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    i'm looking to see what others are doing (re: cancelling/going forward with case) with respect to aortic stenosis, and what their cut-off at an ASC might be.

    let me preface by saying that the entire clinical picture must be taken into consideration, and that an arbitrary number, alone, is not an ideal marker.

    that being said, these were the two most recent cases in question:

    54 y.o. male with AS of 0.6, presents for bilateral frontalis sling under general anesthesia. no other pertinent medical history. METS unknown.

    82 y.o. male with AS of 0.84, two years ago, with history of interventricular conduction delay. presents for inguinal hernia repair (surgeon books MAC, but usually requires room air general). no other pertinent medical history. METS unknown.

    thanks for any input-
    This article was originally published in forum thread: Aortic stenosis and ambulatory surgery center started by ethernaut View original post
    Comments 10 Comments
    1. Teillard's Avatar
      Teillard -
      Quote Originally Posted by ethernaut View Post
      i'm looking to see what others are doing (re: cancelling/going forward with case) with respect to aortic stenosis, and what their cut-off at an ASC might be.

      let me preface by saying that the entire clinical picture must be taken into consideration, and that an arbitrary number, alone, is not an ideal marker.

      that being said, these were the two most recent cases in question:

      54 y.o. male with AS of 0.6, presents for bilateral frontalis sling under general anesthesia. no other pertinent medical history. METS unknown.

      82 y.o. male with AS of 0.84, two years ago, with history of interventricular conduction delay. presents for inguinal hernia repair (surgeon books MAC, but usually requires room air general). no other pertinent medical history. METS unknown.

      thanks for any input-
      The decision is at least 75% exercise tolerance. Not trying to be snarky here at all, but how do you know what the valve area is and not have any info on METS? Velocity flows go with the assessment of just how severe or critical the situation is, and should be with the same echo report you got the valve area from, but again, exercise tolerance is the major determinant. By valve area, both have severe disease. Auscultating the right carotid for the murmur is something you could do to assess the severity as well. If you heard it there, you could assume the worst.
    1. Teillard's Avatar
      Teillard -
      Quote Originally Posted by MmacFN View Post
      welll

      the 82 y/o I wouldnt do with a room air general. Not enough control over the hemodynamics. Im willing to do the 54 even tho his AS is worse because its general and i have control at all times. Frankly, neither of these cases should be done in a stand alone ASC but id be lying if i said it does not happen all the time. So yes, they can be done but they have to be done on my terms not the surgeons (when it comes to the anesthesia). Also, id want to go regional (except spinals) in every case when possible.
      I'm less concerned about what happens in the OR than about what happens in the PACU afterward.
    1. MmacFN's Avatar
      MmacFN -
      True, but i worry more about that for pul. HTN pts who are severe (a little narc and they die). In the OR you can kill someone with AS if its critical and you tx them wrong.

      Quote Originally Posted by Teillard View Post
      I'm less concerned about what happens in the OR than about what happens in the PACU afterward.
    1. Teillard's Avatar
      Teillard -
      Quote Originally Posted by MmacFN View Post
      True, but i worry more about that for pul. HTN pts who are severe (a little narc and they die). In the OR you can kill someone with AS if its critical and you tx them wrong.
      Right, a clean kill is more of a possibility in the OR, but we know, in theory, how to avoid it. It's us after all. It's the stressed/stunned myocardium silently descending to failure as the PACU nurses watch that scares me.
    1. MmacFN's Avatar
      MmacFN -
      yah good point!



      Quote Originally Posted by Teillard View Post
      Right, a clean kill is more of a possibility in the OR, but we know, in theory, how to avoid it. It's us after all. It's the stressed/stunned myocardium silently descending to failure as the PACU nurses watch that scares me.
    1. ethernaut's Avatar
      ethernaut -
      Quote Originally Posted by MmacFN View Post
      welll

      the 82 y/o I wouldnt do with a room air general. Not enough control over the hemodynamics. Im willing to do the 54 even tho his AS is worse because its general and i have control at all times. Frankly, neither of these cases should be done in a stand alone ASC but id be lying if i said it does not happen all the time. So yes, they can be done but they have to be done on my terms not the surgeons (when it comes to the anesthesia). Also, id want to go regional (except spinals) in every case when possible.

      Lastly, there is something to be said for provider comfort. If one isnt used to taking care of mod-critical AS patients under GA or otherwise it can be a recipe for disaster as it is TOTALLY different. So if the provider didnt have the experience id say both are no go cases or turf to someone who does.
      i don't disagree it couldn't be done in an ASC. but to me, the risks are greater than the reward(s). these are elective procedures. and if something went wrong, you can't tell me the first question out of a jury of my peers' mouths would be "Why did you decide to do this at an ASC?"
    1. ethernaut's Avatar
      ethernaut -
      Quote Originally Posted by Teillard View Post
      The decision is at least 75% exercise tolerance. Not trying to be snarky here at all, but how do you know what the valve area is and not have any info on METS? Velocity flows go with the assessment of just how severe or critical the situation is, and should be with the same echo report you got the valve area from, but again, exercise tolerance is the major determinant. By valve area, both have severe disease. Auscultating the right carotid for the murmur is something you could do to assess the severity as well. If you heard it there, you could assume the worst.
      the info i provided here was what was provided to me. i personally didn't do the phone interview, nor did i have access to the chart/interview. the MDA i work with asked me what i thought, and to "throw this question out there to your colleagues and see what they are doing in similar situations." in the end, an arbitrary number is just that. but given the elective procedure, and not worth the possible outcomes, and without adequate staff/backup/equipment, the decision was to send cases to our main campus.
    1. Teillard's Avatar
      Teillard -
      Quote Originally Posted by ethernaut View Post
      i don't disagree it couldn't be done in an ASC. but to me, the risks are greater than the reward(s). these are elective procedures. and if something went wrong, you can't tell me the first question out of a jury of my peers' mouths would be "Why did you decide to do this at an ASC?"
      I don't think the question is whether or not to do the case in the ASC or not. It's whether or not to do the case at all before a valve replacement. Doing the case in an ASC doesn't increase the risk to a severe AS patient. If there is an event, the patient is stabilized in the OR or PACU or isn't. Just like at the main campus. After that it's a transfer to the morgue or the ICU. An ASC has all the necessary personel, medication and equipment to deal with the off chance that there will be an event. If the patient with AS is well enough to be considered for a more minor elective procedure, IMO, he's well enough to have it in an ASC. If he's not, refer him to a cardiac surgeon.
    1. ethernaut's Avatar
      ethernaut -
      Quote Originally Posted by Teillard View Post
      I don't think the question is whether or not to do the case in the ASC or not. It's whether or not to do the case at all before a valve replacement.
      agree. but i'm not sure if valve replacement has even been discussed. so, i can't say.

      Doing the case in an ASC doesn't increase the risk to a severe AS patient. If there is an event, the patient is stabilized in the OR or PACU or isn't. Just like at the main campus. After that it's a transfer to the morgue or the ICU.
      this is a fair assessment.

      An ASC has all the necessary personel, medication and equipment to deal with the off chance that there will be an event.
      i would hesitate to state this. not all ASCs are the same, especially with staff and equipment. i believe we have one arterial line kit, one pressure bag and transducer. probably cords too. but i can bet they haven't been tested in quite some time, and if the expiration dates are within reason. i can assure you we don't have nitroglycerine (except paste), no cardene or anything fancy. i doubt we have levophed. maybe dobutamine. i think we might have a central line kit, but as above, not sure about cords and expiration, etc. as to the staff being adequate, the only people i would trust/depend on are the anesthesia people, one or two OR nurses, and the nurse manager/assistant nurse manager (they both are gone by 3pm). in the face of a crisis, there would be many chickens with their heads cut off. utter chaos on that front. most don't have BLS, let alone ACLS. heck, they can barely even pass yearly required competency modules, in which the material doesn't change. now, is this ideal? nope. but no one in the higher-ups seems to be concerned.

      If the patient with AS is well enough to be considered for a more minor elective procedure, IMO, he's well enough to have it in an ASC. If he's not, refer him to a cardiac surgeon.
      this would be procedure-specific, in my opinion. toe amp with local is much more safer than any general anesthetic or even propofol MAC. but, that's just my opinion here.
    1. J-Dubya's Avatar
      J-Dubya -
      It depends on the ACS. The ones I go to are set up to do healthy patients as fast as possible. At the very least, ASA3 patients slow down the flow, defeating the whole purpose of these places.

      Of course, cataracts are a different story..