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这期ICD有二个病例。一例来自美国，另外一例来自中国。我们一些Members不久前在微信上的讨论过。希望大家也谈谈自己的经验和想法。
病例1: Severe AS病人需要TURB,术前心脏科会诊，建议麻醉医生用腰麻。
90 yr, CAD medical
management, severe AS 0.6, bladder tumor for TURB. Cardiac
surgery
cardiology, and surgery decided to go for bladder surgery
before AS surgery and recommended
spinal. Any recommendations? Regional vs GA. (Pre-op A-line
for sure). Thanks!
Response 1: talk to urologist first for knowing how big and invasive the procedure will
be.
It may be a simple cysto and biopsy. Or surgeon will simplify the procedure if he is
aware of the severity.
option.
If it is the case Mac may be good enough.
Otherwise, ga is the option.
Response 2: surprised that cardiologist recommended spinal.
Response 3:If I'm called as an expert witness, I'll say it's against the standard of care,
since it's listed as a relative contraindication. You may be able to argue your way out, but I
won't do it myself. My 2 cents.
Response 4: Yes, it's not absolute contraintradiction, but in face of better alternatives, I
would not first pick it. How's pressure gradient across the valve? What's pt's exercise
tolerance, and any history of syncope? If answer is no, I feel a bit ez.
Response 5:I had a similar case couple years ago. 92 yo, critical AS, bladder surgery to
improve quality of life, family aware of high risk, willing to take the risk
Response 6:I did GA with LMA. Mostly narcotics, he was breathing 5 / min, minimal gas , pt did
great though he didn't wake up till 4 hours later
Conclusion:Thanks everyone! . The case is done.
1, extensive discussion with pt and his
family, surgeon, every party involved at same page;
2, pre-induction A-line, with baseline ABG,
3, GA with ETT,
remi
infusion plus gas, muscle relaxant,
pt woke 10 minutes after
surgery and extubated without problem.
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