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Dr.Kartik Sonawane Verified account @KartikBSonawane
β€οΈβ€πŸ©Ή π‹πŽπ– 𝐄𝐅, 𝐍𝐨 π†π”π„π’π’π–πŽπ‘πŠ : π’πŒπ€π‘π“ ππ„π‘πˆπŽππ„π‘π€π“πˆπ•π„ ππ„π€π‘π‹π’β€οΈβ€πŸ©Ή #LowEF #HeartFailure #PerioperativeMedicine #Anesthesia #GeriatricAnesthesia #RegionalAnesthesia #NeuraxialAnesthesia #GeneralAnesthesia #GrayZonesInRA #GrayAreasInRA π†π‘π€π˜ π™πŽππ„π’ 𝐒𝐧 𝐑𝐀: Managing patients with low EF is all about preventing sudden swings. They are, PRELOAD sensitive, AFTERLOAD vulnerable, RHYTHM dependent, HYPOXIA intolerant, ANEMIA intolerant, and FLUID-OVERLOAD intolerant. 1️⃣ 🧭 ππ‘π„πŽπ: πŠππŽπ–πˆππ† 𝐓𝐇𝐄 𝐇𝐄𝐀𝐑𝐓 πŸ”Ή EF is only a number - assess physiology πŸ”Ή Look for red flags: dyspnea, edema, orthopnea, tachycardia πŸ”Ή Postpone elective surgery if HF is decompensated πŸ”Ή Continue chronic beta-blockers πŸ”Ή Stop SGLT2 inhibitors 3–4 days before surgery πŸ”Ή Individualize ACEI/ARB/ARNI & diuretics πŸ”Ή Plan anticoagulation & antiplatelet strategy early 2οΈβƒ£πŸ’§ π…π‹π”πˆπƒπ’: π“πˆππ˜ ππŽπ‹π”π’, π“πˆπ†π‡π“ π‘π„π€π’π’π„π’π’πŒπ„ππ“ πŸ”Ή Avoid blind fluid loading πŸ”Ή Give 100–150 mL bolus, then reassess πŸ”Ή Replace loss, not fear πŸ”Ή Use POCUS when unsure πŸ”Ή Start vasopressor early if vasodilated πŸ”Ή Avoid both underfilling & overload 3οΈβƒ£πŸ©Έ ππ‹πŽπŽπƒ: ππ‘πŽπ“π„π‚π“ πŽπ—π˜π†π„π, π€π•πŽπˆπƒ πŽπ•π„π‘π‹πŽπ€πƒ πŸ”Ή Correct anemia preoperatively πŸ”Ή Do not transfuse by Hb alone πŸ”Ή Transfuse one unit at a time πŸ”Ή Reassess after each unit πŸ”Ή Prevent bleeding: TXA, cell salvage, warming, calcium, TEG/ROTEM when available 4οΈβƒ£πŸ’‰ ππ‘π„π’π’πŽπ‘π’ & πˆππŽπ“π‘πŽππˆπ‚: 𝐓𝐑𝐄𝐀𝐓 𝐓𝐇𝐄 πŒπ„π‚π‡π€ππˆπ’πŒ πŸ”Ή Norepinephrine: vasodilated hypotension πŸ”Ή Dobutamine: low output, poor contractility πŸ”Ή Milrinone: LV dysfunction with PH/RV strain πŸ”Ή Vasopressin: catecholamine-resistant vasoplegia πŸ”Ή Phenylephrine: use cautiously (may increase afterload) πŸ”Ή Epinephrine: rescue for severe myocardial depression 5οΈβƒ£πŸ«€ 𝐓𝐀𝐑𝐆𝐄𝐓𝐒: π’π‹πŽπ– 𝐇𝐄𝐀𝐑𝐓, 𝐅𝐔𝐋𝐋 π‚πŽπ‘πŽππ€π‘πˆπ„π’, πƒπ‘π˜ 𝐋𝐔𝐍𝐆𝐒 πŸ”Ή Avoid hypotension πŸ”Ή Avoid tachycardia πŸ”Ή Avoid severe bradycardia πŸ”Ή Maintain sinus rhythm πŸ”Ή Avoid sudden afterload drop πŸ”Ή Avoid sudden afterload rise πŸ”Ή Maintain oxygenation and coronary perfusion 6οΈβƒ£πŸ« 𝐆𝐀: π’πŒπŽπŽπ“π‡ 𝐈𝐍, π’πŒπŽπŽπ“π‡ πŽπ”π“ πŸ”Ή Induce slowly πŸ”Ή Titrate small doses πŸ”Ή Avoid deep volatile anesthesia πŸ”Ή Ventilate gently πŸ”Ή Avoid hypoxia, hypercarbia, acidosis, high PEEP πŸ”Ή Extubate smoothly πŸ”Ή Plan HDU/ICU when risk is high 7οΈβƒ£πŸ¦΄ ππ„π”π‘π€π—πˆπ€π‹: π‚πŽππ“π‘πŽπ‹π‹π„πƒ π’π˜πŒππ€π“π‡π„π‚π“πŽπŒπ˜ πŸ”Ή Not automatically safer than GA πŸ”Ή Avoid dense high spinal πŸ”Ή Prefer low-dose spinal when suitable πŸ”Ή Titrate epidural/CSE slowly πŸ”Ή Keep pressors ready πŸ”Ή Use peripheral nerve blocks as allies πŸ”Ή Choose the technique with least hemodynamic swing 8οΈβƒ£πŸ‘΄ π†π„π‘πˆπ€π“π‘πˆπ‚ π‹πŽπ– 𝐄𝐅: π’πŒπ€π‹π‹ πƒπŽπ’π„, ππˆπ† π‚πŽππ’π„ππ”π„ππ‚π„π’ πŸ”Ή Start low, go slow πŸ”Ή Avoid delirium triggers πŸ”Ή Protect kidneys πŸ”Ή Avoid oversedation πŸ”Ή Mobilize early πŸ”Ή Use multimodal analgesia 9️⃣ πŸ–₯️ πŒπŽππˆπ“πŽπ‘πˆππ†: 𝐒𝐄𝐄 π„π€π‘π‹π˜, 𝐀𝐂𝐓 π„π€π‘π‹π˜ πŸ”Ή Arterial line πŸ”Ή POCUS early πŸ”Ή Do not rely on CVP alone πŸ”Ή Watch urine output, lactate, perfusion, temperature πŸ”Ή Monitor postoperative troponin in high-risk patients πŸ”Ή Decide postoperative destination before induction πŸ”Ÿ 🚨 π‡π˜ππŽπ“π„ππ’πˆπŽπ π€π‹π†πŽπ‘πˆπ“π‡πŒ πŸ”Ή Pause and check πŸ”Ή Classify the phenotype πŸ”Ή Correct the cause πŸ”Ή Reassess and repeat πŸ”Ή Use echo early πŸ”Ή Don’t treat every low BP with fluid 1️⃣1️⃣πŸ”₯ ππŽπ’π“πŽπ: π•πˆπ†πˆπ‹π€ππ‚π„ πƒπŽπ„π’πβ€™π“ 𝐄𝐍𝐃 𝐀𝐓 π’πŠπˆπ π‚π‹πŽπ’π”π‘π„ πŸ”Ή Control pain πŸ”Ή Prevent shivering πŸ”Ή Avoid hypoxia πŸ”Ή Watch fluid creep πŸ”Ή Restart HF drugs when stable πŸ”Ή Look for arrhythmia, ischemia, AKI, delirium 🎯 πŠπ„π˜ π“π€πŠπ„π€π–π€π˜π’ πŸ”Ή In low EF patients, the safest anesthesia is not GA or Neuraxials. πŸ”Ή It is the technique that produces the least hemodynamic swing. 𝐋𝐨𝐰 𝐄𝐅 = 𝐋𝐨𝐰 𝐌𝐚𝐫𝐠𝐒𝐧 βœ… Plan ahead. Optimize. Monitor closely. Treat early. Team approach. Safe outcomes.
KartikBSonawane's tweet photo. β€οΈβ€πŸ©Ή π‹πŽπ– 𝐄𝐅, 𝐍𝐨 π†π”π„π’π’π–πŽπ‘πŠ : π’πŒπ€π‘π“ ππ„π‘πˆπŽππ„π‘π€π“πˆπ•π„ ππ„π€π‘π‹π’β€οΈβ€πŸ©Ή #LowEF #HeartFailure #PerioperativeMedicine #Anesthesia #GeriatricAnesthesia #RegionalAnesthesia #NeuraxialAnesthesia #GeneralAnesthesia #GrayZonesInRA #GrayAreasInRA π†π‘π€π˜ π™πŽππ„π’ 𝐒𝐧 𝐑𝐀: Managing patients with low EF is all about preventing sudden swings. They are, PRELOAD sensitive, AFTERLOAD vulnerable, RHYTHM dependent, HYPOXIA intolerant, ANEMIA intolerant, and FLUID-OVERLOAD intolerant. 1️⃣ 🧭 ππ‘π„πŽπ: πŠππŽπ–πˆππ† 𝐓𝐇𝐄 𝐇𝐄𝐀𝐑𝐓 πŸ”Ή EF is only a number - assess physiology πŸ”Ή Look for red flags: dyspnea, edema, orthopnea, tachycardia πŸ”Ή Postpone elective surgery if HF is decompensated πŸ”Ή Continue chronic beta-blockers πŸ”Ή Stop SGLT2 inhibitors 3–4 days before surgery πŸ”Ή Individualize ACEI/ARB/ARNI & diuretics πŸ”Ή Plan anticoagulation & antiplatelet strategy early 2οΈβƒ£πŸ’§ π…π‹π”πˆπƒπ’: π“πˆππ˜ ππŽπ‹π”π’, π“πˆπ†π‡π“ π‘π„π€π’π’π„π’π’πŒπ„ππ“ πŸ”Ή Avoid blind fluid loading πŸ”Ή Give 100–150 mL bolus, then reassess πŸ”Ή Replace loss, not fear πŸ”Ή Use POCUS when unsure πŸ”Ή Start vasopressor early if vasodilated πŸ”Ή Avoid both underfilling & overload 3οΈβƒ£πŸ©Έ ππ‹πŽπŽπƒ: ππ‘πŽπ“π„π‚π“ πŽπ—π˜π†π„π, π€π•πŽπˆπƒ πŽπ•π„π‘π‹πŽπ€πƒ πŸ”Ή Correct anemia preoperatively πŸ”Ή Do not transfuse by Hb alone πŸ”Ή Transfuse one unit at a time πŸ”Ή Reassess after each unit πŸ”Ή Prevent bleeding: TXA, cell salvage, warming, calcium, TEG/ROTEM when available 4οΈβƒ£πŸ’‰ ππ‘π„π’π’πŽπ‘π’ & πˆππŽπ“π‘πŽππˆπ‚: 𝐓𝐑𝐄𝐀𝐓 𝐓𝐇𝐄 πŒπ„π‚π‡π€ππˆπ’πŒ πŸ”Ή Norepinephrine: vasodilated hypotension πŸ”Ή Dobutamine: low output, poor contractility πŸ”Ή Milrinone: LV dysfunction with PH/RV strain πŸ”Ή Vasopressin: catecholamine-resistant vasoplegia πŸ”Ή Phenylephrine: use cautiously (may increase afterload) πŸ”Ή Epinephrine: rescue for severe myocardial depression 5οΈβƒ£πŸ«€ 𝐓𝐀𝐑𝐆𝐄𝐓𝐒: π’π‹πŽπ– 𝐇𝐄𝐀𝐑𝐓, 𝐅𝐔𝐋𝐋 π‚πŽπ‘πŽππ€π‘πˆπ„π’, πƒπ‘π˜ 𝐋𝐔𝐍𝐆𝐒 πŸ”Ή Avoid hypotension πŸ”Ή Avoid tachycardia πŸ”Ή Avoid severe bradycardia πŸ”Ή Maintain sinus rhythm πŸ”Ή Avoid sudden afterload drop πŸ”Ή Avoid sudden afterload rise πŸ”Ή Maintain oxygenation and coronary perfusion 6οΈβƒ£πŸ« 𝐆𝐀: π’πŒπŽπŽπ“π‡ 𝐈𝐍, π’πŒπŽπŽπ“π‡ πŽπ”π“ πŸ”Ή Induce slowly πŸ”Ή Titrate small doses πŸ”Ή Avoid deep volatile anesthesia πŸ”Ή Ventilate gently πŸ”Ή Avoid hypoxia, hypercarbia, acidosis, high PEEP πŸ”Ή Extubate smoothly πŸ”Ή Plan HDU/ICU when risk is high 7οΈβƒ£πŸ¦΄ ππ„π”π‘π€π—πˆπ€π‹: π‚πŽππ“π‘πŽπ‹π‹π„πƒ π’π˜πŒππ€π“π‡π„π‚π“πŽπŒπ˜ πŸ”Ή Not automatically safer than GA πŸ”Ή Avoid dense high spinal πŸ”Ή Prefer low-dose spinal when suitable πŸ”Ή Titrate epidural/CSE slowly πŸ”Ή Keep pressors ready πŸ”Ή Use peripheral nerve blocks as allies πŸ”Ή Choose the technique with least hemodynamic swing 8οΈβƒ£πŸ‘΄ π†π„π‘πˆπ€π“π‘πˆπ‚ π‹πŽπ– 𝐄𝐅: π’πŒπ€π‹π‹ πƒπŽπ’π„, ππˆπ† π‚πŽππ’π„ππ”π„ππ‚π„π’ πŸ”Ή Start low, go slow πŸ”Ή Avoid delirium triggers πŸ”Ή Protect kidneys πŸ”Ή Avoid oversedation πŸ”Ή Mobilize early πŸ”Ή Use multimodal analgesia 9️⃣ πŸ–₯️ πŒπŽππˆπ“πŽπ‘πˆππ†: 𝐒𝐄𝐄 π„π€π‘π‹π˜, 𝐀𝐂𝐓 π„π€π‘π‹π˜ πŸ”Ή Arterial line πŸ”Ή POCUS early πŸ”Ή Do not rely on CVP alone πŸ”Ή Watch urine output, lactate, perfusion, temperature πŸ”Ή Monitor postoperative troponin in high-risk patients πŸ”Ή Decide postoperative destination before induction πŸ”Ÿ 🚨 π‡π˜ππŽπ“π„ππ’πˆπŽπ π€π‹π†πŽπ‘πˆπ“π‡πŒ πŸ”Ή Pause and check πŸ”Ή Classify the phenotype πŸ”Ή Correct the cause πŸ”Ή Reassess and repeat πŸ”Ή Use echo early πŸ”Ή Don’t treat every low BP with fluid 1️⃣1️⃣πŸ”₯ ππŽπ’π“πŽπ: π•πˆπ†πˆπ‹π€ππ‚π„ πƒπŽπ„π’πβ€™π“ 𝐄𝐍𝐃 𝐀𝐓 π’πŠπˆπ π‚π‹πŽπ’π”π‘π„ πŸ”Ή Control pain πŸ”Ή Prevent shivering πŸ”Ή Avoid hypoxia πŸ”Ή Watch fluid creep πŸ”Ή Restart HF drugs when stable πŸ”Ή Look for arrhythmia, ischemia, AKI, delirium 🎯 πŠπ„π˜ π“π€πŠπ„π€π–π€π˜π’ πŸ”Ή In low EF patients, the safest anesthesia is not GA or Neuraxials. πŸ”Ή It is the technique that produces the least hemodynamic swing. 𝐋𝐨𝐰 𝐄𝐅 = 𝐋𝐨𝐰 𝐌𝐚𝐫𝐠𝐒𝐧 βœ… Plan ahead. Optimize. Monitor closely. Treat early. Team approach. Safe outcomes.
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KhorsandiMaziar's profile image
Maziar Khorsandi @KhorsandiMaziar
My UW Cardiology grand rounds on low EF coronary revasc. Thank you @UWCardiology for the opportunity to give this talk! #coronaryarterydisease #CABG #LowEF @UW @UWCTSurgRes @uwashfellows @UWMedicine @UWSurgery @UWMedHeart https://t.co/x1FftgORbs
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dilmar_cunha's profile image
Dilmar Cunha @dilmar_cunha
52 yrs, 2 years after mitral valve replacement, complaint of shortness of breath EF 12% #CardioTwitter #echofirst #lowef
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MekhaelMario's profile image
Mario Mekhael @MekhaelMario
Intertwined relationship between LV dysfunction and Atrial Disease. Data from @makkayadr previously showed increased #AtrialFibrosis in #LowEF patients (https://t.co/gUZLugHR49). @nmarrouche #ProgressionOfDisease
MekhaelMario's tweet photo. Intertwined relationship between LV dysfunction and Atrial Disease. Data from @makkayadr previously showed increased #AtrialFibrosis in #LowEF patients (https://t.co/gUZLugHR49). @nmarrouche #ProgressionOfDisease https://t.co/91RSbRnepe
PrashSanders's profile image
Prash Sanders Verified account @PrashSanders
There is a lot to do with a progressive atrial disease https://t.co/nPaBbwFe7C
PrashSanders's tweet photo. There is a lot to do with a progressive atrial disease https://t.co/nPaBbwFe7C https://t.co/jZmzf0fqBV
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JCardSurg's profile image
Journal of Cardiac Surgery @JCardSurg
Check out this case series of #lowEF #CABG patients who received perioperative #Impella: https://t.co/CUwK05FOZQ #JOCS #JCardSurg
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