Dive into the intricate world of 'Cardiac Cases for Non-Cardiac Surgery' in our engaging presentation. Uncover the complexities and considerations involved when managing cardiac patients undergoing non-cardiac surgical procedures.

1. CARDIAC CASE FOR NON CARDIAC SURGERY
Dr Nayana Kulkarni
HOD - Department of Anesthesiology,
HCG Manavata Cancer Center
Nasik, India

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• 68 yr male pt
• Diagnosed Ca Prostate with bilateral inguinal direct hernia for Robotic assisted
Radical prostatectomy with bilateral hernia repair under GA+ EA.
CA Prostate with Bilateral Hernia
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• H/o CABG in 2012 HT DM & Insomnia.
• METS at present <4, can walk 1 km only with dyspnoea after few steps
Past history
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• Medications-(9yrs)
• Nebistar 2.5 od
• Ecosprin Av od
• Glycomet GO 1mg bd
• Zolfresh hs
• Flunil 10mg hs
• was diagnosed Ca prostate 2018, took Radiation treatment.
• Now advised surgery due to aggravated urinary symptoms.
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• Doxycycline and amoxicillin
Allergies
Investigations
• CBC- 12/6400/1.91
• F bsl- 154: pp bsl = 233 on dec 16th; 114 / 215 on dec 27th
• HbA1c- 9
• Pt taken on HAI for bsl control.
• Electrolytes- 133/4.5/99, ca+-8.5, triple H negative, LFT-Normal,
• Alb-4.5
• ECG- st strain, anteroseptal st depression, rate normal:
• CXR- prom BVM.
• 2 d echo- apical antero-septal hypokinesia, mild LA dilatation, trival MR,TR,
grade 1 dd, mild Pulmonary hypertension psap - 40mm hg, LVEF- 40%.
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• Mouth opening- MPC grade 3/ loose teeth +
• Limited neck extension.
• ASA lll (RCRI score- 3 class iv, risk is 11% according to RCRI)
• P-78/: BP- 156/90 on medications, no FND, h/o INTERMITTENT tingling
numbness both lower limbs (DM related ?peripheral neuropathy).
• Asked to continue insomnia medication with antihypertensive till day of surgery.
• No rhonchi/ S1 loud/no murmur.
• Breath holding;10sec / BHC-13 counts / PFT-moderate blockage: fev1 – 45%.
Pre-Op
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• 68 Yr/M
• HT & DM Since 9 Years (Micro-angiopathy?)
• IHD 9 Yrs Underwent CABG for TVD
• Abdominal/Pelvic Surgery, Uncontrolled DM - Needs Insulin Preop
• Mild Blockage on PFT
• Semi Urgent Operation Due To Urological Complaints
• Post radiation, so fibrosis increases chances of intra-operative bleeding
• Extended surgery due to bilateral direct hernia repair
• EF 40%, mild pulmonary hypertension and TR/MR mild/mild dilated LA
Risk Factors
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• Robotic surgery- head low position, lithotomy.
• Lap assisted- co2 insufflation/arrhythmias/retention of co2 -acidosis/
• Prolonged anesthesia, intraperitoneal surgery
• Cancer surgery, h/o HT, DM on insulin now, IHD with h/o CABG - compromised
EF - 40% with mild TR, MR LA dilatation, pulmonary hypertension (40mmhg)
• Difficult to approach in event of catastrophe/ (for CPR)
• Inotropes,vasodilators,analgesics,emergency cart, defibrillator ready
• Intubation tray, etomidate, fentanyl, epidural.
Points to Consider
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• General Anesthesia with epidural for analgesia
• Central line, intra-arterial line and use of minimally invasive flotrac monitoring
(Edwards life-sciences) with HPI(hypotension predictive index-had got demo
machine so used it for case)
• Peripheral wide bore intracath 18 gauge
• Pt underwent bowel preparation and 2pcv 4ffp arranged for surgery
• r/o electrolyte disturbances, dehydration
Plan of Anesthesia
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• Epidural 18 g mini-pack at T12-L1 put(space at 6cm), 10cm catheter kept in.
• Induction: etomidate+ fenta+ rocuronium(10mg/100mcg/40mg)
• 8 no flexo nasal tube inserted:RT put/ foleys/pressure points padding done
• Head low 40 degrees adjusted as per hemodynamic response
• Pressure control ventilation,(wt 75 kg- pr insp 20+ peep 5 = tidal vol around 500
to 525 ml RR 15, etco2 around 35 maintained)
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• Maintenance- o2+ n20+ desflurane (2-4%) with fentanyl and epidural top ups
with atracurium and IPPV
• NTG, dobutamine, nikorandil and labetalol used as required with consultation
of cardiologist
• Epidural- 0.125% levo-bupivacaine 3ml per hr baxter pump
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Induction
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• Intraop uneventful, no arrhythmias, or untoward event
• Post op- after reversal,shifted with: P - 76, bp- 126/70, on vc simv
480/15/5/1:2.1/fio2 60% DVT pump connected.
• ABG - no acidosis/ normal lactates- 1.0
• Next morning extubated and shifted to wards on D3
• D4 had junctional tachycardia, potassium 3.2, amiodarone given, kesol
correction given, revived
• Needed potassium correction for 3 days
• Serum mg- normal (2.1)
• Discharged on d8.
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• Risk factors
• Patient specific Surgical
• Functional status
• Urgency of surgery
• Other considerations
• In this patient - h/o CAD
• H/o DM on insulin
• Mild pulmonary hypertension
• Abdominal surgery
• METS<4
• Urological aggravated symptoms are said risk factors
Discussion
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Functional Hemodynamic
Monitoring Protocol
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CONCLUSION
• Cardiac pt undergoing major urologic surgery is complex case requiring great
attention by anesthesiologist
• Cardiovascular disease remain 1st worldwide cause of mortality
• Perioperative risk stratification help in appropriate planning
• Proper planning of supramajor superspeciality surgeries in tertiary care centers
and risk stratification will decide further management in anesthesia and
perioperative period including parameters to monitor, anticipated adverse
events and complications
• Need of invasive monitoring depends upon surgical and patient specific risk
• Planning and implementation of devised plan will ensure optimum patient safety
and favorable outcome
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REFERENCES
• Davenport DL, Ferraris VA, Hosokawa P, Henderson WG, Khuri SF, Mentzer RM Jr. Multivariable predictors of
postoperative cardiac adverse events after general and vascular surgery: results from the patient safety in surgery
study. J Am Coll Surg. 2007 Jun;204(6):1199-210. doi: 10.1016/j.jamcollsurg.2007.02.065. PMID: 17544078.
• POISE Study Group, Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, Villar JC, Xavier D, Chrolavicius S,
Greenspan L, Pogue J, Pais P, Liu L, Xu S, Málaga G, Avezum A, Chan M, Montori VM, Jacka M, Choi P. Effects of
extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised
controlled trial. Lancet. 2008 May 31;371(9627):1839-47. doi: 10.1016/S0140-6736(08)60601-7. Epub 2008 May 12.
PMID: 18479744.
• Kheterpal S, O'Reilly M, Englesbe MJ, Rosenberg AL, Shanks AM, Zhang L, Rothman ED, Campbell DA, Tremper KK.
Preoperative and intraoperative predictors of cardiac adverse events after general, vascular, and urological surgery.
Anesthesiology. 2009 Jan;110(1):58-66. doi: 10.1097/ALN.0b013e318190b6dc. PMID: 19104171.
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