Evaluation of Cardiac Pts for NonCardiac Surgery


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Evaluation of Cardiac Pts for NonCardiac Surgery

  1. 1. Evaluation of the Cardiac Patient for Non-cardiac Surgery Vincent Conte, MD Attending Anesthesiologist and Director of Anesthesia Services at Baptist Children’s Hospital (Ret.) Assistant Clinical Professor FIU School of Nursing
  2. 2. Introduction <ul><li>Patients with co-existing Cardiac disease will be coming for surgery very frequently for NON-cardiac procedures </li></ul><ul><li>Familiarity with the AHA/ACC Guidelines is very important to be able to adequately assess the status of these patients. </li></ul>
  3. 3. Topics of Discussion <ul><li>Familiarize yourselves with the AHA/ACC Guidelines </li></ul><ul><li>Learn to identify which patients present a significant risk of having a cardiac event intraoperatively </li></ul><ul><li>Learn what steps in the evaluation process are important to be done preoperatively to further identify which patients are at risk </li></ul>
  4. 4. Prevalence of Cardiovascular Disease <ul><li>Estimated 22,000,000 US Adults have significant Coronary Artery Disease; 17 per 1000 (2004 AHA) </li></ul><ul><li>Of these, 6,400,000 have active or unstable angina </li></ul><ul><li>Another 50,000,000 have Hypertension (16%); 217 per 1000 </li></ul><ul><li>There are 4,600,000 Strokes each year in the US and 4,800,000 new cases of CHF </li></ul>
  5. 5. <ul><li>That brings the total number of Americans who have some type of Cardiovascular disease to 77,000,000 or 26% of the total population </li></ul><ul><li>The more alarming statistic is that approx. 14% of patients with Hypertension and a normal resting EKG have undiagnosed SIGNIFICANT Coronary Artery disease </li></ul>Prevalence of Cardiovascular Disease
  6. 6. Cardiac Predictors <ul><li>All of the flow charts and models are based on factors that are called “Cardiac Predictors” </li></ul><ul><li>They are graded as Minor, Intermediate, and Major </li></ul><ul><li>The preop evaluation all depends on which predictors are present and how many as well </li></ul>
  7. 7. Minor Cardiac Predictors
  8. 8. Intermediate Cardiac Predictors
  9. 9. Major Cardiac Predictors
  10. 10. Flow Charts Based on Predictors <ul><li>The following are the flow charts created by the AHA/ACC based on which and how many predictors are present preoperatively </li></ul><ul><li>Also keep in mind that your clinical judgment has a lot to do with what level you place the patient at within the flow charts </li></ul><ul><li>If you think the patient is sicker than they look on paper, do not hesitate to place them in a higher risk category to start with </li></ul>
  11. 11. MET Scale <ul><li>Also used to place patients at their appropriate positions in the flow charts is the MET Scale </li></ul><ul><li>This is based on a measure called a “Metabolic Unit” </li></ul><ul><li>A unit is proportional to a certain amount of physical exertion </li></ul><ul><li>Based on how many MET’s a person is functioning at, an approximation of their cardiac status can be made </li></ul><ul><li>IT IS VERY SUBJECTIVE, but can still act as a quick screening scale to rapidly assess overall cardiac status and health </li></ul>
  12. 12. MET Scale
  13. 14. Intermediate Predictors
  14. 18. Cardiac Assessment <ul><li>You can see that for the most part, the charts are easy to follow and do a good job of delineating who and where a patient should be placed in the sequence </li></ul><ul><li>However, a grey area exists with respect to newly diagnosed Valvular Heart Disease that is deemed mild by the Cardiologist </li></ul><ul><li>Some feel that this should be a MAJOR indicator while others feel that it should be an INTERMEDIATE indicator </li></ul>
  15. 19. Cardiac Risk Assessment <ul><li>Other factors may help you determine what category to put such patients. </li></ul><ul><li>Co-existing Hypertension or DM may bump them up to MAJOR while a lack of symptoms and no other co-existing disease may keep them in INTERMEDIATE </li></ul><ul><li>Regardless, a quick phone consultation should be made with the Cardiologist and his recommendations should be noted in the chart as well as documenting that you DID contact the Cardiologist in this matter </li></ul><ul><li>Then you would just proceed along the recommended Anesthesia Treatment guidelines for whichever Valvular lesion the patient might have </li></ul>
  16. 20. Common Intraoperative Cardiac Conditions <ul><li>The most common Cardiac complications you may encounter in the OR are: </li></ul><ul><li>ST Segment changes (Intraop Ischemia) </li></ul><ul><li>Myocardial Infarction </li></ul><ul><li>Sinus Bradycardia </li></ul><ul><li>Non-lethal Ventricular Arrhythmias </li></ul><ul><li>Pulmonary Edema </li></ul>
  17. 21. ST Segment Changes <ul><li>This event can manifest as either elevation or depression of the ST Segment </li></ul><ul><li>The etiology can vary: </li></ul><ul><li>1) Inadequate coronary perfusion vs. demand (AS) </li></ul><ul><li>2) Acute Myocardial Ischemia or Infarction </li></ul><ul><li>3) Myocardial contusion (Trauma) </li></ul><ul><li>4) Electrolyte abnormalities (hypo/hyperkalemia, hypercalcemia) </li></ul><ul><li>5) Head injury with raised ICP and elevated systemic blood pressure </li></ul><ul><li>6) Hypothermia </li></ul><ul><li>7) Post-Defibrillation injury </li></ul>
  18. 22. ST Segment Changes <ul><li>Typically, this is seen in: </li></ul><ul><li>Patients with pre-existing CAD </li></ul><ul><li>Any changes causing either an increase in myocardial O2 demand or decreased supply (Tachycardia, hypertension/hypotension, hypoxemia, hemodilution, or Coronary spasm) </li></ul><ul><li>After head or chest trauma </li></ul><ul><li>During vaginal delivery or C-section </li></ul>
  19. 23. ST Segment Changes <ul><li>PREVENTION: </li></ul><ul><li>Carefully evaluate and prepare patients with CAD preoperatively </li></ul><ul><li>Carefully manage hemodynamics and hematocrit to optimize myocardial O2 Balance </li></ul><ul><li>Identify and evaluate pre-existing ST segment abnormalities preoperatively </li></ul>
  20. 24. ST Segment Changes <ul><li>Manifestations: </li></ul><ul><li>In an awake patient, they may describe Chest pain radiating into the arms and throat </li></ul><ul><li>Dyspnea </li></ul><ul><li>Nausea and vomiting </li></ul><ul><li>Altered level of consciousness or cognitive function </li></ul>
  21. 25. ST Segment Changes <ul><li>EKG/Systemic Manifestations: </li></ul><ul><li>Depression or elevation of the ST segment from the isoelectric level </li></ul><ul><li>Development of Q waves </li></ul><ul><li>Arrhythmias (PVC’s, ventricular tachycardia, Ventricular fibrillation </li></ul><ul><li>Hypotension </li></ul><ul><li>Elevated ventricular filling pressures (stiff ventricle) </li></ul><ul><li>V wave on pulmonary artery wedge tracing </li></ul>
  22. 26. ST Segment Changes <ul><li>Management: </li></ul><ul><li>Verify ST segment changes (check lead placement, compare to previous EKG’s) </li></ul><ul><li>Ensure adequate oxygenation and ventilation (check pulse oximeter, capnograph, send an ABG) </li></ul><ul><li>Treat tachycardia and/or hypertension (B-Blockade with Esmolol, Labetolol, incr. depth of anesthesia) </li></ul><ul><li>NTG IV Infusion, 0.25-2micrograms/kg/min; (titrate to desired effect) </li></ul><ul><li>Calcium Channel Blockade (Verapamil IV 2.5 mg, Diltiazem IV 2.5 mg </li></ul>
  23. 27. ST Segment Changes <ul><li>Management: </li></ul><ul><li>6) Treat hypotension and/or bradycardia </li></ul><ul><li>7) Optimize circulating fluid volume </li></ul><ul><li>8) Support myocardial contractility as needed using inotropic agents (Ephedrine, Dopamine, Dobutamine, Epinephrine) </li></ul><ul><li>9) AVOID NTG/CA Blockers until hypotension or bradycardia are resolved </li></ul><ul><li>10) Inform the surgeon; if possible terminate procedure early </li></ul><ul><li>11) Send blood chemistries (ABG, H/H, Electrolytes, Glucose, CK-MB, Troponin) </li></ul><ul><li>12) Treat underlying causes of ST Segment changes if other than Myocardial Ischemia </li></ul>
  24. 28. ST Segment Changes <ul><li>COMPLICATIONS: </li></ul><ul><li>Myocardial Infarction </li></ul><ul><li>Arrhythmias </li></ul><ul><li>Cardiac Arrest </li></ul><ul><li>Complications from placement of PA catheter </li></ul><ul><li>Complications from placement of TEE </li></ul>
  25. 29. Myocardial Infarction <ul><li>Defined as myocardial cell death due to inadequate cellular perfusion. </li></ul><ul><li>Transmural (Q wave) infarctions involve the entire thickness of the myocardial wall </li></ul><ul><li>Subendocardial (non-Q wave) infarctions involve only the subendocardial portion of the myocardial wall </li></ul>
  26. 30. Myocardial Infarction <ul><li>Etiology: </li></ul><ul><li>Acute occlusion of a coronary artery (thrombus, plaque) </li></ul><ul><li>Inadequate coronary perfusion for a given myocardial O2 demand </li></ul><ul><li>Acute dissection of the aorta </li></ul>
  27. 31. Myocardial Infarction <ul><li>Typical Situations: </li></ul><ul><li>In patients with pre-existing CAD/Angina Pectoris </li></ul><ul><li>In older patients (>70 years old) </li></ul><ul><li>Patients with peripheral vascular disease </li></ul><ul><li>Patients with DM (silent myocardial ischemia) </li></ul><ul><li>During any acute change in myocardial O2 demand or delivery (Tachycardia, hypertension, hypotension, hypoxemia, hemodilution, or Coronary spasm) </li></ul><ul><li>Patients with Aortic or Mitral STENOSIS </li></ul><ul><li>Patients with recent CABG surgery </li></ul><ul><li>Acute Carbon Monoxide poisoning </li></ul>
  28. 32. Myocardial Infarction <ul><li>Prevention: </li></ul><ul><li>Carefully evaluate and prepare patients with CAD preoperatively (evaluate myocardial function and reserve; is patient optimized?) </li></ul><ul><li>Avoid elective anesthesia and surgery in patients with Unstable Angina or with a h/o MI in the previous 6 months </li></ul><ul><li>Optimize hemodynamics and hematocrit during anesthesia </li></ul>
  29. 33. Myocardial Infarction <ul><li>Manifestations: </li></ul><ul><li>Differentiated from Ischemia by persistence and progression of ST segment and T wave changes </li></ul><ul><li>Elevated cardiac isoenzymes </li></ul><ul><li>Awake patient with chest pain, dyspnea, nausea and vomiting </li></ul><ul><li>EKG abnormalities (ST depressions/elevations; hyperacute, prominent T waves; development of Q waves) </li></ul><ul><li>Arrhythmias (PVC’s, V Tach, V Fib, AV Block, Bundle branch block) </li></ul><ul><li>Hypotension, Tachycardia/Bradycardia </li></ul><ul><li>Elevated Ventricular filling pressures </li></ul>
  30. 34. Myocardial Infarction <ul><li>Management: </li></ul><ul><li>VERIFY manifestations of ongoing myocardial ischenia (if patient is awake assess clinical signs and symptoms, check lead placement and check multiple leads, obtain a 12-lead EKG ASAP, evaluate hemodynamic status) </li></ul><ul><li>INFORM the surgeon and terminate surgery ASAP </li></ul><ul><li>Request ICU bed ASAP </li></ul><ul><li>If present, treat Ventricular Arrhythmias (Lido IV 1-1.5mg/kg bolus, then 1-4mg/min; Procainamide IV 500mg over 10-20 minutes, then 2-6mg/min) </li></ul>
  31. 35. Myocardial Infarction <ul><li>Management: </li></ul><ul><li>5) Place an arterial line and monitor blood pressure VERY carefully </li></ul><ul><li>6) Treat tachycardia (MOST important!!) and/or hypertension (increase depth of anesthesia, B-Blockade w/ Esmolol, Labetolol and/or Cardene for hypertension) </li></ul><ul><li>7) NTG IV @ 0.25-2 microgms/min (titrate PRN) </li></ul><ul><li>8) CA Channel Blockers (Verapamil IV 2.5 mg and repeat as needed, or Diltiazem IV 2.5 mg, also repeat as needed) </li></ul><ul><li>9) If hypotension develops, maintain BP with Neosynephrine and volume (cardiac perfusion takes precedence over afterload reduction) </li></ul>
  32. 36. Myocardial Infarction <ul><li>Management: </li></ul><ul><li>10) Consider placing an SG cath to guide with fluid management (go by LVEDP to avoid overload) </li></ul><ul><li>11) Support myocardial contractility as needed with Inotropes such as Dopamine, Dobutamine, Epi (use with EXTREME caution as these will also increase myocardial O2 demand) </li></ul><ul><li>12) Avoid NTG and CA Channel Blockers until hypotension or bradycardia are resolved </li></ul><ul><li>13) Treat pain and anxiety if patient is awake </li></ul><ul><li>14) Send Labs (ABG’s, H/H, electrolytes, CK, CK-MB, Troponins) </li></ul><ul><li>15) If hypotension persists consider placement of an IABP to decrease workload of myocardium and allow to rest and recooperate </li></ul>
  33. 37. Myocardial Infarction <ul><li>Complications: </li></ul><ul><li>CHF </li></ul><ul><li>Arrhythmias </li></ul><ul><li>Cardiac Arrest </li></ul><ul><li>Thrombus formation and complications from their migration </li></ul><ul><li>Papillary muscle dysfunction or rupture </li></ul><ul><li>Rupture of Interventricular septum or ventricular wall </li></ul>
  34. 38. Sinus Bradycardia <ul><li>Definition: A heart rate less than 60 bpm in an adult, in which the impulse formation begins in the sinus node </li></ul><ul><li>Etiology: </li></ul><ul><li>Increased vagal tone (vaso-vagal, valsalva) </li></ul><ul><li>Drug induced </li></ul><ul><li>Hypoxemia </li></ul><ul><li>Cardiac Ischemia </li></ul><ul><li>Hypothermia </li></ul><ul><li>Hypothyroidism </li></ul><ul><li>Brain injury with herniation </li></ul><ul><li>Physiologic (congenital; physical conditioning) </li></ul>
  35. 39. Sinus Bradycardia <ul><li>Typical Situations: </li></ul><ul><li>An isolated finding during preop evaluation </li></ul><ul><li>Following administration of drugs (Narcotics, Halothane, B-Blockers, CA Channel blockers, Anticholinesterases, A2-agonists – Clonidine) </li></ul><ul><li>During Vagal stimulation (Traction on eye or peritoneum, Laryngoscopy and Intubation, Bladder catheterization) </li></ul><ul><li>During hypertensive episodes (Baroreceptor reflex) </li></ul><ul><li>During spinal/epidural anesthesia w/ high level </li></ul><ul><li>ECT </li></ul>
  36. 40. Sinus Bradycardia <ul><li>Prevention: </li></ul><ul><li>Premedicate patients at risk with anticholinergics (Atropine IM 0.4 mg, Robinul IM 0.2 mg) </li></ul><ul><li>Treat bradycardia early during high spinal/epidurals (Atropine IV 0.4-0.8mg, Robinul IV 0.2-0.4mg) </li></ul><ul><li>Avoid excess traction on peritoneum or extraoccular muscles </li></ul><ul><li>Avoid excess manipulation of the carotid sinus </li></ul>
  37. 41. Sinus Bradycardia <ul><li>Manifestations: </li></ul><ul><li>Slow heart rate on EKG, Pulse Oximeter, A-Line, NIBP Monitor, palpation of peripheral pulses </li></ul><ul><li>Hypotension </li></ul><ul><li>Symptoms in a conscious patient: Nausea, Vomiting, Change in mental status </li></ul><ul><li>Junctional or Idioventricular escape beats </li></ul>
  38. 42. Sinus Bradycardia <ul><li>Management: </li></ul><ul><li>Verify bradycardia and assess its hemodynamic significance (Check MULTIPLE monitors to confirm or palpate a peripheral pulse) </li></ul><ul><li>Ensure adequate oxygenation and ventilation (bradycardia is common with hypoxic conditions esp. in pediatric patients) </li></ul><ul><li>Call for help if significant hemodynamic changes are associated with the bradycardia </li></ul>
  39. 43. Sinus Bradycardia <ul><li>Management: </li></ul><ul><li>4) If bradycardia IS associated with SEVERE hypotension, loss of consciousness or seizures, Rx with Epi IV, 10microgram bolus (1cc) and repeat as needed until desired effect is achieved </li></ul><ul><li>5) If Bradycardia fails to resolve with Epi, consider Transcutaneous pacing and Isoproterenol infusion at 1-3 micrograms/min. </li></ul><ul><li>6) Begin CPR if necessary </li></ul>
  40. 44. Sinus Bradycardia <ul><li>Management: </li></ul><ul><li>7) If bradycardia is associated with only mild to moderate hypotension (10-15% drop from pre-brady rate), RX with Ephedrine IV in 5-10 mg increments and/or Atropine IV 0.4mg and/or Robinul IV 0.2mg; Repeat above as necessary until desired effects obtained </li></ul><ul><li>8) Scan surgical field once brady is treated for possible physical causes; if none are present, observe patient closely both intra and post-op </li></ul>
  41. 45. Sinus Bradycardia <ul><li>Complications: </li></ul><ul><li>Escape arrhythmias (Junctional/Idioventricular) </li></ul><ul><li>Cardiac Arrest </li></ul><ul><li>Complications with pacer operation or placement </li></ul><ul><li>Tachyarrhythmias and hypertension secondary to drug treatment (overtreatment will result in “chasing your own tail”) </li></ul>
  42. 46. Non-Lethal Ventricular Arrhythmias <ul><li>Definition: </li></ul><ul><li>Nonlethal ventricular (wide QRS complex) arrhythmias NOT requiring ACLS although they may eventually lead to ventricular fibrillation </li></ul>
  43. 47. Non-Lethal Ventricular Arrhythmias <ul><li>Etiology: </li></ul><ul><li>PVC’s </li></ul><ul><li>Abnormal automaticity of ventricular myocardium </li></ul><ul><li>Re-entry phenomena </li></ul><ul><li>Drug Toxicity </li></ul><ul><li>R on T phenomenon </li></ul>
  44. 48. Non-Lethal Ventricular Arrhythmias <ul><li>Typical Situations: </li></ul><ul><li>PVC’s provoked by tea, coffee, alcohol, tobacco, or emotional excitement </li></ul><ul><li>Patients with Myocardial Ischemia or infarction </li></ul><ul><li>Hypoxemia and/or hypercarbia </li></ul><ul><li>Potassium and/or Acid Base disturbances </li></ul><ul><li>Patients with Mitral Valve Prolapse </li></ul><ul><li>Excessive depth of anesthesia </li></ul>
  45. 49. Non-Lethal Ventricular Arrhythmias <ul><li>Typical Situations: </li></ul><ul><li>7) Direct Mechanical stimulation of the heart </li></ul><ul><li>8) Acute hypertension and/or tachycardia </li></ul><ul><li>9) Acute HYPOtension and/or bradycardia </li></ul><ul><li>10) Drugs (Halothane, Dig, Tricyclics, Aminophylline, antihistamines </li></ul><ul><li>11) Hypothermia </li></ul>
  46. 50. Non-Lethal Ventricular Arrhythmias <ul><li>Manifestations: </li></ul><ul><li>Wide QRS complex on EKG NOT preceeded by a P wave </li></ul><ul><li>PVC’s </li></ul><ul><li>Ventricular tachycardia </li></ul><ul><li>Torsade de pointes (paroxysms of V-tach in which the QRS axis changes direction continuously) </li></ul>
  47. 51. Non-Lethal Ventricular Arrhythmias <ul><li>Management: </li></ul><ul><li>Ensure adequate oxygenation and ventilation </li></ul><ul><li>Check if the arrhythmia is hemodynamically significant </li></ul><ul><li>If it is: Lidocaine IV 1-1.5 mg bolus; consider synchronized countershock if change is severe </li></ul><ul><li>Diagnose the arrhythmia </li></ul><ul><li>If V-tach is present repeat Lido q/15 min and start infusion at 1-4 mg/min; consider synched countershock </li></ul>
  48. 52. Non-Lethal Ventricular Arrhythmias <ul><li>Management: </li></ul><ul><li>6) If Torsade de pointes is present give MgSO4, 1-2 g bolus followed by infusion at 1 mg/min </li></ul><ul><li>7) If PVC’s ONLY are present with Tachycardia and Hypertension deepen anesthesia with IV/inhalational agents </li></ul><ul><li>8) Evaluate for possible myocardial ischemia </li></ul>
  49. 53. Summary <ul><li>Cardiac disease is becoming more and more prevalent every year, so the fraction of your patients who will have significant Cardiac Disease will also be on the rise </li></ul><ul><li>Careful Preop evaluation and testing WILL reduce the morbidity and mortality associated with any patient who has pre-existing Cardiac disease </li></ul>
  50. 54. Summary <ul><li>Unfortunately, due to time pressures and Surgeon pressures, you may be tempted to just “Go for it” and hope for the best BUT </li></ul><ul><li>DON’T </li></ul><ul><li>It will ultimately be your ass hung out to dry and the surgeon will be saying that “Anesthesia never really told me how sick the patient was” </li></ul><ul><li>Stick to your guns and make sure that the PATIENT and their safety comes FIRST!!!!!!! </li></ul>