IS SPINAL ANESTHESIA IN AORTIC STENOSIS SAFE?

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 YouTube channel, where we break down the study, its methods, and its potentially practice-changing implications for anesthesiology.
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[drspokharna]

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

[PaulFronapfel-zcfb]

Been doing this the last 16.5 years. There is so much dogma in anesthesia... it's crazy!

[isticb]

We did few spinal anesthesia in severe aortic stenosis in cesarean section, all patients went well.

[cengizveysal]

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.

[gc]

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. 👍🏻

[alextarno]

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.

[mirmahmud]

Excellent news.thank you very much for sharing..

[briekhnaa]

👍.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.

[sebastiancasta]

The key is in vascular resistance and the degree of stenosis.



[biancogiusto]

i love that minute 6 wall ahah. Great video too

[zakalobi]

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.

[awaistahir]

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

[ghspenn]

Not all aortic stenosis is made equal, and this is the critical component. Mild or moderate - proceed. Severe or symptomatic AS - no spinal.

[HassanMohamed-sgpi]

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?

[georger]

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?

[alexblades]

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

[aranesthesia]

If you start phenylephrine infusion .it will be wonderful and there will be no Hypotension either in GA or Spinal

[priyabansal]

Sir, what about CSE? even if we use very little amount in intrathecal, we can always supplement with epidural if level starts receding

[pskelly]

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.

[jaimemolinaalfaro]

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