Today, we had a guest speaker Christian Spies from Queen’s Hospital in Hawaii who spoke on his experience with his TAVR team and conscious sedation vs. general anesthesia for these patients. More specifically, we are speaking of the transfemoral route.
- Patient selection is key (consider for COPD; bad for OSA)
- Short surgical time for monitored anesthesia care (MAC)
- Decrease invasive monitoring (no PA catheter,+/-CVP)
- No difference in hospital LOS or 1 year mortality rate
- Move from TEE to TTE if MAC
- Be prepared to convert MAC to GA (can be difficult in already tenuous patient in a crowded space under the drapes)
- MAC agents: dexmetetomidine, propofol, ofirimev
- Decrease pressor use
- Develop an algorithm for MAC vs. GA and patient selection
For my own lit search:
- Anaesthesia Nov 2011: Sedation vs general anaesthesia for the ‘high-risk’ patient – what can TAVI teach us?
- JACC May 2012: The Minimalist Approach for Transcatheter Aortic Valve Replacement in High-Risk Patients
- Cardiac Interventions Today May 2012: Rouen Experience Supports Safety of TAVR Using Local Anesthesia
- MedPage Today July 2012: TAVI: No Need for Patients to ‘Go Under’
- Amer J Card Jan 2013: Effect of Local Anesthetic Management With Conscious Sedation in Patients Undergoing Transcatheter Aortic Valve Implantation
- SCA 2013: PBL — Anesthesia for TAVR
- Indian Heart J March 2014: Transcatheter aortic valve implantation under conscious sedation – the first Indian experience
- TCTMD Mar 2015:As TAVR Evolves, Local Anesthesia Could Be an Option for Lower-Risk Patients
There was an article in the Washington Post: New machine could one day replace anesthesiologists.
I don’t know about that. The trial is done on “healthy” patients for colonoscopies — a procedure that’s commonly performed under sedation. What happens when you get an unhealthy patient or a patient who doesn’t have a diagnosed disease (obstructive sleep apnea is pretty common and often comes without a diagnosis at time of surgery)? What if the patient obstructs or needs an emergent intubation? I think I’ll keep my friendly anesthesiologist.
Originally posted on The Context Of Things:
Last April, I wrote about how maybe Slack could revolutionize the workplace; then in February, I wrote about how they got to a $2 billion valuation with no CMO, which is insanely rare for a lot of companies.
There’s something much better than either of those posts currently on Medium and while there are about 90 different individual parts of interest, here’s one that makes a lot of sense (to me, at least):
Butterfield, Slack’s CEO, saw a larger problem with email, an organizational memory problem: “Whether you’re the CEO or an intern, on your first day at an email-based organization, you can’t see into anything — it’s all locked in people’s inboxes. You literally have no access to anything that happened in the past. There might’ve been hundreds of thousands or millions of messages exchanged at the company before you got there.” Slack doesn’t make everything transparent, but it brings…
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A study out of Turkey…
Curious to see how this works in our ASA 3 and 4 CABG cases.
I came across this excerpt from Atul Gawande while browsing the TED articles.
It made me realize that only the basic factoids for a foundation in medicine are taught in medical school. The article should open the eyes of my peers; it is ok to accept and understand the fragility of life without thoughts of failure. Compassion, empathy, resourcefulness, etc. aren’t easily teachable concepts or behaviors. One would hope that aside from understanding things on a cellular to anatomical to physiological to pharmacological level, a basic lesson in emotions, communication, and coping would be equally as important as learning the fundamental medical knowledge to clinically treat patients.
Why all this talk about an adductor canal block (ACB)?
For years, femoral nerve blocks (FNB) have been the gold standard for pain control in more invasive knee/lower leg surgeries (total knees, ACLs, etc.). More recently, adductor canal blocks have been gaining in popularity over femoral nerve blocks because there seems to be less motor blockade from ACB than FNB. This is important because it decreases fall risk and allows earlier patient ambulation while also providing adequate analgesia.
- Regional Anesthesia & Pain Medicine – Aug 2013. Kwofie et al. The effects of ultrasound-guided ACB vs FNB on quadriceps strength and fall risk.
- Regional Anesthesia & Pain Medicine – Nov 2013. Jaeger et al. ACB vs FNB for analgesia after TKA: a randomized, double-blind study.
- Anesthesiology – Mar 2014. Kim et al. ACB vs FNB for TKA: a prospective, randomized, controlled trial.
- Clinical Orthopedics and Related Research – 1999. Mudumbai et al. Continuous ACBs are superior to continous FNBs in promoting early ambulation after TKAs.
- Clinical Anesthesiology – Feb 2014. O’Rourke. Study supports ACBs after TKAs.
- Clinical Trials. 2013-2015. ACBs in ACLs.
Anesthesiology Mar 2014. Kim et al. Adductor Canal Block versus Femoral Nerve Block for Total Knee Arthroplasty: A Prospective, Randomized, Controlled Trial.
How to place an adductor canal block