IS SPINAL ANESTHESIA IN AORTIC STENOSIS SAFE?
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- čas přidán 31. 01. 2024
- For years, the use of spinal anesthesia (SA) in patients with aortic stenosis (AS) was almost taboo, feared for the risk of causing dangerous drops in blood pressure. Many anesthesiology professionals might recall the stern warnings and the potential for examination pitfalls regarding this topic. 🚫💉But what if we told you that recent research is flipping this script? A groundbreaking study by Van Herreweghe et al., featured in the Regional Anesthesia and Pain Medicine journal, is challenging old beliefs with new evidence. 📚🔍
The verdict? The results are more than encouraging. With 35 patients studied, there were zero instances of cardiac arrest in the 24 hours following surgery, and no uptick in mortality rates. Even more compelling, SA didn't increase intraoperative hemodynamic instability or lead to worse outcomes, regardless of the severity of AS. A paradigm shift: low-dose spinal anesthesia with isobaric bupivacaine could be a safer alternative to general anesthesia for AS patients, challenging decades-old contraindications and opening new doors for safer, more effective patient care. 💡🚪
Watch the video with us on NYSORA's CZcams channel, where we break down the study, its methods, and its potentially practice-changing implications for anesthesiology.
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Excellent news.thank you very much for sharing..
Great, you have endorsed my practice of spinal anesthesia with low dose isobaric ropivacaine and levo bupivacaine with support of minimal doses of phenylephrine or ephedrine in patients with low ejection fraction or with aortic stenosis. Thanks for this study. a volume of 1ml of 0.75 % ropivacaine gives a very good anaesthetic levels for such high risk patients
thank you for your comments, but low ejection fraction is not aortic estenosis
i love that minute 6 wall ahah. Great video too
Too flamboyant from 35 only patients, most of them required vasopressors as well. Still won't just do spinal for moderate-severe AS. Its also surgical time and site practice/guidlines for such patients, so lots of trouble, not worth it. GA not always causes hypotension, or at least not long lasting as does the spinal. HDU capacity is another limiting factor.
i’ve been doing Ga for critical aortic stenosis for almost 20 yrs - working in an institution with VERY AGGRESSIVE ortho … light ga+ a block with no opioids always worked for me .
even if i wanted to do spinal - most patients wouldn’t qualify for various reasons - plavix or Xerelto and etc ; not cooperative combative demented ; spinal instrumentation in the past and etc …
moderate AS and preserved function- most providers would consider spinal anyways whenever feasible…
my understanding is that in most of Europe Otrho is very selective and they are less aggressive , hence they operate on relatively “ healthier “ patient . even if patients are “ severe AS “ - they most likely lack other significant co- morbidities . Private US ortho will operate on anyone breathing and with a heartbeat …
There are a lot of ethical issues in this study.
Can we change the practice upon a single case series?
What is the level of evidence of this study?
30% of patients required vasopressor, 1 of three patients, this is huge .
What do you mean exactly by low dose?, Is it correlated with body weight, Surface area,length? Or AS grade?
What if the dose is not enough? What is plan B?
What type of cardiac output monitor was applied?, and what is the data from it?
Lastly, did the patients sign for the consents and were aware that they are lab animals, and They will be exposed to an out of label procedure that may endanger their lives?
Regarding the last question. You cannot do a trial of this sorts in a european country without getting aproval by an ethics commitey. You need wirtten conests of every patient with activly opting in and being able to pull back even after data was produced.
Been doing this the last 16.5 years. There is so much dogma in anesthesia... it's crazy!
Greetings dear Dr. Hadzic. Very interesting topic, but in cases of severe aortic stenosis, there is concern about not achieving an adequate balance and that peripheral vascular resistance will fall excessively, compromising coronary filling and generally causing hypoperfusion. I suppose that many colleagues would agree to use minimally invasive monitoring and immediately have vasopressors infused to compensate for any imbalance. Greetings, as always thanks for the interesting contribution. 👍🏻
Excellent discussion. But the answer continuous: No, conceptually it's contra indicated until you analyse the patient and decide. I would suggest continuous spinal to titrate the isobaric bupivacaine.
We did few spinal anesthesia in severe aortic stenosis in cesarean section, all patients went well.
Which LA did you use? Which doses? Did you use arterial line in every case? Greetings from Chile
Can you link to the study?
excellent
Is 2 mls of 0.5% isobaric Bupivicaine always sufficient to achieve adqeuate sensory level to facilitate surgery.for total hip replacement
. E.g. aiming for block height of T12. Does a lower dose risk a higher proportion of inadequate anesthesia / block failure?
I think anesthesia management should be tailored for every patient according patient condition, surgical procedure and most importantly anesthesiologist experience. I want to ask if we need invasive hemodynamic monitoring in these patients under spinal anesthesia. Thank you.
What are your view in c section and severe aortic stenosis
The key is in vascular resistance and the degree of stenosis.

Brilliant
What is best dentist short local anestetiz c?
👍.close monitoring and vigilant anesthesia team can make it possible. If prompt and proper dose of vasopressor is used to counterbalance sympathectomy related hypotension then in mild to moderate aortic stenosis, spinal anesthesia should not be considered contraindicated.
Indeed. But the same holds true for general anesthesia, no?
Sir, what about CSE? even if we use very little amount in intrathecal, we can always supplement with epidural if level starts receding
YES. A bit more involving, but absolutely and option. So is continuous spinal. What would be your initial dose of spinal?
Sir, initial dose can be 4mg to 5mg of heavy bupivacaine with 25mcg fentanyl, then after checking dermatome level, supplementing with may be 2 to 3ml of 2% lignocaine with adrenaline through epidural catheter, under guidance of senior anaesthetists
What about CSE
You can use low dose spinal without the fear of receding block in case surgery gets prolonged and you can suplement epi if needed and use epi for post op pain option too.
2nd option is unilateral spinal when duration of surgery you are sure will cover spinal with heavy marcaine
however not agreed nd feel safe with mentioned technique in mod-severe aortic stenosis
Thumbs up. I do it. low dose spinal long lasting epidural
Or go one sided spinal with heavy Marcain to decrease the sympathetic block
What about medicolegal aspect , if patient with A.S. has cardiac arrest under spinal anesthesia and cannot be revived .
The same under GA. You are supposed to be able to manage hemodynamics under both types of anesthesia. The anesthetist can be the problem, not the technique.
9% out of 35 patients needed a Norepinephrine gtt? That is pretty high to suggest SAB with severe or critical AS may not need invasive arterial BP monitoring… coupled with absolute contraindication in doing this in almost all texts, the N of 35 is way to low to suggest this is safe.
Not all aortic stenosis is made equal, and this is the critical component. Mild or moderate - proceed. Severe or symptomatic AS - no spinal.
Exactly. It depends on the valve opening area, below 2,5 cm in square- no spinal.
even Severe Aortic stenosis?
Interesting but for me is always more safe general anesthesia in this case, i don’t understand the reason for use spinal anesthesia in severe aortic stenosis , it’s a potencial risk
If you start phenylephrine infusion .it will be wonderful and there will be no Hypotension either in GA or Spinal
Hello Dr. Hadzic!
Completely different topic: Is it possible that muscles are so tense that the pain therapist breaks off the needle?
Greetings from Gießen, Germany
Iris
Needle breaking is reported in the literature. Needles are tougher than muscles; this is usually caused by the technique choices or defect in needle material. We would love to hear more - which procedure, which needle, what happened to the brokeneedle, etc. Greetings!
I think that, in this kind of patients, is far more dangerous a general anesthesia with non invasive arterial pressure monitoring, then a spinal anesthesia whith invasive blood monitoring...
Thank you. The monitoring should be the same regardless of which anesthetic is given - GA vs Spinal. GA in fact - results in more intraoperative hypotension and need for vasopressors. THoughts? Greetings
Why not use hyperbaric pubivacaine and control the level better than the isobaric one?
Isobaric stays were injected; hyperbaris is dependent on the patient position - not possible to control the sympathetic block. Unless you have another strategy you use? If so , please share! Greetings
@@nysoravideo I mean we can precisely control the level by changing the position of the patient even in case we used a slightly larger dose than 10 mg, until the drug is fixed, then we position the patient appropriately according to the site of surgery.
Anesthesia is filled with unproven dogma. Good job MYSORA.
Здравствуйте! Возможно ли Ваше приложение на русском языке?
No
This is an academically taboo practice that many anesthesiologists have likely been quietly doing without issue for many years lol
Glad there's finally some data to match against the dogmatism.
Individualized patient care is key- bupi only spinal is slow and gentle. Looking forward to more data
Right on. We all know colleagues "who do spinal only when general fails!" Greetings and thanks for watching!
I'm very interested in that what the sentence would be if I did SA and patient died. The mentioned study is not very persuading due to small groups of patients and metodology. I don't understand why you promote SA while nowadays GA is so safe. It can be even charmful for young anesthesiologists which can try do SA in aortic stenosis and it can't have a happy ending every time. For me not, maybe not yet.
The sentence would be the same under GA. You are supposed to be able to manage hemodynamics under both types of anesthesia. The anesthetist can be the problem, not the technique.
Two big caveats to make such grand conclusions. Number one: what power do you generate with a study of 35 patients? Not much so I'd say your study is pretty underpowered to make your conclusion. Also moderate and severe but not critical AS? I would posit that you can almost do anything to a moderate AS within reason and not get into trouble. We probably all ready do since we don't echo most patients. A 2cc isobaric bupi works in a private practice settings especially a place like HSS (high volume) but it all depends on your surgical time. Hell if you have surgeons that can do a joint in under an hour, you could get away with much lower dosages in your spinal and thus could do critical AS. A lot of "rules" can be broken when you can control for a lot of factors i.e. blood loss, surgical time, etc.
Another big qualifier is that the sympathectomy doesn't just magically stop after the procedure is over. So if you are running an alpha agent intraop don't just turn it off at the end of the case!
All good points! THis is a research report, not a study, so no comparisons where made, or needed. Thus, the power does not apply. ALL aortic stenoses were included and they were more "severe" than "moderate" - details in the paper. Agree with you if the surgeons take their time - regional may not be best. There are 1) Surgeons who can operate under regional 2) Surgeons who can operate under regional only when GA is also given 3) Surgeons who can operate only under GA & 4) Surgeons who can not operate regardless of the type of anesthesia given! ;) What was presented here is a recently published research report - based on the patients in one of our institutions in the specified time period. At NYSORA, we have not put a patient with aortic stenosis to sleep for years; those numbers were not reported in the research report. Sick patients and aortic stenosis patients with hip fracture or LW surgery folks do not need a cardiac anesthesiologist and TEE for safe anesthesia - they need regionalists. Greetings and thank you for watching! It'd be great to hear if you do any spinals for these patients at HSS?
@@nysoravideo Good to know. As in all things medicine or science the truth is in the grey. There are no blanket statements about anything. SAB in the right hands is fine in a particular AS as can be said about GA. The craftsman matters more than the tools...
small limited study , observation, no control , no randomization … spinal without significant sympathetic blockade ; i’m sure patients were hand picked for a spinal for a specific surgery .
hence generalized recommendation can not be made ….
also - assumption that spinal is a panacea - is a false assumption…
narrative that spinal is safer or superior - is no longer universally supported.
what about anticoagulation ; prolonged surgery; surgery when higher level of spinal block is needed .
i hope this limited observational study will be taken with grain of salt and approach will remain conservative , rather than cavalier .
All good points. The report and the video do mention several times the patient and procedure selection. It definitively formally challenges the established teaching - no spinal in AS. What the report documented is that spinal anesthesia is applicable to these patients, under the low dose-low level conditions. And yes, if the hip fracture in an institution talked 5 hours, and 3 L of blood, and the patients come to OR on IV heparin, we would not do spinal. However, general anesthesia would not be much safer under those conditions either! Greetings!
Done a lot, for decades, under all forms of neuraxial anesthesia. Nothing new.
That's some AGGRESSIVE draping at 6:00 mark. Why would you want to complete obstruct your visualization of the surgical field?
Indeed. SOmetimes, we would rather not see our surgeons...: Greetings
@@nysoravideo 🤣
So take home message
Low dose low level
Low sympathetic block with isobaric solution.
Interesting.
Yes. The most common mistake by non-regionalists is - "I have only one shot to make it work, so I will injecte a bit more to make sure it works". That causes problems with hypotension in elderly even in patients without aortic stenosis. The temptation to injection "just a bit more" is what gets folks in trouble with spinal. It's the same as giving 400 mg of Propofol for induction to make sure it works! This would get patients with aortic stenosis in serious trouble, no? Greetings.
@@nysoravideoHello from an anaesthesiologist from greece. The problem with increasing the dose of spinal is because you are not sure if the surgeon is going to be quick or not. Anyway I don’t want to emphasize on this. I’ve read the study and i would like to know what means severe aortic stenosis for the patients on this study. Did they have aortic velocity >4 m/sec? In our hospital we perform spinal anesthesia on patients with aortic stenosis with velocity
Not convinced
THere is really nothing to be convinced about - what is presented is the facts from NYSORA's practice, it is not subject for discussion, actually. Which aspect of the video are you not convinced about? Greetings!
Case series are facts 😂 and REGAIN RCT is not ? 😂😂😂
@@ammaralshaker REGAIN was not a study in patients with aortic stenosis. Case series described one Center's experience - which is safety with low-dose spinal. Greetings
@@nysoravideo
I know exactly what REGAIN was about .. it’s just strange that you used the word “FACTS “ to describe the findings of this weak study in this video while in other occasions you try to “ DeBUNK” real facts taken from a top notch scientific trial such as REGAIN
Just saying 🤷🏻♂️
❤
Nice study, thank you. Still, I would challenge your statement that GA "always" comes with hypotension. As with low dose / low level spinal anesthesia, the dosage is the main determinator. In my daily practice it is not uncommon to induce GA in the elderly / frail trauma patient with 0.05 Fentanyl + 10 -20 mg of Propofol followed by insertion of the LMA under continuous spontaneous breathing. Jokingky I sometimes state that a single 20cc syringe of 1% Propofol gets me through a whole day in the OR without the need for a vasopressor
The technique you mention would work very well in surgeries without painful impact but I highly doubt that with Fentanyl 0.05 + 10 -20 mg Propofol and LMA with spontaneous breathing you can adequately and safely manage a patient undergoing orthopedic surgery
Very grateful Dr Hadzic for his permanent contributions, very complete and informative, greetings
0,05 Fentanyl + 20 mg of Propofol ist for induction of anesthesia. I usually titrate in some Sevoforane for maintanance and you might need additional Fenta during the case. If the depth of anesthesia matches the level of surgical stimulation there rarely is arterial hypotension. I can manage a patient with an LMA and spontaneous ventilation in any case where muscle relaxation ist not required. I do it every day. @@marcosmayer1966
It depends on the extent of the surgery. A GA for open colonic resection would probably be affected by some hemodynamics perturbation. In these cases, neuraxial anesthesia gives better results in this regard.
Nah. I'd rather place an Arterial line and do general anesthesia. Thanks for the video, though.
Just put it in the relevant textbooks and I will do it, otherwise a big NO...cause in the court you have to explain some things...
You should explain the fact that you haven't been able to manage hemodynamics under spinal anesthesia. It may happen with saphenous stripping too. It's a matter of anesthetist's skills, not of technique safety.
@@RobertoStarnari Not a matter of discussion at all...
😁
First of all why to put patients at risk when safer alternative like general anaesthesia is available.. and moreover isobaric spinal drug solutions are not available worldwide frequently.. Giving spinal in AS or MS puts a lot of stress in anaesthesiologist leaving the haemodynamics to the fate of the patient.. I prefer to give general anaesthesia in fixed cardiac output lesions
far-reaching conclusions based on a small number of cases...