spinal in low ef
Started by anbuitachi
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deleted697535
What case?
I don't think id give this guy a spinal. 150 mins is too long.
If i had to would do cse with maybe 8mg isobaric, aline, phenyl drip. Dob or something around too
I don't think id give this guy a spinal. 150 mins is too long.
If i had to would do cse with maybe 8mg isobaric, aline, phenyl drip. Dob or something around too
prostate resection
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No personal cutoffs as long as they can lay flat (functional test to show me the change in pre load doesn't knock them over the edge). Your spinal only decreases afterload which makes forward flow better.
Aside: It's also kinda silly to have a hard number cutoff if you know how much inter-echocardiographer variance there is with the number you get for EF. Or even how much EF can change with the same person give different stimulus during a procedure.
Spinal for NICM is better than Spinal for ICM, as their coronaries are not the problem.
Fwiw I should mention it's not any safer for spinal vs general. In fact, it's much harder to take away the anesthetic in a spinal. In an emergency, spinals are inherently less safe than general because you have the extra step of inducing general anesthesia before you get to controlled resuscitation.
Turp or open?
would not do a spinal on this guy
Even if the EF was 60 I would not do a spinal for this case - GETA
What's the evidence anyway that neuraxial anesthesia is any worse than GETA in HFrEF?
I don't care as much about the number as the functional status. Can the patient lay flat without getting short of breath? Are they volume or sodium overloaded? How's their pulmonary pressures? etc.
The time doesn't matter as a good dose of isobaric can last 3-4 hours easily.
The time doesn't matter as a good dose of isobaric can last 3-4 hours easily.
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Have never done spinals for prostate surgeries myself. I think low ef isn’t necessarily a contraindication to spinal though. They are likely going to be more prone to hypotension than a normal heart, but this can be countered with vasoactive infusion. I guess being stuck on a vasoactive infusion in PACU due to a spinal would not be fun though.
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15 mg isobaric. No problem. Neo if needed.
I probably would put the guy to sleep though.
I probably would put the guy to sleep though.
Maybe can get away with 120 minutes.
It's a TURP. If I do spinal I can avoid extubation and just wheel him out.
Was thinking of just doing 12.5mg with epi and phenylephrine infusion
It's a TURP. If I do spinal I can avoid extubation and just wheel him out.
Was thinking of just doing 12.5mg with epi and phenylephrine infusion
D
deleted697535
That can last hours. Like crazy variabilty. My fellow got 6 hours out of 15mg for a hip recently. Very similar patient for hip #. I begged him to do GA but anyways
could do epidural so the sympathectomy could be a bit more gradual. plus can redose.
Have done isobaric with low EF 20-30%, whiff of epi or ephedrine after spinal, no issues
Quite a difference between ef 20 and ef 30
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Why not epidural if you really want to avoid geta
Is it though?
I would do 1.75 ccs 0.5% isobaric bupivicaine. Little effect on hemodynamics (assuming mild RV dysfunction), would definitely last 2.5 hours.
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LV ejection fraction comes nowhere close to telling the whole story about someone's cardiac function. There are plenty of 20%ers who are compensated and just fine, and there are just as many 35%ers currently hospitalized for a decompensated exacerbation. The important questions are:
1. What is their baseline cardiac output? An LVEF of 20% is fine if the diastolic volume is huge (as tends to be the case with the eccentric hypertrophy that comes with longstanding cardiomyopathy), the heart rate is adequate, and they don't have severe regurgitant lesions.
2. How are the other organs? Red flags and signs of badness that go along with a low EF are wet lungs, chronic cardiorenal syndrome, and congestive hepatopathy.
3. What is the pt's functional status and their NYHA class? It's silly to say a low EF can't get a spinal if they have prior demonstrated cardiopulmonary reserve. Furthermore, much of the sympathectomy physiology is beneficial for HFrEF. Venodilation improves congestion while afterload reduction improves stroke volume...
1. What is their baseline cardiac output? An LVEF of 20% is fine if the diastolic volume is huge (as tends to be the case with the eccentric hypertrophy that comes with longstanding cardiomyopathy), the heart rate is adequate, and they don't have severe regurgitant lesions.
2. How are the other organs? Red flags and signs of badness that go along with a low EF are wet lungs, chronic cardiorenal syndrome, and congestive hepatopathy.
3. What is the pt's functional status and their NYHA class? It's silly to say a low EF can't get a spinal if they have prior demonstrated cardiopulmonary reserve. Furthermore, much of the sympathectomy physiology is beneficial for HFrEF. Venodilation improves congestion while afterload reduction improves stroke volume...
chronic ef 20 last year too. nyha 3. not in acute decompensation
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deleted87051
It depends. If they have dilated cardiomyopathy with a huge LV, they can still generated a decent stroke volume and CO with a low EF. I’m frequently impressed how stable these patients are.
With Mets < 4, symptomatic, concomitant RV failure as you say in the OP and coming for a TURP I’m just gonna put the guy to sleep.
I’m not worried about the spinal. It’s the 2.5hr MAC that I don’t want to deal with it.
Ya GA all day long for me. Ef 10% or 65%.
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I am regional heavy when I can be, but this is one case I just don’t use it.
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deleted697535
Its interesting, we have a lot of regionalists in my dept that want to "save people from a GA". Far healthier than this guy. Direct quote. Then a crock like this comes along and they all do GA...
Or even better cancel the case til a cardiac guy is around to do GA
why not?
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deleted697535
Because you cant titrate it.
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deleted697535
I think so not sure. We dose our spinals using 4 separate injections. 2.5mg q10mins
I do four separate needle passes, that way you can bill for 4 spinals 😎
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