Would embolic vs ischemic origin make a difference in your decision to proceed?

Would size of infarct or region involved make a difference?

6 months.

 

[USC2k7]

Less than 3 months is a non-starter. Otherwise how important is the proc? More than a year is safest, but the curve definitely starts flattening after 3 months

Timing of Elective Surgery After Ischemic Stroke

Hey all,

Case came through for preop evalaution at outpatient center

75 yo Elective shoulder scope Beach chair

Admit for 2.5 months ago. Acute infarct on top of old lacunar stuff on mri.

Bp controlled 120-130 per office notes. On an aspirin and statin.

Thoughts on timing? Any good data? I did a prelim search....

Would embolic vs ischemic origin make a difference in your decision to proceed?

Would size of infarct or region involved make a difference?

 

[jwk]

Decent ortho could also do this in lateral position. Beach chair sucks for a lot of reasons.

 

[Psai]

Wouldn't proceed. Beach chair in an old guy for an elective surgery? No thanks.

 

[MoMoGesiologist]

Just give him his aspirin and keep his vitals within baseline, he'll be fine... (probably)

 

[vector2]

I wouldn't proceed with any elective case after only 2.5 months. The type of procedure and positioning is mostly irrelevant- what you want to avoid is the inflammatory response and hypercoagulability that comes the second the scalpel hits the skin. You have a paper published in JAMA telling you that the increased risk of MACE post CVA doesn't drop off til about 9 months. I'd wait at least 6 (hopefully closer to 9) for something high risk like beach chair.

 

[deleted171991]

Elective shoulder in beach chair, less than 3 months after a stroke? Good joke, next!

Look up the latest non-cardiac surgery guidelines for the exact number of months to postpone the surgery for.

 

[deleted171991]

Just give him his aspirin and keep his vitals within baseline, he'll be fine... (probably)

That is correct, sir. Unfortunately, that 5% chance of being wrong could cost you a lot in a court of law.

 

[anes121508]

6 months.

That’s what’s I was taught and believe I’ve seen as a loose guideline

 

[anes121508]

Less than 3 months is a non-starter. Otherwise how important is the proc? More than a year is safest, but the curve definitely starts flattening after 3 months

Timing of Elective Surgery After Ischemic Stroke

Exactly the paper I have saved to my g drive and what I used to give my two sense on the case.

 

[anes121508]

Just give him his aspirin and keep his vitals within baseline, he'll be fine... (probably)

Would probably be good enough for your family member?

 

[anes121508]

I wouldn't proceed with any elective case after only 2.5 months. The type of procedure and positioning is mostly irrelevant- what you want to avoid is the inflammatory response and hypercoagulability that comes the second the scalpel hits the skin. You have a paper published in JAMA telling you that the increased risk of MACE post CVA doesn't drop off til about 9 months. I'd wait at least 6 (hopefully closer to 9) for something high risk like beach chair.

I Completely agree

 

[anes121508]

Elective shoulder in beach chair, less than 3 months after a stroke? Good joke, next!

Look up the latest non-cardiac surgery guidelines for the exact number of months to postpone the surgery for.

Yeah, except that it wasn’t a joke (I thought it was).

Crazy part is neurologist that “knows” the patient (loose term because neurologist didn’t even know patient suffered a stroke when she saw pt in office after being discharged) gets involved and sends generic clearance letter to ortho office.

Called neurologist to ask if she is aware of recent stroke. She was not. Said she would call me back. Neurologist ends up “clearing” pt for surgery. Left me wondering if there is something I’m missing...hence my post to you all with tons of experience

 

[Arch Guillotti]

Wouldn't proceed. Beach chair in an old guy for an elective surgery? No thanks.

You still have to decide how long to wait. Can’t punt the case indefinitely.

 

[fakin' the funk]

Wouldn't proceed. Beach chair in an old guy for an elective surgery? No thanks.

Like...ever?

 

[fakin' the funk]

Hey all,

Case came through for preop evalaution at outpatient center

75 yo Elective shoulder scope Beach chair

Admit for 2.5 months ago. Acute infarct on top of old lacunar stuff on mri.

Bp controlled 120-130 per office notes. On an aspirin and statin.

Thoughts on timing? Any good data? I did a prelim search....

Would embolic vs ischemic origin make a difference in your decision to proceed?

Would size of infarct or region involved make a difference?

I know the stereotype of orthos is they're dumb but COME ONNN MANNNN

 

[Low Flow]

Elective shoulder in beach chair, less than 3 months after a stroke? Good joke, next!

Look up the latest non-cardiac surgery guidelines for the exact number of months to postpone the surgery for.

Med student question: what’s the concern regarding beach chair positioning?

 

[deleted171991]

Med student question: what’s the concern regarding beach chair positioning?

Hypotension.

The distance between one's auditory meatus (i.e. brain) and one's lower arm can be 20-30 cm, which corresponds to a pressure difference of at least 20 cm H2O (approximation for the column of blood) divided by 13.6 (times mercury is denser than water) = about 15 mm(Hg). Hence if one maintains the patient at a MAP of 65 or less, the brain is actually swimming in 50 mmHg pressure. Do that for a long time in a patient who's at more than 65 mmHg even at baseline (i.e. autoregulates brain perfusion between much higher values than 50 and 150 mmHg, which are the values for healthy patients), and it will result in generalized hypoxic ischemic brain injury, i.e. brain death.

Ideally one should keep the patient at his resting BP while sitting in a non-stressful setting (e.g. preop clinic). That can be as high as 140/70, for example, or higher, which orthopods will hate, because it can increase bleeding (especially in arthroscopic procedures). Of course, none of the whiners would learn how to do the surgery in lateral position, with much lower anesthetic risk.

 

[nimbus]

Anybody using cerebral oximetry for beach chair cases?

 

[Psai]

Anybody using cerebral oximetry for beach chair cases?

Cerebral oximetry seems like a massive waste of money

 

[deleted875186]

Anybody using cerebral oximetry for beach chair cases?

I actually like the idea of cerebral ox for these cases. You can actually do something if the sats start to drop. Then again, would the surgeon be ok with you stopping the case due to persistently low sats in a surgery they otherwise do uneventfully most of the time?

 

[Ronin786]

I actually like the idea of cerebral ox for these cases. You can actually do something if the sats start to drop. Then again, would the surgeon be ok with you stopping the case due to persistently low sats in a surgery they otherwise do uneventfully most of the time?

It's pretty funny that we'd rather delude ourselves into thinking the monitor is meaningless and everything will be alright instead of using it to provide a higher level of care for our patients.

Not pointing fingers at you, I probably do the same, but that's the sad state of anesthesiology nowadays.

 

[anes121508]

Anybody using cerebral oximetry for beach chair cases?

Case was done with cerebral ox and Aline titrate bp per neuro recs. Lady did fine. Lucky I guess, or maybe cerebral ox saved the day.

 

[MoMoGesiologist]

Case was done with cerebral ox and Aline titrate bp per neuro recs. Lady did fine. Lucky I guess, or maybe cerebral ox saved the day.

What does the cerebral ox and aline gain you? Why not just titate to MAP>90 on NIBP? Or is the ortho guy asking for hypotension in the recent stroke patient and you wanna use cerebral sats to prove it's unsafe?

Also, what's to stop the ortho guy saying "hey cerebral sats look normal, keep bringing BP down" (of course assuming he knows what that is which I think I would have a stroke if he did).

 

[deleted171991]

Anybody using cerebral oximetry for beach chair cases?

I would if I could (not available in our ASC). I use it in my CEAs all the time.

 

[secants]

Any difference for block/sedation vs GA with recent stroke timing in regards to periop risks?

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[Fart Daddy Smooth]

Hypotension.

The distance between one's auditory meatus (i.e. brain) and one's lower arm can be 20-30 cm, which corresponds to a pressure difference of at least 20 cm H2O (approximation for the column of blood) divided by 13.6 (times mercury is denser than water) = about 15 mm(Hg). Hence if one maintains the patient at a MAP of 65 or less, the brain is actually swimming in 50 mmHg pressure. Do that for a long time in a patient who's at more than 65 mmHg even at baseline (i.e. autoregulates brain perfusion between much higher values than 50 and 150 mmHg, which are the values for healthy patients), and it will result in generalized hypoxic ischemic brain injury, i.e. brain death.

Ideally one should keep the patient at his resting BP while sitting in a non-stressful setting (e.g. preop clinic). That can be as high as 140/70, for example, or higher, which orthopods will hate, because it can increase bleeding (especially in arthroscopic procedures). Of course, none of the whiners would learn how to do the surgery in lateral position, with much lower anesthetic risk.

To my eyes, beach chair position looks similar to semi-Fowler's position. Does this mean that a blood pressure taken from a patient sitting in semi-Fowler's position would be subject to the same pressure difference you mention here?

 

[nimbus]

To my eyes, beach chair position looks similar to semi-Fowler's position. Does this mean that a blood pressure taken from a patient sitting in semi-Fowler's position would be subject to the same pressure difference you mention here?

Yes. Most blood pressures in outpatients are taken in the sitting position. I don’t think the risk of hypopersion is actually very high but there are rare case reports.

 

[anes121508]

What does the cerebral ox and aline gain you? Why not just titate to MAP>90 on NIBP? Or is the ortho guy asking for hypotension in the recent stroke patient and you wanna use cerebral sats to prove it's unsafe?

Also, what's to stop the ortho guy saying "hey cerebral sats look normal, keep bringing BP down" (of course assuming he knows what that is which I think I would have a stroke if he did).

I was being sarcastic. However, if I was forced to do this case Under ga in a beach chair I’d probably use the cerebral ox. What does it gain you? Just one extra piece of information really. May or may not be helpful. Doesn’t guarantee anything. Doesn’t hurt anything, unless like you pointed out the ortho guy wanted it for justifying pushing no lower, which I assure you is not the case (our orthos wouldn’t know that thing even existed). I wonder though since auto regulation is said to be impaired post stroke, you might see the cerebral ox go down unexpectedly despite staying within 20% of baseline. Also, who knows what patients baseline truly is. I’d use it like this: keep pt bp where the neurologist recommended and if cerebral ox drops, push the bp higher.

What does the Aline give you? A continous measurement of the pressure rather than every 2-5 min on the cuff with an occaisional timeout and needing to reposition the cuff. I notice this scenario all the time: Cuff shows map of 65. 3 min go bye and map is 50. Crna pushes neo. Manual cycle cuff a min later and map is 65. 3 min go by and map is again 50. Crna pushes neo. Now how many of those 7 min was the map below 65? How much time was spent below 60? Now this is obviously an exaggerated and poorly managed example, but you get my point right? In a case with high risk of stroke why not have the ability have tighter control of the BP? Not positive but I doubt small hits of hypotension time after time over the course of the case could add up in a lady with recent stroke, baseline neuro cognitive disorder, and micro vascular disease. Who knows, but if I had to do a case like this, I’d take whatever precautions and conservative measures I could (within reason). I realize aline isn’t what’s used in the office and doesn’t always correlate. So I’d take a look at both in the beginning and go from there.

“(of course assuming he knows what that is which I think I would have a stroke if he did”.... 100% agree

 

[anes121508]

I would if I could (not available in our ASC). I use it in my CEAs all the time.

Anyone using it in vads or ecmo folks?

 

[deleted171991]

To my eyes, beach chair position looks similar to semi-Fowler's position. Does this mean that a blood pressure taken from a patient sitting in semi-Fowler's position would be subject to the same pressure difference you mention here?

Beach chair is 90 degrees where I work. Semi-Fowler is around 30. So the differences are much smaller in the latter.

 

[coffeebythelake]

Yes. Most blood pressures in outpatients are taken in the sitting position. I don’t think the risk of hypopersion is actually very high but there are rare case reports.

The question you are getting to is this -- Does cerebral auto regulation differ between anesthetized and awake patients?

 

[nimbus]

The question you are getting to is this -- Does cerebral auto regulation differ between anesthetized and awake patients?

Yes. Some good references on this link.


https://www.openanesthesia.org/aba_cerebral_autoregulation/

 

[deleted171991]

The question you are getting to is this -- Does cerebral auto regulation differ between anesthetized and awake patients?

The way I see it is this: I am putting my patients in a controlled coma, hence I cannot count on ANY autoregulation beyond what I can measure. So hoping that the patient's brain or kidneys won't get hurt by 90/60 for an hour, when he lives at 160/90 or higher, is just bad medicine, in my book. The closer a patient is to his unstressed resting vitals, the better he'll probably do.

I don't know why so many "anesthesia providers" don't feel the need to reverse some of the vasodilating effects of general inhalational anesthesia with some pressors. Yes, it takes a bit of work, but it's proven to decrease the risk of AKI, and probably other bad stuff. I wouldn't be surprised if the drop in IQ after cardiac surgery is due to those lower (than the patient's usual) MAP numbers.

Even in non-cardiac surgery, we are so obsessed with that stupid MAP over 65 number (above that, everything is just dandy), but we tend to forget that ICU patients (on which the studies were done) are just sedated, not completely knocked out to a level where one can do surgery on them. Who knows what effects our inhalational anesthetics have on various autoregulatory structures in the body/brain/brainstem etc., when we can't even explain how they produce their anesthetic effects?

 

[deleted162650]

Keep in mind that cerebral O2 requirement/consumption is markedly decreased in the anesthetized brain, and that the deeper the anesthetic (i.e the closer to an isoelectric EEG) the lower the O2 needs.

Gives me an idea - hypothermia protocols for all beach chair shoulder patients with a history of CVD.

 

[anes121508]

Keep in mind that cerebral O2 requirement/consumption is markedly decreased in the anesthetized brain, and that the deeper the anesthetic (i.e the closer to an isoelectric EEG) the lower the O2 needs.

Gives me an idea - hypothermia protocols for all beach chair shoulder patients with a history of CVD.

Now you’re talking.

 

[kmurp]

Case was done with cerebral ox and Aline titrate bp per neuro recs. Lady did fine. Lucky I guess, or maybe cerebral ox saved the day.

You did this at an ASC? If so, that surprises me. Did you just use ISB or did you use GA?

 

[Noyac]

Cerebral oximetry seems like a massive waste of money

That’s what people said when the BIS came out. And now every nurse and most young anesthesiologists use it for every case.

 

[Echo33]

Cerebral oximetry seems like a massive waste of money

I think cerebral oximetry is great. When you consider the entire cost of the procedure I think it’s hardly a massive waste of money.

Cerebral oximetry allows the use of hard data and goal-directed therapy. I’m never satisfied with a Bp that’s sagging in a sitting case but I care much more when the cerebral saturation drops. I’ve done many cases with it and it certainly changes my management.

Many cases need significantly higher BP than I would have thought to stay within baseline.

Basically harmless, non-invasive monitor

I think the technology will get better and cheaper and in 10-20 years cerebral oximetry will become a standard monitor like pulse ox

 

[Psai]

That’s what people said when the BIS came out. And now every nurse and most young anesthesiologists use it for every case.

I don't believe in bis either. I almost never use it.

 

[dhb]

I think the technology will get better and cheaper and in 10-20 years cerebral oximetry will become a standard monitor like pulse ox

But it is a pulse-ox: you're just measuring forehead sats.

 

[MoMoGesiologist]

I think cerebral oximetry is great. When you consider the entire cost of the procedure I think it’s hardly a massive waste of money.

Cerebral oximetry allows the use of hard data and goal-directed therapy. I’m never satisfied with a Bp that’s sagging in a sitting case but I care much more when the cerebral saturation drops. I’ve done many cases with it and it certainly changes my management.

Many cases need significantly higher BP than I would have thought to stay within baseline.

Basically harmless, non-invasive monitor

I think the technology will get better and cheaper and in 10-20 years cerebral oximetry will become a standard monitor like pulse ox

So for the cases you use cerebral ox, it often changes your management. For the cases you don't use it, are you getting worse outcomes? Are you treating something that's changing outcomes? We never really used it in residency, we just kept BPs high. Even on cardiac cases where the cerebral sats dropped, didn't really change management. I did see it used in peds cardiac once where it was an early indicator of anemia, so that was pretty cool.

 

[Echo33]

But it is a pulse-ox: you're just measuring forehead sats.

This is what I used to think too. Believe me I have used them enough to know they have limitations. You’ll start to appreciate them more after doing hundreds of cardiac cases with them. I see large drop in cerebral sats with pulse ox showing 100 percent and ABG showing super-normal PaO2. Most of these machines have good technology to account for scalp blood, though I admit that’s always on my mind.

As others have pointed out, in my opinion the two biggest limitations are:

1: They don’t tell you what the problem is, and can lead to things like potential uneccessary blood administration (one could argue a potential harmful indirect consequence of following them) or pressor/ionotrope administration

2: only give a regional snapshot (frontal lobe)

As far as outcomes, luckily I haven’t had any beach chair cases with bad neurologic outcomes. I tend to use cerebral oximetry selectively in these cases: think of the older, diabetic, asa3 who may be a bit higher risk. I’ll add cerebral oximetry to my monitors as one more piece of data. For patients I’m really worried about, I’ll obviously place an a-line

By no means do I think it’s perfect or necessary in all cases but I think it is helpful, when taken in context of the whole picture, and is absolutely worth the cost.

 

[pgg]

But it is a pulse-ox: you're just measuring forehead sats.

It's functionally different than pulse oximetry, doesn't require pulsatile flow, mostly measures venous blood sat, has a shallow and a deep sensor so subtraction allows some degree of focus on deeper tissue.

If you use it for carotids enough you will see unilateral changes associated with things the surgeon does, and this information can guide interventions like shunt placement. In cardiac surgery I've found it occasionally helpful in convincing certain perfusionists to run MAPs a little higher. In theory it could help you pick up aortic cannula misplacement if you miss the other signs. It's a tool like any other, you have to know how it works and have specific interventions in mind if it gives you numbers you don't like, otherwise it's just noise.

 

[sethco]

That’s what people said when the BIS came out. And now every nurse and most young anesthesiologists use it for every case.

Ehh, I'm selective in when I use it in Cardiac cases. Significant atheroma load, Aortic surgery, open chamber surgery, MAZE Procedure, known Carotid disease, previous CVA or TIAs, etc. I also use it for CEAs. Do people actually use it for General cases like they were using a BIS monitor? That's dumb

I definitely prefer the Foresight over the Invos