Preoperative management


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  • Normal finding in rest and stress CT study
  • Good wall thickening and motion
  • LV dilatation and multiple perfusion abnormalities both with stress and rest .
  • extensive regional and global dysfunction and LV dilatation .
  • Radionuclide Ventriculography using gamma camera
  • Stunned myocardium refers to transient depression of contractile function secondary to an acute ischemic insult. Hibernating myocardium is a form of contractile dysfunction of living myocytes in the setting of chronic ischemia or chronically reduced flow reserve Myocardial stunning is a temporary condition, a relatively short period (days, weeks) of postischaemic left ventricular dysfunction following a short episode of profound ischaemia [1]. The delay in recovery of the contractile deficit is not related in any way to residual regional hypoperfusion or irreversible cellular damage, but rather a consequence of a slow repair process of the minimal damage inflicted to the contractile proteins during the ischaemic episode. It is now well accepted that free radical production and intracellular calcium overload occurring typically at the time of reperfusion are to be blamed for this cellular damage [2, 3]. This phenomenon, first described in a controlled experimental setting was found to occur clinically as frequently as ischaemia itself in many patients with various ischaemic syndromes Hibernating myocardium, a clinical concept popularized by Rahimtoola, describes a more chronic (months, years) and supposedly stable condition of regional segmental dysfunction in patients with documented coronary obstructive lesions, in which revascularization procedures (CABG or PTCA) result more often in a partial rather than complete functional recovery [5]. In contrast to myocardial stunning where no histopathological abnormalities at the cellular level are demonstrable, biopsies of hibernating segments taken at the time of surgery have revealed marked structural alterations including substantial loss of myofibrillar content, cellular swelling and increased glycogen content [6]. Despite these alterations the dysfunctioning segments retain some contractile reserve when stimulated with inotropic agents. This characteristic of hibernating myocardium is used to advantage for diagnostic purposes.[
  • Preoperative management

    1. 1. Anesthesia For Cardiac Surgery Preoperative management 1 Abeer elnakera Anesthesia lecturer 2010
    2. 2. Why it is considered journey? <ul><li>Let us go in a journey throughout anesthetic management of cardiac surgery ……… </li></ul><ul><li>I hope to arrive safely without catastrophes </li></ul><ul><li>happy journey with help of </li></ul><ul><li>GOD </li></ul>
    3. 3. <ul><li>The anesthesiologist must follow the the progress of surgery intently and anticipate problems associated with each step because surgical manipulations often have a profound impact on circulatory function </li></ul><ul><li>let us go </li></ul>
    4. 4. objectives <ul><li>To understand how to clinically evaluate the cardiac pt. undergoing cardiac surgery </li></ul><ul><li>To know the importance of various cardiac testing procedures and correlate them with the clinical condition </li></ul><ul><li>To emphasize the importance of revision for patient medications </li></ul>
    5. 5. preoperative evaluation <ul><li>define the status of the patient’s medical condition </li></ul><ul><li>identify areas of uncertainty that require further evaluation, consultation or testing </li></ul><ul><li>Advise a strategy to improve or stabilize ongoing medical conditions prior to surgery </li></ul><ul><li>determine a prognostic risk classification </li></ul><ul><li>provide information to formulate an intraoperative and postoperative plan. </li></ul><ul><li>The anesthesiologist must clearly understand the intended surgical procedure. </li></ul>
    6. 6. preoperative evaluation <ul><li>is the most important thing in patient anxiolysis and assurance </li></ul>
    7. 7. Cardiovascular evaluation <ul><li>The information obtained from direct history and physical exam. will determine the requirement for subsequent evaluation, consultation or testing. </li></ul>
    8. 8. Cardiovascular evaluation 1- history the severity of the pathologic condition
    9. 9. AHA/ACC classification of chronic heart failure Marked symptoms at rest despite maximal medical therapy D. Refractory end-stage heart failure Structural heart disease, dyspnea and fatigue, impaired exercise tolerance C. Symptomatic heart failure Previous myocardial infarction left ventricular dysfunction, valvular heart disease B. Asymptomatic heart failure Hypertension, diabetes mellitus, coronary artery disease, family history of cardiomyopathy A. High risk for developing heart failure
    10. 10. The Canadian Cardiovascular Society Classification System of angina pectoris . <ul><li>Class I: Ordinary physical activity, such as walking and climbing stairs does not cause angina. Angina occurs with strenuous, rapid, or prolonged exertion </li></ul><ul><li>Class II: Slight limitation of ordinary activity. Angina occurs on walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in the cold or wind, under emotional stress or only during the few hours after awakening. Angina occurs on walking more than two blocks on the level and climbing more </li></ul><ul><li>than one flight of ordinary stairs at a normal pace and under normal conditions </li></ul><ul><li>Class III: Marked limitations of ordinary physical activity. Angina occurs on walking one or two blocks on the level ground and climbing one flight of stairs in normal conditions and at a normal pace </li></ul><ul><li>Class IV: Inability to carry on any physical activity without anginal discomfort. Symptoms may be present at rest </li></ul>
    11. 11. Other cardiac symptoms <ul><li>Symptoms of right heart failure : </li></ul><ul><ul><li>Pedal edema </li></ul></ul><ul><ul><li>Weight gain </li></ul></ul><ul><li>Palpitations </li></ul><ul><li>Low cardiac output symptoms </li></ul><ul><ul><li>Easy fatigability </li></ul></ul><ul><ul><li>Syncope </li></ul></ul><ul><li>Thromboembolic manifestation secondary to LA thrombus </li></ul><ul><li>Cyanotic spells </li></ul><ul><li>Recurrent chest infection, dyspnea and orthopnea secondary to pulmonary congestion </li></ul>
    12. 12. 2-Physical examination <ul><li>Airway assessment </li></ul><ul><li>Auscultation of chest : wheezes, rales, diminished air entry </li></ul><ul><li>Auscultation of the heart : murmurs, gallop, arrhythmias </li></ul>
    13. 13. 2-Physical examination <ul><li>Vital signs: </li></ul><ul><ul><li>Pulse </li></ul></ul><ul><ul><li>Bl. P. Must be < 180/110 </li></ul></ul>sinus AF controlled Not controlled Apical pulse less than 100
    14. 14. 3-investigations <ul><li>Electrocardiogram: </li></ul><ul><ul><li>Rate and rhythm abnormalities: </li></ul></ul><ul><ul><ul><li>Arrhythmias are potentially more serious and require immediate evaluation (e.g. Electrolyte abnormalities ,digitalis toxicity) </li></ul></ul></ul><ul><ul><ul><li>AF is considered controlled if ventricular rate </li></ul></ul></ul><ul><ul><ul><li>< 80-90/min at rest and not exceed 120/min for stress or exercise </li></ul></ul></ul><ul><ul><li>Cardiac chamber enlargement </li></ul></ul><ul><ul><li>Conduction defects </li></ul></ul>
    15. 15. Electrocardiogram: <ul><ul><li>Ischemia and infarction: </li></ul></ul><ul><ul><ul><li>New findings of active ischemia require immediate </li></ul></ul></ul><ul><ul><ul><li>attention. </li></ul></ul></ul><ul><ul><ul><li>The presence of Q waves indicates an old transmural myocardial infarction </li></ul></ul></ul><ul><ul><li>Metabolic and drug effects: </li></ul></ul><ul><ul><ul><li>Hypokalemia or hyperkalemia </li></ul></ul></ul><ul><ul><ul><li>Digitalis toxicity </li></ul></ul></ul><ul><ul><li>a normal ECG does not preclude the presence of significant cardiac disease in the adult, child, or infant. </li></ul></ul>
    16. 16. Chest radiograph <ul><li>According to the necessity for the planned clinical procedure (i.e. a lateral chest film is essential in a repeat sternotomy), </li></ul><ul><li>assessing the patient’s clinical condition (a history of smoking, recent respiratory infection, chronic obstructive pulmonary disease (COPD), or cardiac disease.) </li></ul>
    17. 17. Chest radiograph <ul><li>An assessment of pulmonary condition and maybe cardiovascular status </li></ul><ul><ul><li>radiographic evidence of pulmonary vascular congestion suggests poor systolic function. </li></ul></ul><ul><ul><li>For patients with valvular heart disease, </li></ul></ul><ul><ul><li>a normal CXR is more useful than an abnormal radiograph in assessing ventricular function. </li></ul></ul><ul><ul><li>The presence of a cardio-to-thoracic ratio < 50% is a sensitive indicator of an ejection fraction > 50% and of a cardiac index > 2.5 L/min/m2. </li></ul></ul>
    18. 18. Chest radiograph <ul><li>An assessment of pulmonary condition and maybe cardiovascular status </li></ul><ul><ul><li>For patients with CAD , an abnormal CXR is more useful than a normal radiograph in assessing ventricular function. Cardiomegaly is a sensitive indicator of a reduced ejection fraction </li></ul></ul>
    19. 19. Chest radiograph <ul><li>An assessment of pulmonary condition and maybe cardiovascular status </li></ul><ul><ul><li>In infants and children </li></ul></ul><ul><ul><ul><li>with increased pulmonary blood flow (as with a large ventricular septal or atrial septal defect), the pulmonary artery and pulmonary vasculature is prominent. </li></ul></ul></ul><ul><ul><ul><li>In contrast, patients with reduced pulmonary blood flow </li></ul></ul></ul><ul><ul><ul><li>(as with tetralogy of Fallot or pulmonary atresia) </li></ul></ul></ul><ul><ul><ul><li>may manifest a small pulmonary artery and diminished vascularity. </li></ul></ul></ul><ul><ul><ul><li>Some congenital lesions are </li></ul></ul></ul><ul><ul><ul><li>associated with classic radiographic cardiac silhouettes : </li></ul></ul></ul><ul><ul><ul><li>the boot-shaped heart of tetralogy of Fallot, </li></ul></ul></ul>
    20. 20. Stress testing <ul><li>To establish the diagnosis of CAD, </li></ul><ul><li>Assess the severity of known CAD, </li></ul><ul><li>Establish the viability of regions of myocardium, </li></ul><ul><li>or evaluate anti-anginal therapy. </li></ul>
    21. 21. Stress testing <ul><li>Types : </li></ul><ul><ul><li>Exercise </li></ul></ul><ul><ul><li>Pharmacological using </li></ul></ul><ul><ul><ul><li>Adenosine </li></ul></ul></ul><ul><ul><ul><li>Dipyridamol </li></ul></ul></ul><ul><ul><ul><li>Dobutamine ß1 agonist </li></ul></ul></ul><ul><ul><li>Pharmacologic stress testing can be performed in conjunction with myocardial perfusion scintigraphy or echocardiography . </li></ul></ul>Potent coronary dilators
    22. 22. Myocardial perfusion scintigraphy <ul><li>assesses myocardial blood flow, myocardial viability, the number and extent of myocardial perfusion defects, and allows for risk stratification. </li></ul><ul><li>Myocardial perfusion scintigraphy is performed most commonly in conjunction </li></ul><ul><li>with stress testing. </li></ul>
    23. 23. Myocardial perfusion scintigraphy
    24. 24. Myocardial perfusion scintigraphy
    25. 25. Myocardial perfusion scintigraphy
    26. 26. Myocardial perfusion scintigraphy
    27. 27. Radionuclide angiography <ul><li>Radionuclide angiography allows assessment of RV and LV performance. </li></ul><ul><ul><li>SV,EF, COP </li></ul></ul><ul><li>CONGENITAL ANOMALIES </li></ul><ul><ul><li>INTRACARDIAC SHUNTS </li></ul></ul>
    28. 28. Radionuclide angiography
    29. 29. Echocardiography <ul><li>TTE and TEE has revolutionized the noninvasive structural and functional assessment of acquired and congenital </li></ul><ul><ul><li>heart disease. They allow </li></ul></ul><ul><ul><li>Assessment of cardiac anatomy. </li></ul></ul><ul><ul><li>Assessment of ventricular function </li></ul></ul><ul><ul><li>Assessment of valvular abnormalities. </li></ul></ul><ul><ul><li>Assessment of prosthetic valves </li></ul></ul>
    30. 30. Echocardiography <ul><li>TTE and TEE also allow: </li></ul><ul><ul><li>Characterization of cardiomyopathies </li></ul></ul><ul><ul><li>Assessment of the pericardium. </li></ul></ul><ul><ul><li>Assessment of cardiac and extra cardiac masses. </li></ul></ul><ul><ul><li>Contrast echocardiography allowing assessment of myocardial perfusion, intracardiac Shunts </li></ul></ul>
    31. 31. Stress echocardiography. <ul><li>Resting abnormalities indicate prior infarction, hibernating or stunned myocardium; </li></ul><ul><li>stress-induced abnormalities are specific for ischemia. </li></ul><ul><li>dobutamine stress echocardiography </li></ul><ul><ul><li>may be useful in determining myocardial viability. Regions that are hypo kinetic, a kinetic, or dyskinetic at rest and improve with dobutamine administration probably contain areas of stunned or hibernating myocardium. Such areas demonstrate functional improvement after myocardial revascularization. </li></ul></ul>
    32. 32. Cardiac catheterization <ul><li>Cardiac catheterization remains the gold standard for evaluation of acquired and congenital heart disease. </li></ul>
    33. 33. RT. Heart catheterization
    34. 34. RT. Heart catheterization <ul><li>pressure measurements in the right atrium, right ventricle, pulmonary artery, and pulmonary artery occlusion position </li></ul><ul><li>Right atrial, right ventricular, and pulmonary angiography may be performed </li></ul><ul><ul><li>on infants and children to delineate congenital </li></ul></ul><ul><ul><li>lesions. </li></ul></ul>
    35. 35. LT. Heart catheterization
    36. 36. LT. Heart catheterization <ul><ul><li>It allows </li></ul></ul><ul><li>measurement of Pressures in the aorta, left ventricle, and left atrium </li></ul><ul><li>Assessment of EF </li></ul><ul><li>CORONARY ANGIOGRAPHY </li></ul><ul><li>COP determination </li></ul>
    37. 37. Cardiac catheterization <ul><li>Both Systemic and pulmonary vascular resistances are made using hemodynamic and cardiac output data </li></ul><ul><li>Saturation data : </li></ul><ul><ul><li>multiple samples from locations in the great </li></ul></ul><ul><ul><li>vessels and cardiac chambers are necessary to localize the shunt and determine its magnitude and direction. </li></ul></ul>
    38. 38. Cardiac catheterization <ul><li>Allows assessment of valve lesions </li></ul><ul><li>Assessment of pulmonary vascular anatomy: </li></ul><ul><ul><li>For infants and children with congenital heart </li></ul></ul><ul><ul><li>disease, special procedures may be necessary to assess the pulmonary vasculature and the extent of pulmonary vascular disease. </li></ul></ul>
    39. 39. 4-Preoperative medications <ul><li>vary with each clinical condition </li></ul><ul><ul><ul><li>stop digitalis for one half life before CPB </li></ul></ul></ul><ul><ul><ul><li>OR </li></ul></ul></ul><ul><ul><ul><li>Correction of electrolyte disturbances hypokalemia ,hypomagnesaemia and hypocalcaemia ( notice the pt on diuretics) in patients with risk of HF or rapid AF </li></ul></ul></ul>
    40. 40. 4-Preoperative medications <ul><li>continue antianginal ( The discontinuance of beta-blockers has been associated with an increased risk of angina and myocardial infarction (MI) </li></ul><ul><li>continue ant arrhythmic and hypertensive ttt </li></ul><ul><li>Major anticoagulants , such as warfarin Coumadin), should be discontinued in elective </li></ul><ul><ul><li>cases, with conversion to intravenous heparin if anticoagulation is critical </li></ul></ul>
    41. 41. euroscore <ul><li>C:My DocumentsRisk Calculator.mde </li></ul>
    42. 43. Summery <ul><li>Anesthesia for cardiac surgery is a continuum that starting from preoperative assessment, Preoperative visit is highly important </li></ul><ul><li>The patient must be evaluated clinically then by investigation </li></ul><ul><li>It is highly important to correlate the clinical data with testing results </li></ul>
    43. 44. Thank you