Cardiac patient for non cardiac surgery

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preoperative evaluation and optimisation .

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Cardiac patient for non cardiac surgery

  1. 1. Cardiac Patient For Non Cardiac Surgery -Preoperative Evaluation Dr Pankaj N Surange MBBS,MD,FICMR Graded Specialist Anesthesia Artemis Health Institute
  2. 2. REFERENCES <ul><li>ACC/AHA Guidelines 2002-updated 2006(perioperative Beta Blockade Therapy) </li></ul><ul><li>BJA 95(1): 3-19 2005- perioperative Myocardial Infarction </li></ul><ul><li>BJA 93: 2004-Sympathomodulatory Therapies In Perioperative Medicine </li></ul>
  3. 3. GOALS <ul><li>PT CURRENT STATUS </li></ul><ul><ul><li>IDENTIFICATION OF PTS UNSTABLE CV DS </li></ul></ul><ul><ul><li>IDENTIFICATION OF PTS WITH KNOWN AND SYMPTOMATIC CAD </li></ul></ul><ul><ul><li>IDENTIFICATION OF PTS AT RISK OF CAD </li></ul></ul><ul><ul><ul><ul><ul><li>PVD </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>HTN </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>DM </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>SMOKING </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>HYPERCHOLESTROLEMIA </li></ul></ul></ul></ul></ul>
  4. 4. GOALS <ul><li>THERAPIES TO BRING PT IN OPTIMAL CONDITION </li></ul><ul><li>ANESTHETIC PLAN </li></ul><ul><ul><ul><li>PROCEDURE </li></ul></ul></ul><ul><ul><ul><li>PTS PHYSIOLOGY </li></ul></ul></ul>
  5. 5. approach <ul><li>Preoperative </li></ul><ul><ul><ul><li>Evaluation, risk stratification, and preparation </li></ul></ul></ul><ul><li>Intraoperative </li></ul><ul><ul><ul><li>smooth induction </li></ul></ul></ul><ul><ul><ul><li>smooth recovery </li></ul></ul></ul><ul><ul><ul><li>adequate monitoring </li></ul></ul></ul><ul><li>Postoperatively </li></ul><ul><ul><ul><li>cont. monitoring and vigilance </li></ul></ul></ul>
  6. 6. PREOPERATIVE CARDIAC EVALUATION <ul><li>ACC/AHA GUIDELINES-5 FACTORS FOR RISK STRATIFICATION </li></ul><ul><ul><li>Recency Of Coronary Revascularization </li></ul></ul><ul><ul><li>Recency Of Last Favourable Cardiac Evaluation </li></ul></ul><ul><ul><li>+Nce Of Comorbidities-clinical Predictors </li></ul></ul><ul><ul><li>Functional Status </li></ul></ul><ul><ul><li>Risk Of Proposed Surgery </li></ul></ul>
  7. 7. 1-CORONARY REVASCULARISATION <ul><li>Complete coronary surgical revascularization -5 yrs </li></ul><ul><li>PCI-- 6months-5 yrs </li></ul><ul><li>No recurrent S/S of ischemia </li></ul><ul><li>Clinical status is stable </li></ul><ul><li>No further cardiac testing is necessary </li></ul>
  8. 8. 2-Coronary evaluation <ul><li>Past 2 years </li></ul><ul><li>Invasive/non invasive tech </li></ul><ul><ul><li>Favorable </li></ul></ul><ul><ul><li>No definite change or new symptom </li></ul></ul>No further cardiac testing is necessary
  9. 9. 3-Clinical predictors <ul><li>Major </li></ul><ul><ul><li>Unstable coronary syndromes </li></ul></ul><ul><ul><ul><li>recent MI with evidence for ischemia </li></ul></ul></ul><ul><ul><ul><li>unstable or severe angina (Canadian class III or IV) </li></ul></ul></ul><ul><ul><li>Decompensated CHF </li></ul></ul><ul><ul><li>Significant arrhythmia </li></ul></ul><ul><ul><ul><li>high grade AV block </li></ul></ul></ul><ul><ul><ul><li>symptomatic ventricular arrhythmia (with organic disease) </li></ul></ul></ul><ul><ul><ul><li>supraventricular arrhythmia with uncontrolled rate </li></ul></ul></ul><ul><ul><li>Severe valvular disease </li></ul></ul>
  10. 10. <ul><li>Intermediate </li></ul><ul><ul><li>Mild angina pectoris (Canadian class I or II) </li></ul></ul><ul><ul><li>Prior MI by history or pathological Q waves </li></ul></ul><ul><ul><li>Compensated or prior CHF </li></ul></ul><ul><ul><li>Diabetes mellitus </li></ul></ul><ul><ul><li>Renal insufficiency (creatinine > 2) </li></ul></ul>
  11. 11. <ul><li>Minor </li></ul><ul><ul><li>Advanced age </li></ul></ul><ul><ul><li>abnormal ECG (LVH, LBBB, ST-T change) </li></ul></ul><ul><ul><li>Rhythm other than sinus </li></ul></ul><ul><ul><li>Low functional capacity </li></ul></ul><ul><ul><li>History of stroke </li></ul></ul><ul><ul><li>Uncontrolled systemic hypertension </li></ul></ul>
  12. 12. 4-Functional Capacity <ul><li>1 MET </li></ul><ul><ul><li>Can you take care of self? </li></ul></ul><ul><ul><li>Eat, dress, use toilet? </li></ul></ul><ul><ul><li>Walk indoors in house? </li></ul></ul><ul><ul><li>Walk a block or two on level at 2-3 mph? </li></ul></ul><ul><ul><li>Do light housework like dusting or dishes? </li></ul></ul><ul><li>4 METs </li></ul><ul><li>4 METs </li></ul><ul><ul><li>Climb a flight of stairs, walk up hill? </li></ul></ul><ul><ul><li>Walk on level at 4 mph? </li></ul></ul><ul><ul><li>Run a short distance? </li></ul></ul><ul><ul><li>Heavy housework </li></ul></ul><ul><ul><li>Golf, bowling, dancing, doubles tennis </li></ul></ul><ul><ul><li>Swimming, singles tennis football, basketball, skiing </li></ul></ul><ul><li>>10 METs </li></ul>1 MET = 3.5 ml/kg/mt VO2 >10 METs-Excellent 7-10 good 4-7 moderate ≤ 4 poor
  13. 13. 5-Surgical risk <ul><li>High (reported cardiac risk > 5%) </li></ul><ul><ul><li>emergent major operations, esp. in elderly </li></ul></ul><ul><ul><li>aortic and other major vascular procedures </li></ul></ul><ul><ul><li>peripheral vascular procedures </li></ul></ul><ul><ul><li>anticipated prolonged procedure with large fluid shift/blood loss </li></ul></ul>
  14. 14. <ul><li>Intermediate (reported cardiac risk < 5%) </li></ul><ul><ul><li>carotid endarterectomy </li></ul></ul><ul><ul><li>head and neck </li></ul></ul><ul><ul><li>intraperitoneal & intrathoracic </li></ul></ul><ul><ul><li>orthopedic </li></ul></ul><ul><ul><li>prostate </li></ul></ul>
  15. 15. <ul><li>Low (reported cardiac risk < 1%) </li></ul><ul><ul><li>endoscopic procedures </li></ul></ul><ul><ul><li>superficial procedure </li></ul></ul><ul><ul><li>cataract </li></ul></ul><ul><ul><li>breast </li></ul></ul>
  16. 16. 9 step algorithm
  17. 17. 9 step algorithm
  18. 18. 9 step algorithm 9 step algorithm
  19. 19. PREOP TESTING <ul><li>ECG </li></ul><ul><li>DETECT LVH,BBB & CONDUCTION DEFECT </li></ul><ul><li>PREVIOUS MI </li></ul><ul><li>BASELINE FOR INTRA AND POST OP COMPARISON </li></ul><ul><li>INCREASED PERIOP RISK </li></ul><ul><ul><ul><li>ST DEPRESSION MORE THAN .5 MM </li></ul></ul></ul><ul><ul><ul><li>LVH WITH STAIN PATTERN </li></ul></ul></ul><ul><ul><ul><li>LBBB </li></ul></ul></ul>
  20. 20. <ul><li>EXERCISE STRESS TEST </li></ul><ul><li>STRONGEST DETERMINANT OF RISK AND NEED FOR INVASIVE MONITORING </li></ul><ul><li>LEAD SELECTION </li></ul><ul><li>ECG CRITERIA </li></ul><ul><ul><li>1 M M OF J POINT DEPRESSION </li></ul></ul><ul><ul><li>2MM OF ST DEPRESSION AT 80 MS FROM J POINT </li></ul></ul><ul><ul><li>ST ELEVATION </li></ul></ul><ul><ul><li>NON ECG RESP </li></ul></ul><ul><ul><ul><li>LOW ACHIEVED HR </li></ul></ul></ul><ul><ul><ul><li>SYSTOLIC HYPOTENSION </li></ul></ul></ul><ul><ul><ul><li>INABILITY TO EXERCISE FOR MORE THAN 3 MIN </li></ul></ul></ul>
  21. 21. PHARMACOLOGICAL STRESS TEST <ul><li>Two Categories </li></ul><ul><ul><li>Dobutamine Stress Echo-incr. Mvo2 </li></ul></ul><ul><ul><ul><ul><li>New/Incr In Rwma </li></ul></ul></ul></ul><ul><ul><ul><ul><li>More Than 5/16 Lt Ventricular Segm Involvement </li></ul></ul></ul></ul><ul><ul><li>Dipyridamole Thallium-mimics Coronary Art Dialatation Resp Associated With Exercise </li></ul></ul><ul><ul><ul><ul><li>Infarcted Area-fixed Defect </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ischemic Area-reversible Defect </li></ul></ul></ul></ul>
  22. 22. ECHOCARDIOGRAPHY <ul><ul><li>LVEF </li></ul></ul><ul><ul><li>RWMA </li></ul></ul><ul><ul><li>Valvular Abn </li></ul></ul><ul><ul><li>Cong Cardiac Defects </li></ul></ul>
  23. 23. CORONARY ANGIOGRAPHY <ul><ul><ul><li>Non Invasive Testing-high Risk Of Adverse Outcome </li></ul></ul></ul><ul><ul><ul><li>Angina Unresponsive To adequate Medical Therapy </li></ul></ul></ul><ul><ul><ul><li>Unstable Angina-intermediate And High Risk Sx </li></ul></ul></ul><ul><ul><ul><li>High Clinical Predictor In High Risk Sx </li></ul></ul></ul>
  24. 24. PERIOP THERAPY <ul><li>BETA BLOCKERS </li></ul><ul><ul><li>CVS EFFECTS </li></ul></ul><ul><ul><ul><li>↓ HR-(diastolic Time) </li></ul></ul></ul><ul><ul><ul><li>↓ Contractility </li></ul></ul></ul><ul><ul><ul><li>Plaque Stabilization- ↓ Shear Forces </li></ul></ul></ul><ul><ul><ul><li>Antiarrythmic Effect </li></ul></ul></ul><ul><ul><li>ELIGIBILITY CRITERIA </li></ul></ul><ul><ul><ul><li>CLINICAL -ANY 2 </li></ul></ul></ul><ul><ul><ul><ul><li>AGE>65 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>HTN </li></ul></ul></ul></ul><ul><ul><ul><ul><li>CHR SMOKER </li></ul></ul></ul></ul><ul><ul><ul><ul><li>SER CHOLESTROL>240 mg/dl </li></ul></ul></ul></ul><ul><ul><ul><ul><li>DM </li></ul></ul></ul></ul><ul><ul><ul><li>CARDIAC RISK INDEX CRITERIA </li></ul></ul></ul><ul><ul><ul><ul><li>HIGH RISK SX PROCEDURE </li></ul></ul></ul></ul><ul><ul><ul><ul><li>IHD </li></ul></ul></ul></ul><ul><ul><ul><ul><li>CVA </li></ul></ul></ul></ul><ul><ul><ul><ul><li>DM </li></ul></ul></ul></ul><ul><ul><ul><ul><li>CRF </li></ul></ul></ul></ul>
  25. 25. OTHER THERAPIES <ul><li>Alpha-2 Adrenergic Agonist </li></ul><ul><li>Regional Anesthesia </li></ul><ul><ul><li>Epidural </li></ul></ul>

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