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Introduction
Administering anaesthesia to patients with preexisting cardiac disease is an interesting challenge. Most common cause of peri-operative morbidity and mortality in
cardiac patients is ischaemic heart disease(IHD). IHD
is number one cause of morbidity and mortality all over
the world1. Among the estimated 25 million patients in the
United States who undergo surgery each year, approximately 7 million are considered to be at high risk of IHD.
Indian figures are not available.Goldman et al reported
that 500,000 to 900,000 MIs occur annually worldwide
with subsequent mortality of 10-25%.Care of these patients require identification of risk factors, pre-operative
evaluation & optimization, medical therapy, monitoring and
the choice of appropriate anaesthetic technique and drugs.
Evaluation
Patients having any sort of cardiac ailment need to
be evaluated properly preoperatively 6.
History
History elicits the severity, progression and functional limitation introduced by cardiac disease. History
should include:-.
1.
2.
3.
4.
Risk stratification
In 1977, Goldman and colleagues proposed the landmark Cardiac Risk Index2 . Although not validated prospectively, this index was used extensively for preoperative cardiac risk assessment for the next two decades.
Subsequently, other cardiac risk indices were proposed
and adopted. In 1996, a 12-member task force of the
American College of Cardiology and the American Heart
Association (ACC/AHA) published guidelines regarding
the perioperative cardiovascular evaluation of patients
undergoing noncardiac surgery3 . In March 2002, these
guidelines were updated based on new data. The overriding theme remains that preoperative intervention is rarely
necessary, simply to lower the risk of surgery, unless such
1. Professor & Head, 2. Assistant Professor Deptt. of Anaesthesiology and Resuscitation, Dayanand Medical College & Hospital, Ludhiana.
Correspondence to: Geeta Tayal 1841, Street No. 6, Maharaj Nagar,Ludhiana. 141001. Email: kaultejk@yahoo.com
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Points Co mme n ts
5.
1.
11
2.
10
3.
0-5 points = 1%
4.
5.
6.
Emergency operations
7.
13-25 points=14%
8.
Intrathoracic, intraperitoneal
or aortic operation
9.
Aortic stenosis
6.
6-12 points = 7%
Class 4 angina
20
2.
20
3.
10
4.
10
5.
10
6.
Class 3 angina
10
7.
Emergency operation
10
8.
9.
10.
11.
12.
13.
Dysrrhythmias.
Examination
A careful general physical examination should be
done. It should include assessment of vital signs like blood
pressure, pulse rate and rhythm, jugular venous
pulse,oedema, pallor, cyanosis, clubbing , jaundice, lymphadenopathy. In systemic examination, cardiovascular
system should be examined for heart sounds & any murmur. Further evaluation is needed as per the findings.
Respiratory system also needs to be assessed in details.
3
4
1.
7.
Laboratory investigations
Anaesthetic management
1.
2.
Diabetes
<1: no testing
3.
Angina
4.
Q waves on ECG
5.
Ventricular arrhythmias
i. Stable haemodynamics ii. Prevent MI by optimizing myocardial oxygen supply and reducing oxygen demand iii. Monitor for ischaemia iv. Treat ischemia or infarction if it develops v. Normothermia vi. Avoidance of
significant anaemia
Management depends upon the type of surgery
whether emergency or elective. For emergency surgery
proceed for the surgery with medical management of
cardiac ailment. For elective surgery perioperative man281
Major clinical predictors are unstable coronary syndrome, decompensated heart failure, significant
dysrrhythmia and severe valvular disease. They mandate intensive management even if that leads to delay or cancellation except emergency surgery.
2.
Intermediate clinical predictors are mild angina pectoris, previous MI by history or pathological Q waves,
compensated or prior heart failure, insulin dependent
diabetes mellitus,and renal insufficiency. These are
markers of enhanced risk of peri-operative cardiac
complications. It appears reasonable to wait for 4-6
weeks after MI for elective surgery.
3.
Preoperative management
At risk patients need to be managed with pharmacologic and other perioperative interventions that can ameliorate perioperative cardiac events . Three therapeutic
options are available before elective noncardiac surgery.1.
2.
However it may not be necessary to intervene preoperatively (except for beta blocker therapy or 2 agonists) to improve perioperative outcome. Beta blockers
have been shown to be useful in reducing perioperative
morbidity and mortality in high risk cardiac patients and
preferably titrated to a heart rate of 50 to 60 bpm7. 2
agonists by virtue of their sympatholytic effects can be
useful in patients where beta blockers are contraindicated.
Nitroglycerine lowers LVEDP by reducing preload . It
improves collateral coronary flow and reduce systemic
B.P. Other agents like calcium channel blockers , ACE
inhibitors, aspirin, insulin, statins prove to be beneficial
perioperatively.
Coronary intervention should be guided by patients
cardiac condition( unstable angina, left main or equivalent
CAD, three vessel disease,decreased LV function) and
by the potential consequences of delaying the noncardiac
surgery for recovery after coronary revascularization 3
.Patients who underwent PCI had better outcome after
noncardiac surgery. However the need for dual anti-platelet therapy for several months to one year can significantly impact the perioperative course. Acute postoperative stent thrombosis has been reported when anti-platelet agents were temporarily held preoperatively to reduce
chance of bleeding. Continuing the therapy can lead to
significant postoperative bleeding. Discontinuing or modifying anti-platelet therapy should involve a multidisciplinary
team of cardiologist, surgeon, anaesthesiologist 8 .
Preanaesthetic considerations
Preoperative visit to the patient is very important. A
good rapport should be made with the patient and written
consent obtained. Patient should be explained about the
risk of surgery and anaesthesia.It is important to continue
the medications till the day of surgery like beta
blockers,calcium channel blocker ,digitalis.Potassium level
should be normal as hypokalemia can cause digitalis toxicity. Anticoagulants should be stopped.
Premedication
Significance of premedication in allaying anxiety in
cardiac patients is of paramount importance. This is to
prevent increase in B.P. and HR which can disturb the
myocardial oxygen supply and demand and can induce
ischaemia. Any combination of benzodiazepine like
lorazepam and opioid like morphine should be given one
hour prior to arrival in operation theatre.
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283
Intraoperative management
Monitoring
Incidence of ischaemia in the intraoperative period
is low( as compared with pre and postoperative period)
i. ECG is the most commonly used monitoring tool .
If ECG is to be used effectively as an ischaemic monitor,
the monitor should be set on diagnostic mode. Monitoring
three ECG leads ( II,V4,V5 or V3,V4,V5 ) improves recognition of ischaemia. The ST segment trending system
also helps in the detection of ischaemia ii. Blood pressure
iii. Pulse oximetry iv. Capnography v. Temperature monitoring vi. Urine output monitoring vii. Central venous pressure viii. Pulmonary artery pressure and cardiac output
can be measured with pulmonary artery catheter as required. In a haemodynamically unstable patient, the requirement of volume or inotropes can be judiciously calculated and response monitored closely ix. TEE
(transesophageal echocardiography) is a sensitive monitor for ischaemia. However TEE is not advocated for
routine use 9.
Choice of anaesthetics
General anaesthesia
1. Intravenous anaesthetics
ThiopentoneIt reduces myocardial contractility, preload and blood pressure and there is slight increase in heart rate. It should be administered slowly
and with caution.
Propofol-It reduces arterial blood pressure and
heart rate significantly. There is dose dependent reduction in myocardial contractility.It can be used in with good
ventricular function but is not good induction agent for
patients with CAD.
Ketamine-It is not good in IHD and valvular heart
disease patients.It is however a useful agent in situations
like cardiac tamponade and cyanotic heart disease.
Regional anaesthesia
MidazolamIt produces decrease in mean arterial pressure and increase in heart rate. It provides excellent amnesia and is widely used for patient with CAD
284
Hypertension
Hypertension is the commonest cardiac disease all
over the world. These patients are documented to have
associated CAD, left ventricular dysfunction, renal failure
which increase the perioperative risk. Hence it is advisable
to control BP preoperatively. But this does not need surgery to be deferred for weeks, to achieve ideal blood pressure control, in patients with mild to moderate hypertension. It is also important to evaluate for target organ damage. It is advisable to continue antihypertensives till the day
of surgery. For patients with marked elevations of BP intra
or post operatively should be managed by either nitroglycerine or sodiumnitroprusside by I.V. infusion. Intraarterial
B.P. monitoring is recommended for such patients. Any
factors of sympathetic stimulus should be avoided.
Dysrrhythmias
Dysrrhythmias may be a marker of severity of underlying CAD or left ventricular dysfunction. Asymptomatic ventricular ectopics with stable haemodynamic parameters do not need any treatment preoperatively. Similarly prophylactic treatment is not required in supraventricular tachycardia . In atrial fibrillation rate needs to be
controlled . Perioperatively if they occur can be treated
by calcium channel blockers ,beta blockers,adenosine.
Patients with conduction delay ,LBBB do not require pacing unless there is history of syncope.But in complete heart block, patients need to be paced.In patients on
permanent pace makers ,electro cautery should be used
with caution and for minimum period of time.The cautery plate should be as far as possible from the heart .Use
of bipolar cautery decreases the risk of pacemaker dysfunction. Use of magnet will turn pace maker into asynchronous mode , preventing unwanted inhibition.
The material submitted remains only an overview
of the guidelines, which will continue changing from time
to time, depending upon the evidence procured over a
period of time. Also the techniques need to be tailored
varying from patient to patient, surgical needs and the
facilities available.
285
References
1.
2.
3.
6.
Hall MJ, Owings MF. 2000 National Hospital Discharge Survey. Hyattsville, MD: Department of Health and Human Services; 2002. Advance Data From Vital and Health Statistics,
No. 329.
7.
London MJ, Zaugg M, Schaub MC, et al. Perioperative betaadrenergic receptor blockade: physiologic foundations and clinical controversies. Anesthesiology 2004; 100:170.
8.
9.
4.
5.
10. Breen P, Park K W. General anesthesia versus regional anesthesia. Int Anesthesiol Clin 2002; 40:61.
11. Bonow RO, Carabello B, de Leon AC Jr, et al. Guidelines for the
management of patients with valvular heart disease: Executive
summary: a report of theAmerican College of Cardiology /American Heart Association Task Force on Practice Guidelines (committee on management of patients with valvular heart disease).
Circulation 1998;98:1949-84.
2002
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2003
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2004
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2005
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2006
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2007
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