Case discussion

[Katheudontas parateroumen]

70ym has stable c spine fracture (don’t remember the details but neurosurgery wants in Miami J at all times and to revisit outpatient in a few months kind of thing). Presents with cardiogenic shock from critical Aortic stenosis. On low dose NE, BP 90/60s but not intubated. Let’s say cardiologists wants to do a TAVR, your choice as to general vs MAC.

Would you do general upfront (AFOI) or do MAC? If MAC, how worried would you be to emergently intubate someone with a high risk procedure and possible difficult airway? And related, what are your risk/benefit for MAC sedation cases in patients with known difficult airways? Would you just intubate them ahead of time instead?

For this case I planned towards general given his shock state already.

This is a semi hypothetical case. No right answers. Just wanna see thoughts from everyone.

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[DrOwnage]

Not cards trained, but I did a good amount of TAVRs in training. Sounds like low dose precedex and propofol MAC to me. Also why norepi?

 

[patriot6]

Going to sleep. I don't want to have to manage BOTH hemodynamic instability and a difficult airway when his cardiogenic shock progresses. I would want to know more regarding his c-spine fracture. Cord compression? High fracture? Myelopathic symptoms? AFOI is not the wrong answer, but if I'm not too terribly concerned about his c-spine, I'd consider an asleep FOI or Glidescope with manual-in line.

 

[Twiggidy]

This really depends on the "eye test" of the patient. Are they kind of a chill 70 year old or a highly anxious 70 year old. If they former, a good conversation and plenty of local anesthesia for the groin access with a touch of propofol (and I mean like 1 or 2 cc). The most painful part is getting groin access which can be done with a generous amount of local and when the percutanous close at the end and hopefully vitals improve with a valve that is opening. If they're the later it's likely a FOB (depends on physical exam) which really is unfortunate because again, in the correct hands this TAVR really only takes like 30 mins.

I would do my best to do this with light MAC.

 

[ERRES2288]

Would this patient even be candidate for TAVR? I’ve never done one in a patient with active cardiogenic shock on vasopressors.

If cards persisted, I’d put patient to sleep which would also allow use of TEE

 

[GassYous]

I would do a thorough history and physical, look at old anesthesia records, give aspiration prophylaxis, hob 30 degrees, preox 3 minutes, airway blocks, awake fiberoptic removing the front of the c collar and maintaining manual in line stabilization but avoiding cricoid pressure to avoid worsening cervical spine disease. Use etomidate for hd stability and roc after the tube is in.

That's for the boards, I also did a bunch in residency and everyone did fine with a precedex/prop mac.

 

[DrOwnage]

Is it physically possible to do a TAVR if you have to crash onto bypass?

 

[Silo004]

Would this patient even be candidate for TAVR? I’ve never done one in a patient with active cardiogenic shock on vasopressors.

If cards persisted, I’d put patient to sleep which would also allow use of TEE

Man they don't stop TAVRs for anything.

That said, assuming that the patient doesn't have another reason for being hypotensive -- thinking infection here, mainly -- I would go to sleep with pre-op art line and attempt slow inhaled induction with boluses of alfentanil for comfort, glidescope advanced as tolerated and then roc when I see cords.

AFOI seems ... like an adventure. And you haven't said anything to me about is airway that precludes a look with glide.

Does pt have hx of difficult intubations?

 

[Twiggidy]

Is it physically possible to do a TAVR if you have to crash onto bypass?

Crashing on to bypass should be in the back of everyone's mind when doing a TAVR, even in a "normal" TAVR patient.

 

[vector2]

Going to sleep. I don't want to have to manage BOTH hemodynamic instability and a difficult airway when his cardiogenic shock progresses. I would want to know more regarding his c-spine fracture. Cord compression? High fracture? Myelopathic symptoms? AFOI is not the wrong answer, but if I'm not too terribly concerned about his c-spine, I'd consider an asleep FOI or Glidescope with manual-in line.

I think it's unlikely he's got significant cord compression or myelopathy if OP says NSGY thinks they can sit on it for months and revisit it as an outpatient. If the rest of the airway is OK I'd just be using a glide or a mcgrath.

70ym has stable c spine fracture (don’t remember the details but neurosurgery wants in Miami J at all times and to revisit outpatient in a few months kind of thing). Presents with cardiogenic shock from critical Aortic stenosis. On low dose NE, BP 90/60s but not intubated. Let’s say cardiologists wants to do a TAVR, your choice as to general vs MAC.

Would you do general upfront (AFOI) or do MAC? If MAC, how worried would you be to emergently intubate someone with a high risk procedure and possible difficult airway? And related, what are your risk/benefit for MAC sedation cases in patients with known difficult airways? Would you just intubate them ahead of time instead?

For this case I planned towards general given his shock state already.

This is a semi hypothetical case. No right answers. Just wanna see thoughts from everyone.

These kind of scenarios are usually of more utility if you provide a bit more info. As you know there's more factors to consider beyond just the c--spine and "AS" "90/60" "low dose NE" when deciding what to do. Twig alluded to the "eye test" here. Beyond the anxiety component vis a vis a MAC, what's the gestalt you get about how "sick" the patient is when you look at him. Is he on O2? Are his lungs wet? Can he lie flat? What's the mixed venous or the lactate? Is he peeing? Is he in cardiogenic shock because his organs and extremities are truly being malperfused or did someone see a SBP of 88 and history of AS and de facto call it cardiogenic shock? Does he have other valvular lesions, pHTN, or RV failure? How bout CAD?

There's a lot of calculus that goes in to how best to anesthetize this guy for a perc BAV or emergent TAVR...

 

[Hoya11]

70ym has stable c spine fracture (don’t remember the details but neurosurgery wants in Miami J at all times and to revisit outpatient in a few months kind of thing). Presents with cardiogenic shock from critical Aortic stenosis. On low dose NE, BP 90/60s but not intubated. Let’s say cardiologists wants to do a TAVR, your choice as to general vs MAC.

Would you do general upfront (AFOI) or do MAC? If MAC, how worried would you be to emergently intubate someone with a high risk procedure and possible difficult airway? And related, what are your risk/benefit for MAC sedation cases in patients with known difficult airways? Would you just intubate them ahead of time instead?

For this case I planned towards general given his shock state already.

This is a semi hypothetical case. No right answers. Just wanna see thoughts from everyone.

I would intubate this guy with a glidescope. He goes to the ICU intubated.

Anesthetic is sevo and roc and fentanyl. Airway is controlled.

 

[nimbus]

I would intubate this guy with a glidescope. He goes to the ICU intubated.

Anesthetic is sevo and roc and fentanyl. Airway is controlled.

Same but I would consider extubation at the end of the procedure if he was stable or got better after the TAVR is deployed.

 

[woopedazz]

I'd just do a GA like they were getting non-cardiac surgery and then do a video +/-FO assisted intubation thereafter. Deep exchange for LMA at end of case and then wake-up with c-spine protections on.

 

[GassYous]

I'd just do a GA like they were getting non-cardiac surgery and then do a video +/-FO assisted intubation thereafter. Deep exchange for LMA at end of case and then wake-up with c-spine protections on.

What's the point of changing to lma

 

[lovemango]

I'd just do a GA like they were getting non-cardiac surgery and then do a video +/-FO assisted intubation thereafter. Deep exchange for LMA at end of case and then wake-up with c-spine protections on.

Why the deep exchange for LMA?

 

[woopedazz]

I just don't wanna jaw thrust the c-spine if I take it out deep.

 

[Iso4ane]

Titrate remifentanil very carefully and slowly to get him through the initial groin access, and lots of, ‘Sir sorry this may be uncomfortable and you may feel pressure, but your going to be okay.’ (Assuming he’s somewhat calm and cooperative at baseline)