Reduced EF and spinal anesthesia
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Arch Guillotti
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Pretty low😎
If you are really worried about it put in an art line and have your pressor of choice in line. Coload with fluids. Or do an epidural
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Whether someone with HFrEF can tolerate a spinal is more complex and nuanced than just the "EF."
There are plenty of LVEF 20-25% pts who would do great with neuraxial and plenty of LVEF 35-40% pts who would crash and burn.
Hate to hijack this thread but... what do you all do for the 90+ year old grandma with low EF getting a "gamma nail" type hip fixation? These cases are quick (<30 mins), supine position, two small incisions, and not that stimulating. Some of my colleagues have been doing spinals but I think it is overkill. I usually slip in an LMA and run a prop drip, usually 50mcg fentanyl for the whole case. My n ~ 100 has shown good results.
Depends what mood I'm in. Patients with spinals definitely look the best in pacu.. comfortable and generally cooperative.
Data doesn't seem to demonstrate significant benefits to spinal though. So LMA is definitely we easier. I'll usually thrown in a fascia iliaca block too
unless contraindicated, we do spinals +/- fascial iliaca block.
2.5ml isobaric bupivicaine. +/- pressors infusing depending on patient.
what do you like to induce with for your LMAs for these low EF patients?
Not that it’s really the point, but I find that’s way more isobaric bupi than most of these nails need, and definitely way more than they need if they have a regional block also.
And I’m not OP, but I give these old people 25 of fent as soon as we hit the OR, then 20mg increments of propofol q1m (it’s a long time when you’re actually waiting) until I see the first sign of muscular relaxation in their face, or their eyes become heavy. stop giving propofol. Now wait longer, perhaps another 1-2 minutes. They’ll accept the LMA fine.
Remember, peak neuro effect of propofol in healthy patients with normal EF is about 90 seconds. In these folks it’s longer, often on the order of 3-4 minutes. We just get in the habit of rushing.
I find that the small increments given with good spacing cause substantially diminished CV response. Yes, they’ll probably need something, but even if you give them 60mg total over 3+ full minutes, they are often much more stable than 40-50mg given as a bolus.
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I use 1ml in elderly
I do a TKA with 1.5ml plus 25mcg fent and a prop gtt. Pt moving legs in pacu and ready for rehab
My cut off is about 55%, 60 to be sure...
There is no proven benefit to spinals outside of GA section... and with glidescope im sure the difference has closed a lot if studies were redone
There is no proven benefit to spinals outside of GA section... and with glidescope im sure the difference has closed a lot if studies were redone
Prop, fent, lido, neo 1/kg, lma and fi
for tka i use mepi
for tka i use mepi
Seeing several chf patients in training (not just mine) go into acute exacerbation, after vasodilating 50% or more of their body with a spinal, was enough to prove to me that a GA is often the “path of MORE resistance” (hemodynamically speaking), and the “better” anesthetic for those patients. I don’t like spinals in folks with EF issues. Yeah, yeah....you’ve got some “secret sauce” spinal that works great....
I do my best to keep stable patients “stable”, and try not to make simple things “complicated”. General anesthesia for me, unless the patient has some sort of serious pulmonary issue that makes me want to keep them off a vent.
(This study will tell you the BP drop is due more to a CO, rather than SVR drop. Either way, I still feel a general anesthetic gives me more hemodynamic stability...)
www.ncbi.nlm.nih.gov
I do my best to keep stable patients “stable”, and try not to make simple things “complicated”. General anesthesia for me, unless the patient has some sort of serious pulmonary issue that makes me want to keep them off a vent.
(This study will tell you the BP drop is due more to a CO, rather than SVR drop. Either way, I still feel a general anesthetic gives me more hemodynamic stability...)
Spinal anesthesia-induced hypotension is caused by a decrease in stroke volume in elderly patients - PMC
Hypotension is common during spinal anesthesia (SA) and is caused by a decrease in systemic vascular resistance (SVR) and/or cardiac output (CO). The effect of the dose of bupivacaine administered intrathecally on the changes in CO in elderly ...
www.ncbi.nlm.nih.gov
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surgerty length too variable here
Whenever I do anesthesia for TAVR, I carefully auscultate their heart with my stethescope so I am more sensitized to picking up a subtle AS murmur which would be a hard stop to considering a spinal. I also look for signs of dehydration which would lead me to do GA versus signs of fluid overload which would push me in the direction of a spinal. My choice is dependent on the patient and the surgeon but I am doing more general for hip nailings. During the early days of COVID I was doing everything to push spinals.
50mg lidcoaine + 25-50mg propofol + 2 full minutes of circulation time
Agree that’s way too much isobaric. No offense but this is something that might fly in residency, but when you’re in private practice and on your 7th case for the day, no one really does this. Guaranteed the surgeon will make fun of you in the break room for giving homeopathic doses of prop and staring at the screen for 6-8 minutes. Just give a little more propofol, nothing dangerous, and chase it with some phenylephrine. The LMA will seat better because the patient will be more relaxed. Half of your propofol is being redistributed by the time you’re placing the LMA and there’s the chance the patient might buck and cough. Not to mention desat during that timeframe because those patients are usually poor at preoxygenating.
can just give 20 of sux and use prop for amnesia
I don’t use paralytics and LMAs together. I know some do when having trouble seating the LMA. At that point I just put an ETT in and call it a day.
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If they're sick, you can do FI block+MAC. I've done some of these cases with just FI block and some sedation. Precedex, ketamine, 30-40 prop gtt
why not? i do it frequently
there is no evidence it causes any problems
later generation SGA have gastric ports to vent if you are worried about insufflating stomach
I do these cases with ETT now. Had a bad experience where patient filled up the LMA with what looked like pea soup. Turns out the airway is not so easy to access with the OR table at neurosurgical height and the arm taped over the face and everything draped. Now it’s just 50 prop 50 fent and 50 roc
Sorry your issue is with SGA in general? Or with SGA and muscle relaxants?
Just for this particular case. The way the (small) OR is set up makes things relatively inaccessible. Need to have room for C-Arm, screen, radiology tech, equipment rep. Sometimes the anesthesia stuff just gets shunted to the side. Also, as previously mentioned, the patient position makes the airway had to get to quickly. No benefit that I see for SGA vs ETT in this case…
I've actually never used one of those SGAs, they sound nice. But I don't think paralytics and LMAs go together; I would rather have a definitive airway in a paralyzed patient. I just don't see the benefit. I also don't like to controlled ventilate through LMAs, I would rather have the patient breathe on the bag or with PSV. I don't like freely giving succ to patients either unless there's an indication. Just my cup of tea.
D
deleted875186
I second general anesthesia for a lot of these, I ask like LMAs. While I will dose the propofol 20-30 mg at a time, usually ever 30-60 seconds for patients with cardiomyopathy or low EF with clinical heart failure, I don’t do this for older people necessarily if decent heart function, just give an appropriate dose along with vasopressor. If patient is sicker I might have norepinephrine push rather than phenylephrine.
I do prefer spinals if patients are very confused but not combative, I think it helps the mental status to avoid GA. I’ve done some hips with zero sedation, patient just a little confused and hypoactive delirium, some can lay still for the whole procedure with a spinal.
I do prefer spinals if patients are very confused but not combative, I think it helps the mental status to avoid GA. I’ve done some hips with zero sedation, patient just a little confused and hypoactive delirium, some can lay still for the whole procedure with a spinal.
even the easiest most straightforward spinal has the potential to be patchy or inadequate a certain percentage of the time..
putting one of these "pleasantly" demented people on the hip table awake with no sedation is really relying on everything going smoothly
i can see the scenario where they feel some pressure or a twinge of pain and that "pleasant" delirium changes to a freak out and then a propofol bolus and surgeon complaining..
i put 99% of these to sleep with an LMA and the more frail they are the more likely i am to breath them down with sevo, stick in an LMA.
You can do a 3 in 1 nerve block plus or minus sedation.
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Having to give prop, precedex, and ketamine seems more cumbersome and not any more hemodynamically stable than just slipping in an LMA and running 1.2 of sevo
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Ahh, the magical block!
How are you doing spinals on these people? They usually have quite a bit of discomfort and usually need a team of people to have them sit forward after I give a little ketamine and fent to help with the discomfort when I try spinal.
D
deleted875186
This is what I do. In fact I find older people are the only ones who can actually tolerate this. If you have a hip fracture in a “younger” fifty or sixty year old, I may not even try a spinal because positioning is such a challenge with pain.
Exactly this.
ketamine 15 and lateral
Fracture side or non?
Personally isobaric bupi and fracture side up to minimal pain
Do you bend leg?
Respectfully disagree on all counts. This adds a modest amount of time. I am in a busy PP with decent acuity, and no surgeon is going to give me **** when I tell them a plan for a patient like we’re discussing with a severely depressed EF. Standard old person, sure, just get on with it. Anyway, different strokes.
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Fracture side up to minimize pain
You can use 2 cc of isobaric bupi or 2% mepi
That's probably more than you need tbh but that's what I like
You can use 2 cc of isobaric bupi or 2% mepi
That's probably more than you need tbh but that's what I like
D
deleted87051
Fracture side down is supposed to be less painful. Takes away the gravitational component.
100 fent, 50 prop, 50 roc, 100 phenyl.
Then i take a 25 sprotte and place it between the anesthesia cart and the mayo stand*...
Then i sit down for quite a while and continue buying nonsense off amazon. I have quite a stockpile
* this area is our sharps bin
Great job practicing, but I wouldn't call anyone getting a TAVR a "subtle AS murmur"
Fracture side up, especially if the surgery will be done in lateral position.
50 prop and 30 ketamine, then move over to the OR bed in lateral position. Spinal in and patient is already in position for prep and drape.
Spinal usually in before propofol wears off
Is there a big difference in how much gravity you feel 1 foot away?
They are saying that the fracture pain is worse if the fractured lower extremity side is up and has to sag down to the bed thus causing more movement at the fracture site. I think either side is equivocal after propofol and ketamine.
Plus, I prefer them sitting up legs crossed indian style so that the spinal is easier
got a ef 10% add on today for fracture. reminded me of this thread ha!
The fracture essentially makes them double jointed, so cross-legged sitting position should be much easier. Patients can’t really use the excuse that they’re not flexible enough.
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