spinal in low ef

[anbuitachi]

Anyone have any personal cutoffs for EF for not doing spinal? Need it for a 2,5 hour case in patient with EF 20% NICM , Mets <4, symptomatic and some RV dysfunction. What dose would you put if yes to spinal?

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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

 

[anbuitachi]

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

prostate resection

 

[dchz]

Anyone have any personal cutoffs for EF for not doing spinal? Need it for a 2,5 hour case in patient with EF 20% NICM , Mets <4, symptomatic and some RV dysfunction. What dose would you put if yes to spinal?

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.

 

[dchz]

prostate resection

Turp or open?

 

[Hoya11]

Anyone have any personal cutoffs for EF for not doing spinal? Need it for a 2,5 hour case in patient with EF 20% NICM , Mets <4, symptomatic and some RV dysfunction. What dose would you put if yes to spinal?

would not do a spinal on this guy

Even if the EF was 60 I would not do a spinal for this case - GETA

 

[vector2]

Anyone have any personal cutoffs for EF for not doing spinal? Need it for a 2,5 hour case in patient with EF 20% NICM , Mets <4, symptomatic and some RV dysfunction. What dose would you put if yes to spinal?

What's the evidence anyway that neuraxial anesthesia is any worse than GETA in HFrEF?

 

[GassYous]

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.

 

[Guillemot]

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.

 

[Arch Guillotti]

15 mg isobaric. No problem. Neo if needed.

I probably would put the guy to sleep though.

 

[anbuitachi]

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

 

[deleted697535]

15 mg isobaric. No problem. Neo if needed.

I probably would put the guy to sleep though.

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

 

[linkin06]

could do epidural so the sympathectomy could be a bit more gradual. plus can redose.

 

[caligas]

Have done isobaric with low EF 20-30%, whiff of epi or ephedrine after spinal, no issues

 

[coffeebythelake]

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

 

[caligas]

Quite a difference between ef 20 and ef 30

50%

 

[amyl]

Why not epidural if you really want to avoid geta

 

[GassYous]

Quite a difference between ef 20 and ef 30

Is it though?

 

[DrOwnage]

I would do 1.75 ccs 0.5% isobaric bupivicaine. Little effect on hemodynamics (assuming mild RV dysfunction), would definitely last 2.5 hours.

 

[vector2]

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...

 

[anbuitachi]

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...

chronic ef 20 last year too. nyha 3. not in acute decompensation

 

[nimbus]

Quite a difference between ef 20 and ef 30

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.

 

[vector2]

chronic ef 20 last year too. nyha 3. not in acute decompensation

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.

 

[sevoflurane]

Ya GA all day long for me. Ef 10% or 65%.

 

[sevoflurane]

I am regional heavy when I can be, but this is one case I just don’t use it.

 

[deleted697535]

I am regional heavy when I can be, but this is one case I just don’t use it.

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

 

[anbuitachi]

I am regional heavy when I can be, but this is one case I just don’t use it.

why not?

 

[deleted697535]

why not?

Because you cant titrate it.

 

[anbuitachi]

Because you cant titrate it.

oh , thats what he meant?

 

[deleted697535]

oh , thats what he meant?

I think so not sure. We dose our spinals using 4 separate injections. 2.5mg q10mins

 

[anbuitachi]

I think so not sure. We dose our spinals using 4 separate injections. 2.5mg q10mins

like keep the needle there and inject 2.5mg q10 min? great idea

 

[Hork Bajir]

I do four separate needle passes, that way you can bill for 4 spinals