Well compensated heart failure: numbers vs. function

[Laurel123]

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Just wanted to get everyone's thoughts on this case.

40 yo male for umbilical and gigantic inguinal hernia repair. Past medical history includes a cardiac arrest in 2002 when he was found to have a severe dilated cardiomyopathy and an AICD and pacer was placed. History of alcohol abuse, now stopped. His recent checkup six months ago showed he continues to have severe dilated cardiomyopathy with an EF of 10%. He is paced at 75 and is able to walk around doing daily house activities and can even walk up one flight of stairs at a normal rate. He feels well. He is on an ACE, amiodarone, lasix. How would you manage?

 

[dhb]

strait epidural

 

[VentdependenT]

Just wanted to get everyone's thoughts on this case.

40 yo male for umbilical and gigantic inguinal hernia repair. Past medical history includes a cardiac arrest in 2002 when he was found to have a severe dilated cardiomyopathy and an AICD and pacer was placed. History of alcohol abuse, now stopped. His recent checkup six months ago showed he continues to have severe dilated cardiomyopathy with an EF of 10%. He is paced at 75 and is able to walk around doing daily house activities and can even walk up one flight of stairs at a normal rate. He feels well. He is on an ACE, amiodarone, lasix. How would you manage?

1)See if surgeons can do it local.

2)Epidural is a good idea. If he's not in liver failure. Would you bother checking coags or LFT's before hand. I'd say sure. His ETOH abuse was bad enough to take his heart out....why not the liver too?

3)Single Shot Spinal would work as well. But remember that it can take this dude's pressure out. I'd stick with isobaric bupivicaine with some fentanyl. Shoot for L2-3 level I suppose. I'd take an epidural over a spinal though.

4)Hes Class II CHF. Pretty damn good for that low of an EF. I'd like to avoid putting him to sleep for this if I could. If I did, he'd get an a-line. Have some inotropic support in the room. Phenylephrine would be a BAD idea. Ephedrine is a GOOD idea. He may need a little nitro at the end for extubation. I've had to put people like this to sleep before...kinda blows but its good experience.

There is no reason that a good surgeon cannot do this case under local. Many ways to go at this as you can see.

Does this dude have an AICD?

 

[bigdan]

an AICD and pacer was placed

Yep.

dc

 

[Noyac]

I'd probably put an LMA in him.

2 hernia's and one of them being umbilical. Unless the umbilical is really small, the surgeon is going to need to use a boat load of local (possibly in the toxic range). The repairs are never as good when done under local (if I remember right the best repairs are under general for some reason, may be wrong) and you don't want to have to do him next year again when he is in worse shape.

 

[Laurel123]

Yeah, just curious as to how different people would approach a patient who has terrible numbers, but decent function.

I actually did this case last week. First, the inguinal hernia looked like he had a softball in his scrotum. It was sore and huge and I didn't think local would be the option. The surgeon is a great surgeon too. Then, he also had an umbilical hernia too that was a decent size. He was on plavix and aspirin, though I think he had stopped them for a couple of days. Anyways, I ruled out local. I didn't want to do a spinal. And I think an epidural would have been decent idea, but it would have to be a pretty high level to cover the umbilical hernia. Plus, I feel that a patchy local or epidural would be more stressful on the patient than a general anyways.

Anyways, I did GETA. No A-line. Turned off the AICD until bovie was done.

 

[huktonfonix]

with the information that he was on aspirin AND plavix and had held them for a couple of days there is no way Im doing any sort of neuraxial block on him.