Reduced EF and spinal anesthesia

[dannyboy1]

Great job practicing, but I wouldn't call anyone getting a TAVR a "subtle AS murmur"

Of course I would never do a spinal in AS patients. I’ve always wondered why the decreases SVR from GA is preferred to the decreased SVR from spinal….

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[Arch Guillotti]

Of course I would never do a spinal in AS patients. I’ve always wondered why the decreases SVR from GA is preferred to the decreased SVR from spinal….

Have done many spinals on patients with mild AS and never had a problem.

 

[Arch Guillotti]

Of course I would never do a spinal in AS patients. I’ve always wondered why the decreases SVR from GA is preferred to the decreased SVR from spinal….

I have never bought into it but spinal is not reversible whereas ga is “titrateable”

 

[Urzuz]

So much easier to just do a block + general than messing with spinals for these patients.

Especially since the REGAIN trial (https://www.nejm.org/doi/full/10.1056/NEJMoa2113514), I’ve stopped doing spinals regularly unless there is a compelling indication.

Fascia iliaca block + LMA with 0.5 MAC sevo (or less) + phenylephrine infusion. Easy peezy. Even the 90 year olds will be awake and back to their baseline within ten minutes of being in PACU.

 

[epidural man]

Lol this is a great question . What a breathtaking failure of critical thinking and lack of understanding.

Teach us.

 

[GassYous]

Teach us.

Well 10% is not 10%. Is it well compensated? Is it reduced and dilated? Is it acute or chronic? Is it due to loading conditions? The TTE is just a snapshot of one point in the patient's condition. We all know that patients are dynamic, especially under anesthesia and with the stress of surgical insult.

 

[deleted875186]

Well 10% is not 10%. Is it well compensated? Is it reduced and dilated? Is it acute or chronic? Is it due to loading conditions? The TTE is just a snapshot of one point in the patient's condition. We all know that patients are dynamic, especially under anesthesia and with the stress of surgical insult.

Sure we understand this, but in most cases cardiomyopathy with LVEF 10% isn’t going to improve significantly with optimal medical management, unless the echo was take during acute heart failure from cardio genie shock for some reason. 10% EF is pretty much always going to mean severe heart failure.

 

[GassYous]

Sure we understand this, but in most cases cardiomyopathy with LVEF 10% isn’t going to improve significantly with optimal medical management, unless the echo was take during acute heart failure from cardio genie shock for some reason. 10% EF is pretty much always going to mean severe heart failure.

The point that poster was trying to make is that ef isn't just a number that you can have a hard cutoff for. You can't really say oh 40% is ok for spinal but 30% isn't.

 

[PpfSuxTube]

Of course I would never do a spinal in AS patients. I’ve always wondered why the decreases SVR from GA is preferred to the decreased SVR from spinal….

You almost definitely have, we all have and didnt know it.

And why not. There are cardiac centres that do total spinals for their surgical avrs... ive not done it, seema like a production but it seems to go fine.

Spinals arent the problem with AS. Decr svr is...

 

[nimbus]

Sure we understand this, but in most cases cardiomyopathy with LVEF 10% isn’t going to improve significantly with optimal medical management, unless the echo was take during acute heart failure from cardio genie shock for some reason. 10% EF is pretty much always going to mean severe heart failure.

I have seen people who have gone from 15-20% to 40% with CRT.

 

[deleted875186]

I have seen people who have gone from 15-20% to 40% with CRT.

Sure, CRT has evidence that it improves EF and heart failure symptoms, but only if patient has a low EF and IVCD, even then the improvement is usually modest, yojr case is quite extraordinary. The dude with AF and cardiomyopathy isn’t going to get better.

 

[nimbus]

Sure, CRT has evidence that it improves EF and heart failure symptoms, but only if patient has a low EF and IVCD, even then the improvement is usually modest, yojr case is quite extraordinary. The dude with AF and cardiomyopathy isn’t going to get better.

Thought we are just talking about folks with low EF.

Great thing about EPIC is that it’s easy to find all the old echos. It’s not that rare.

In this study, highest quartile of patients had LVEF improve by 17%.

https://www.ahajournals.org/doi/full/10.1161/circulationaha.113.006124

 

[deleted875186]

Thought we are just talking about folks with low EF.

Great thing about EPIC is that it’s easy to find all the old echos. It’s not that rare.

In this study, highest quartile of patients had LVEF improve by 17%.

https://www.ahajournals.org/doi/full/10.1161/circulationaha.113.006124

Anyone with low EF and CHF has seen a cardiologist and been assessed if CRT is indicated. In fact most will see their cardiologist for clearance before their elective surgery for a spinal block. Maybe hip fracture is the exception, but for the most part spinals are elective surgery. So I don’t usually ever see a situation where I can say “EF is low, but maybe it’ll get better after a dual chamber pacer is placed by the cardiologist before this surgery”. Also, the only population for CRT is low EF with an IVCD and clinical heart failure class 3 or 4 I beleive, not every low EF patient.

 

[dchz]

What is your cut off for spinals in patients with reduced EF? At what LVEF would you think general is a safer option than spinal for electric ortho cases?

I feel like absolute statements like these oversimplify the complexity of physiology and the cardiovascular system in general. No one method of anesthesia is safer than the other. Like @vector2 said below, it is way more nuanced than just the EF.

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.

got a ef 10% add on today for fracture. reminded me of this thread ha!

It'll be 20% once they lose some blood!! and 10% of 300cc ventricle is still 30ccs per beat.

Of course I would never do a spinal in AS patients. I’ve always wondered why the decreases SVR from GA is preferred to the decreased SVR from spinal….

What's wrong with doing spinal in AS pts? SVR decrease is SVR decrease, neither the heart nor the anesthesiologist should care about what modality of anesthesia it came from. As long it's treated appropriately, it shouldn't be affected by the modality of anesthesia.

Sure, CRT has evidence that it improves EF and heart failure symptoms, but only if patient has a low EF and IVCD, even then the improvement is usually modest, yojr case is quite extraordinary. The dude with AF and cardiomyopathy isn’t going to get better.

That's absurd, plenty of people with a fib and cardiomyopathy get better after the tachycardia is controlled.