laparascopic cholecystectomy anaesthetic implications ischemic heart disease.

1. Anaesthetic management
for lap cholecystectomy
in patient with CAD
Dr. Daisy Karan
Professor, Dept of Anaesthesioly & Critical Care,
IMS & SUM Hospital

2. AIM OF THE DISCUSSION
 How to provide” safe anaesthesia” for” non cardiac surgery” in
patient suspected or diagnosed of having ‘CORONARY ARTERY
DISEASE’ .
 CAD is a spectrum of closely related manifestations all resulting
from imbalance between demand and supply of oxygen to heart
ANGINA AMI HEART FAILURE
SCD
ISCHEMIC
CARDIOMYOPATHY

3. WHAT’S THE DIFFERENCE FROM NORMAL
PATIENTS ?
 Increased perioperative cardiac morbidity and mortality
 Exaggerated hypotension (induction )
 Exaggerated hypertension (laryngoscopy,intubation,abdominal
distension,pain )

5. PREOP GOALS- IDENTIFY SIGNS OF IHD
Risk factors
 Male gender/ post menopausal
women
 Increasing age
 Hypercholesterolemia
 Systemic hypertension
 Cigarette smoking
 Diabetes mellitus
 Obesity
 Sedentary lifestyle
 Family history (premature
development of ischemic heart
disease)
History & symptoms
 Dyspnoea-NYHA classification for
exercise tolerance
 Angina-(stable or unstable) Canadian
classification for angina
 H/O previous MI
 H/O PCI ( timing and type)
 Metabolic Equivalents (MET SCORE)
 Specific Diagnostic tests(ECG with
pathological Q waves)
 Risk of peri-operative re-infarction
is related to the time elapsed
 Incidence of re-infarction
 30-80% - < 3 months
 15% - 3-6 months
 5% - > 6 months

8. WHY TO DO RISK STRATIFICATION ?
 Helps to determine whether pre-op intervention is required before
undergoing surgery.
 Identifies peri-op risk factors like associated disease (thyroid
disease,diabetes)
 Helps the health providers to calculate the benefit –to-risk ratio for a
procedure better.
 Tries to modify risk factors by pharmacologic interventions.
 Helps to decide when to take up the patient for surgery.
Risk is related to both surgery and patient specific characteristics

9. Surgical risk estimate according to type of surgery

10. HOW URGENT IS SURGERY?
 EMERGENCY SURGERY (required WITHIN 6 HRS)
 URGENT SURGERY ( necessary WITHIN 6-24 HRS)
 TIME SENSITIVE SURGERY (WITHIN 1-6 WEEKS) (ONCOSURGERY )
 ELECTIVE SURGERY (can delay upto 1 year )

11. 2014)
RCRI
NSQIP/MICA
PATIENT SPECIFIC RISK CALCULATION

12. Risk of major cardiac events (MACE)
0=0.4% , 1=0.6%, 2=6.6% , >3= 11%

14. Case scenario
 A 55 YR OLD MALE with history IHD with drug eluting stent in situ POSTED FOR
ELECTIVE LAPARASCOPIC CHOLECYSTECTOMY.
 H/O HTN ,BP-142/89mm Hg
 No H/O Chest pain or breathlessness on daily work.
 DES 1year back with no new symptoms.
 Medications-DAPT, atenolol,ACEI
 ECG- Anterolateral ischemia.

15. PREOP EVALUATION
 HISTORY TAKING
 CVS EXAMINATION
 FUNCTIONAL STATUS- GOOD
 RISK STRATIFICATION
 FURTHER TESTING × as RCRI Score is =1
& Intermediate surgery
 PROCEED FOR SURGERY

16. PREOP MEDICATION MANAGEMENT
Beta blockers
CCB,Diuretics
Statins
Antihypertensives (ACEI)-
Antiarrhythmics
Nitrates
Antiplatelets –Aspirin and Clopidogrel
Should continue the therapy and may
recommend initiation in untreated patients
Already taking should continue taking including
morning of surgery to minimize tachycardia and
ischemia.
However not initiated prophylactically
May be continued in periop period
Should continue
Typically continued particularly with prior heart failure
Only held back in pts with hemodynamic instability or
extensive surgery with anticipated third space loss.

18. Bridging with intravenous antiplatelet agents

19. PREOP INVESTIGATIONS
Routine Investigations
 Hematocrit
 Blood glucose
 Lipid profile
 Renal function tests
 X-ray chest
Special Investigations
 ECG(12 –LEAD)
 EXERCISE ECG
(TMT)/DOBUTAMINE STRESS
TEST
 ECHO
SCREENING BIOMARKERS
 BNP (>92 ng/ml), or NT-pro-
BNP (300ng/l)
 TROPONIN
If RCRI>2

20. Conclusion:
Preoperative NT-proBNP is strongly associated with vascular death and MINS within 30
days after noncardiac surgery and improves cardiac risk prediction in addition to the
RCRI.

21. ↑IAP
↑CO2
POSITION
LAPARASCOPY AN ADDED CHALLENGE TO
ANESTHETIST
↓VR
• ↓LVEF

22. IN IHD patients there is higher elevation in RAP and
PCWP and higher fall in CO
HIGH LEVELS OF ADRENALINE AND CATECHOLANINES
Tachycardia
Coronary vasoconstriction
increased tendency of thrombosis in coronary vessels CO2
Contractility
Arrhythmia

23. What can be done…..?
MINIMISE
HEMODYNAMIC
EFFECT
GRADUAL
INSUFFLATION
↑ CIRCULATING
VOLUME BEFORE
PNEUMO.
Pre-load
augmentation
Stockings to ↓
pooling
Minimise duration
of fasting
LIMIT IAP <15 mm Hg
AVOID SNS STIMULATION
α blockers
βblockers
Vasodilators
Dexmed

24. ISCHEMIA PRECIPITATING FACTORS
O2 Demand
 Wall stress :
 *Preload
 *Afterload
 Heart rate
 Contractility
O2 Supply
 Coronary blood flow
( CPP= DBP-LVEDP )
 O2 content
 LEFT shift of O2-Hb dissociation
curve.
 Heart rate - ↓diastolic time

25. INTRAOP GOALS
Low to normal HR
Normal BP
Maintain CPP=ABP-LVEDP
Avoid hypothermia
Maintain myocardial contractility
Adequate arterial oxygen content

26. INTRAOP MONITORING
ECG(Lead II &Lead V5)
Invasive arterial BP
CVP/PA catheter
TEE instead
RISK<BENEFIT

27. INTRAOP DRUG CHOICE
PREMEDICATION-
 To allay anxiety, fear use benzodiazepenes (MIDAZOLAM).
 Effective control of catecholamine surge with intravenous opiods (FENTANYL)
Opiods may be selected as the primary anesthetics in pts. with compromised LV
function.
INDUCTION-
 ETOMIDATE: causes minimal hemodynamic changes
 PROPOFOL :decrease myocardial contractility with significant decrease in BP and HR.
 THIOPENTONE: decrease myocardial contractility with significant INCREASE IN HR

28. INTRAOP DRUG CHOICE
INTUBATION- (Blunting the hemodynamic response is crucial)
 VECURONIUM most cardio stable
MAINTENANCE-
AHA guidelines suggest volatile anesthetics for maintenance of anesthesia in pts.
who are hemodynamically stable with no evidence of CHF.
 Avoid halothane
 ISOFLURANE is safer
 N2o use is questionable as it increases PVR, predisposes to diastolic
dysfunction and subsequent myocardial ischemia.

29. MANAGING PERIOP MI
RISKS REMAIN TILL 72 HRS
DIAGNOSIS: ECG
 Any ST upsloping >1mm
 ST downsloping of >2mm
 ST elevation
 T wave inversion
TREATMENT:
 Stop surgery & desufflate abdomen
 100 % oxygen
 inj. Morphine/opiods
 sublingual nitrate/ β blockers
 Aspirin/statin
 inj heparin if plausible to stop stent
thrombosis

30. MANAGING CARDIAC
ARRHYTHMIAS
CAUSES
1. REFLEX INCREASE IN VAGAL
TONE DUE TO SUDDEN
STRETCHING OF
PERITONEUM
2. LIGHT PLANE OF
ANESTHESIA
3. EMBOLISM
4. HYPERCARBIA
5. HYPOXIA

31. CONCERN DURING EMERGENCE AND
EXTUBATION
EXTUBATION
OPIODS/LIGNOCAINE/
ESMOLOL/VASODILAT
ORS
SUPPLEMENT
OXYGEN
POST OP PAIN
MULTIMODAL
TECHNIQUES
STOP
SHIVERING
AND PONV
ISCHEMIA
MONITORING
12 Lead ECG
MONITOR
URINE OUTPUT

32. TAKE HOME MESSAGE
 Urgent surgery
 Low risk surgery
 High risk surgery with MET>4
 RCRI≤ 1
 Elevated risk
 RCRI≥ 2
 MET< 4 or unknown
NO FURTHER
TESTING
STRESS TESTING
BIOMARKERS
CT Angio
Optimise oxygen supply /demand
imbalance