too cautious?

[Skrubz]

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so here's a case that i faced yesterday...

60-ish vet scheduled for urgent/semi-emergent surgery for retinal detachment, GA required per ophtho resident. hx of diabetes, HTN and standard VA stuff... except that he tells me he gets short of breath when walking up the stairs in his split-level house, plus "occasionally passes out with strenuous activity". last syncopal episode 2 years ago. no chest pain.

no murmur on exam, no carotid bruits. P-thal from 2 years ago totally normal. has an old echo from 10 years ago that shows LVH but normal valves.

i'm feeling a little uncomfortable at this point. yeah, he doesn't have a murmur and he has normal valves and no septal hypertrophy on a 10-year old echo. but syncopal episodes with exertion? the main thing i'm concerned about is the possibility of undiagnosed AS... i talk with one of my attendings (our VA attendings are really conservative) and he agrees with me that despite the normal exam, we should get an echo because on the off chance that the patient has AS, we could kill him on induction if we don't know about it.

the surgeons are riding my @$$ all day as i negotiate with cards to get the echo done, which turns out to be completely normal.

what do y'all think? too conservative? should i have bothered getting the echo?

 

[nimbus]

Not too careful at all. Retinal detachment is not an emergency (unless it's Friday). Syncope with exertion is a big red flag for me too. Don't care about a murmur, you need to know if he has tight AS. Too bad it took all day to get a simple echo. That is why I hated the VA. Sometimes you need to trust your intuition. You did the right thing. Your surgeons should be grateful for keeping EVERYBODY (patient, you, them) out of trouble.

 

[Planktonmd]

so here's a case that i faced yesterday...

60-ish vet scheduled for urgent/semi-emergent surgery for retinal detachment, GA required per ophtho resident. hx of diabetes, HTN and standard VA stuff... except that he tells me he gets short of breath when walking up the stairs in his split-level house, plus "occasionally passes out with strenuous activity". last syncopal episode 2 years ago. no chest pain.

no murmur on exam, no carotid bruits. P-thal from 2 years ago totally normal. has an old echo from 10 years ago that shows LVH but normal valves.

i'm feeling a little uncomfortable at this point. yeah, he doesn't have a murmur and he has normal valves and no septal hypertrophy on a 10-year old echo. but syncopal episodes with exertion? the main thing i'm concerned about is the possibility of undiagnosed AS... i talk with one of my attendings (our VA attendings are really conservative) and he agrees with me that despite the normal exam, we should get an echo because on the off chance that the patient has AS, we could kill him on induction if we don't know about it.

the surgeons are riding my @$$ all day as i negotiate with cards to get the echo done, which turns out to be completely normal.

what do y'all think? too conservative? should i have bothered getting the echo?

If he has Aortic stenosis would you send him for aortic valve replacement before fixing his retinal detachment?
Why do you think you would "Kill him on induction"?
Anyone who has bad enough Aortic stenosis to cause syncope would not have a negative stress test.

 

[Masseter Spasm]

I rarely do ophtho cases. Why did the surgeons insist on GA? My experience during residency was that they rarely requested GA--despite the reality that ophtho cases in an academic center are prolonged/tedious. (I am sure all residents/attendings can recall providing MAC for 2 hour cataracts in ASA 4 patients.)

My father recently needed a procedure for an acute retinal detachment. The procedure was done urgently in an office. My father is fairly healthy and recalls being "awake" during the procedure. (I doubt he received any anesthesia other than local or regional block by the ophthalmologist)

Given the situation, however, I agree with you Skrubz. I had a somewhat similar situation when I rotated through my residency's pre-operative clinic. I saw a similar patient presenting for a craniotomy for tumor. He described non-specific symptoms like Dyspnea on exertion, fatigue, etc.. He had a classic systolic ejection murmur on exam. No cardiac studies had ever been performed. I saw him at 4:30 p.m. and his surgery was scheduled for the next day 7:30 a.m.. Somehow I got the ECHO done and it was normal. (The patient actually had to go to another hospital for the study.) The patient got the procedure and did well post-operatively.

 

[milrisome]

First, I'd like a little more info, like what else was going on two years ago with the last syncopal event. If there was a work-up (and it seems there might have been with the stress test done about the same time) maybe another cause was found. Also, are there risk factors for AS, such as HTN, hypercholest, CAD?

Secondly, with no murmur, the AS has to be very bad--so bad that there's not enough blood ejected to make enough noise for you to hear it. If it's that bad, I doubt he could even climb one flight of stairs. And they probably would have heard a murmur 2 years ago.

I would have proceeded. Looking at the ACC/AHA guidelines, unless there is severe valvular disease, pt's can go to the OR and have post-op management for their cardiac problems.

 

[GeddyLee]

I too would wonder they they "need" GA. My experience has been that any procedure for RD would be amenable to a retrobulbar block and minimal sedation. This would have at least saved the aggravation...not to mention the cost of an echo. Even with a normal echo, why the heck is this guy having syncopal episodes with exertion?? I'd still be wary of GA in this patient even with the normal echo....so I'd probably still want to do this as a MAC.

 

[Noyac]

IF he has AS are you not going to do the case? He needs his retina fixed. Sure it can be done under MAC or regional but the surgeons say they can't do it that way. Have them put a note in the chart stating that they must have GA for the case. It may not help you completely if something goes wrong but you never know. Now if you are convinced that he has AS document your concerns and plan (postop cardiac workup) and treat him as him has AS.

What if the guy sues you b/c you wouldn't proceed without the echo and unfortunately he is blind now b/c it took too long to get the echo which showed no AS after all. Its possible. Maybe he has an arrhythmia instead of AS that is causing his syncope and SOB.

 

[UTSouthwestern]

First, I'd like a little more info, like what else was going on two years ago with the last syncopal event. If there was a work-up (and it seems there might have been with the stress test done about the same time) maybe another cause was found. Also, are there risk factors for AS, such as HTN, hypercholest, CAD?

Secondly, with no murmur, the AS has to be very bad--so bad that there's not enough blood ejected to make enough noise for you to hear it. If it's that bad, I doubt he could even climb one flight of stairs. And they probably would have heard a murmur 2 years ago.

I would have proceeded. Looking at the ACC/AHA guidelines, unless there is severe valvular disease, pt's can go to the OR and have post-op management for their cardiac problems.

I would argue that no murmur means no or very mild AS. As a person with AS develops worsening stenosis, the murmur should increase markedly, not decrease to nothing. Think flow through a big straw versus flow through a pinhole. Which one will generate more turbulent flow?

This patient has longstanding hypertension and likely compensatory LVH. He is likely also overweight and poorly conditioned. If he overexerted himself (yes even in the brutal weather of Palo Alto), he may have passed out from exhaustion. If no history suspicious of arrythmia, uncontrolled diabetes, or other coexisting conditions exist, a 2 year old history of syncope without angina or significant change in exercise tolerance in the past six months, you probably could have forgone the echo.

Also, consider doing a poor man's stress test: walking down the preop area hallway or squatting and rising several times (if the patient is able to do so) and repeating your physical exam looking for too rapid a heart rate, an enhanced murmur, changes on the EKG or telemetry readout, etc.

In the end, however, if you have the suspicion and feel that a more in depth procedure is necessary to evaluate the patient, don't feel bad that you erred on the side of caution.

 

[Planktonmd]

I would argue that no murmur means no or very mild AS.
.

The murmur's intensity does not correlate with the severity of the stenosis, and the murmur decreases and could disappear at the final stages of severe aortic stenosis, these are the patients who are going to die and might not even benefit from valve replacement, we rarely see this type of patient these days and you don't need a murmur to diagnose them, they are usually very symptomatic ( CHF, Angina and Syncope).

 

[UTSouthwestern]

The murmur's intensity does not correlate with the severity of the stenosis, and the murmur decreases and could disappear at the final stages of severe aortic stenosis, these are the patients who are going to die and might not even benefit from valve replacement, we rarely see this type of patient these days and you don't need a murmur to diagnose them, they are usually very symptomatic ( CHF, Angina and Syncope).

The murmur's intensity does correlate with the severity until decompensation. As you said, at that point the patient would be in florid heart failure and extremely symptomatic, which this patient is not experiencing.

In my practice, I see this type of patient at least weekly for AVR or percutaneous aortic valvuloplasty, usually the latter. Even those who are decompensated and in florid failure still have a significant murmur, although the cardiologists will tell you that it has decreased leading up to the procedure, correlating with impending or active failure.

 

[milrisome]

So either he has horrible AS and no murmur or minimal to no AS and no murmur. That's what I was trying to say. In a guy who can go up the stairs in his house I doubt he's got horrible AS.
The question still remains as to why the syncope? You have to go back and find out what was going on 2 years ago.

 

[UTSouthwestern]

So either he has horrible AS and no murmur or minimal to no AS and no murmur. That's what I was trying to say. In a guy who can go up the stairs in his house I doubt he's got horrible AS.
The question still remains as to why the syncope? You have to go back and find out what was going on 2 years ago.

You are correct. If the guy was moving furniture all day long or working outside on his car all day long, in the summer time, that might answer the question right there, given his comorbidities. I'd look into arrythmias, but an interval of two years without any episodes or worsening of his exercise intolerance would make me less concerned about his CV status at this time.

 

[coprolalia]

Well, my first thought was aortic tract outflow obstruction (like HOCM). But, you said he had no septal wall abnormalities. And usually HOCM has a murmur too.

What was the reason they wanted to do this under GA? We typically use midazolam and an alfetanil "stun" when the opthamologist places the retrobulbar block. After that, it's pretty much smooth sailing.

copro, CA-2