Anaesthesia in Cardiac Patients for Non-cardiac SurgeryRashad Siddiqi
The reader should be able to:
(1) identify factors which will lead to increased cardiovascular risk for patients undergoing non-cardiac surgery
(2) decide which patients require further cardiovascular testing
(3) make optimization plan for such patients
(4) understand the principles of anaesthesia for patients with cardiac disease
Evaluation of prosthetic valve function and clinical utility.Ramachandra Barik
Many of the prosthesis-related complications can be prevented or their impact minimized through optimal prosthesis selection in the individual patient and careful medical management and follow-up after implantation.
Anaesthesia in Cardiac Patients for Non-cardiac SurgeryRashad Siddiqi
The reader should be able to:
(1) identify factors which will lead to increased cardiovascular risk for patients undergoing non-cardiac surgery
(2) decide which patients require further cardiovascular testing
(3) make optimization plan for such patients
(4) understand the principles of anaesthesia for patients with cardiac disease
Evaluation of prosthetic valve function and clinical utility.Ramachandra Barik
Many of the prosthesis-related complications can be prevented or their impact minimized through optimal prosthesis selection in the individual patient and careful medical management and follow-up after implantation.
Identify the etiology of perioperative hypertension.
Outline the appropriate evaluation of perioperative hypertension.
Review the management options available for perioperative hypertension
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
2. Why it is necessary
• Approximately 500,000 to 900,000 patients per year undergoing non-
cardiac surgery suffer a perioperative cardiac death
• Impact of vascular disease and comorbidity on postoperative outcome
• Assess current medical status and cardiac risks posed by the planned
operation
• Recommend strategies that may influence short- and long-term outcomes
• In 1977 Goldman introduced the Cardiac Risk Index Score (CRIS) to guide
more quantitatively the assignment of cardiac risk in patients undergoing
noncardiac surgery.
3. Risk-stratification of surgery
Low Risk surgery (reported cardiac risk generally
<1%)
Endoscopic procedures,
Superficial procedure,
Cataract surgery,
Breast surgery,
Ambulatory surgery
Intermediate Risk surgery (reported cardiac risk generally 1%-
5%)
Intraperitoneal and intrathoracic
surgery,
Carotid endarterectomy Head and
neck surgery,
Orthopedic surgery,
Prostate surgery
High Risk surgery (reported cardiac risk often >5%) Aortic and other major vascular
surgery Peripheral vascular surgery
4. Life or limb is
threatened if not
in operating
room within
24 hours
Delay of >1-6
weeks
foranagement
further
evaluation
would negatively
affect outcome
Delay for up to
1 year
Life or limb is
threatened if not
in operating
room within
6 hours
Emergent Urgent
Time-
Sensitive
Elective
Definition of Timing of Surgery
ACCA/ AHA 2014
5. Patient scheduled for surgery with known or risk factors for CAD
(Step 1)
Emergency Yes Clinical risk stratification
and proceed to surgery
No
ACS†
(Step 2)
Yes
Treatment options should
be discussed in a multi-
disciplinary team.
No
Estimated perioperative risk of MACE
based on combined clinical/surgical risk
(Step 3)
Low risk (< 1%)
(Step 4)
No further
testing
(Class III:NB)
Proceed to
surgery
Elevated risk
(Step 5)
A stepwise approach
6. Elevated risk
(Step 5)
Moderate or greater
( 4 METs) functional
capacity
Excellent
(> 10 METs)
No further
testing
(Class IIa)
Moderate/Good
( 4–10 METs
No further
testing
(Class IIa)
Proceed to
surgery
Poor OR unknown
functional capacity
(< 4 METs):
Will further testing impact
decision making OR
perioperative care?
(Step 6)
No
Proceed to surgery according to GDMT OR alternate strategies
(noninvasive treatment,
palliation) (Step 7)
Yes
Pharmacologic
stress testing
(Class IIa)
If
abnormal
Coronary
revascularization
according to
existing CPGs
(Class I)
If
normal
7. Recommendations on routine pre-operative ECG
Supplemental Preoperative Evaluation
Recommendations COR LOE
Pre-operative ECG is recommended for patients who have risk factor(s)
and are scheduled for intermediate- or high-risk surgery. I C
Pre -operative ECG may be considered for patients who have risk factor(s)
and are scheduled for low-risk surgery. IIb C
Pre-operative ECG may be considered for patients who have no risk factors,
are above 65 years of age, and are scheduled for intermediate-risk surgery.
IIb
C
Routine pre-operative ECG is not recommended for patients who have no
risk factors and are scheduled for low-risk surgery.
III: No
Benefit
B
ESC guideline 2014
8. Timing of Elective Noncardiac Surgery in Patients With Previous
Revascularization
Recommendations COR LOE
Elective noncardiac surgery should be delayed 2 weeks(14
days) after balloon angioplasty… IIa B
…and 4 weeks (30 days) after BMS implantation
IIa B
Elective noncardiac surgery should optimally be delayed 12
months (365 day)s after DES implantation. This delay may be
reduced to 6 months for the new generation DES.
IIa
B
Perioperative Therapy
ESC guideline 2014
9. Antiplatelet Agents: Recommendations
COR LOE
It is recommended that aspirin be continued for 4 weeks after BMS implantation and for
12 months after DES implantation, unless the risk of life-threatening surgical bleeding on
aspirin is unacceptably high.
I C
Continuation of P2Y12 inhibitor treatment should be considered for 4 weeks after BMS
implantation and for 12 months after DES implantation,unless the risk of life-threatening
surgical bleeding on this agent is unacceptably high
II a C
In patients treated with P2Y12 inhibitors, who need to undergo surgery, postponing
surgery for at least 5 days after cessation of ticagrelor and clopidogrel—and
for 7 days in the case of prasugrel—if clinically feasible, should be considered unless the
patient is at high risk of an ischaemic event.
IIa C
ESC 2014
10. Perioperative Therapy
Perioperative Beta-Blocker Therapy
Recommendations COR LOE
Peri-operative continuation of betablockers is recommended in
patients currently receiving this medication.
I B
Pre-operative initiation of betablockers may be considered in patients
scheduled for high-risk surgery and who have 2 clinical risk factors IIb B
Pre-operative initiation of betablockers may be considered in patients
who have known IHD or myocardial ischaemia IIb B
When oral beta-blockade is initiated in patients who undergo non-
cardiac surgery, the use of atenolol or bisoprolol as a first choice may be
considered.
IIb B
Initiation of peri-operative high dose beta-blockers without
titration is not recommended
III
B
Pre-operative initiation of betablockers is not recommended in
patients scheduled for low-risk surgery. III
B
ESC guideline 2014
11. Perioperative Statin Therapy
Recommendations COR LOE
Statins should be continued in patients currently taking statins
and scheduled for noncardiac surgery. I C
Perioperative initiation of statin use is reasonable in patients
undergoing vascular surgery atleast 2 weeks before surgery. IIa B
Perioperative Therapy
ESC guideline 2014
Recommendations COR LOE
Continuation of ACEIs or ARBs, under close monitoring, should be
considered during non-cardiac surgery in stable patients with
heart failure and LV systolic dysfunction.
IIa C
Initiation of ACEIs or ARBs should be considered at least 1 week
before surgery in cardiac-stable patients with heart failure and LV
systolic dysfunction.
IIa C
Transient discontinuation of ACEIs or ARBs before non-cardiac
surgery in hypertensive patients should be considered.
IIa C
Angiotensin-Converting Enzyme Inhibitors/ ARB
12. Patients treated with oral anticoagulant
VKA or NOAC
• Patients treated with oral anticoagulant therapy using vitamin K
antagonists (VKAs) are subject to an increased risk of peri and post
procedural bleeding.
• Bridging anticoagulation is usually considered in patients at very high
thromboembolic risk (mechanical heart valves, recent [< 12 weeks]
embolic stroke, or venous thromboembolism
• If the international normalized ratio(INR) is ≤ 1.5, surgery can be
performed safely
• It is recommended that VKA treatment be stopped 3 – 5 days before
surgery (depending on the type of VKA), VKAs should be resumed on
1 or 2 day after surgery— depending on adequate haemostasis
13. Implanted cardiac rhythm devices
• Only bipolar cautery or a harmonic scalpel will be used
• In pacemaker-dependent patients, reprogramming to the DOO or
VOO setting can minimize oversensing and failure to pace
• In patients with ICDs, turning off tachy therapies is helpful to avoid
unnecessary patient shocks.
14. VALVULAR HEART DISEASE
• Echocardiography is critical for quantification of degree of stenosis or
regurgitation and determination of surgical risk.
• Symptomatic severe AS patients should undergo valve replacement prior to
surgery
• TAVR may be considered for patients with severe symptomatic disease for
whom open surgery is not an option
• Symptomatic mitral stenosis patients who are good candidates for balloon
valvulotomy or surgical commisurotomy should undergo treatment before
elective surgery.
• Left-sided regurgitant valve lesions are better tolerated than stenotic
lesions.
15. HEART FAILURE
• In the setting of active nonobstructive HF, it is optimal to delay
surgery for diuresis until euvolemia is achieved
• Special care must be taken in HOCM to avoid arterial dilation and
overdiuresis
• Natriuretic peptide measurement can help manage and predict
perioperative events
16. Hypertension
• The pharmacologic management of patients with hypertension
should be continued perioperatively
• BP should be maintained near preoperative levels to reduce the risk
for myocardial ischemia.
• A hypertensive crisis in the postoperative period—defined as
diastolic BP higher than 120 mm Hg and clinical evidence of
impending or actual end-organ damage—poses a definite risk for MI
and cerebrovascular accident (CVA, stroke)
17. Take home message
• Emergency surgery can be done in cardiac patients by
multidisciplinary team approach .
• B-blockers should be continued or started preoperatively in patients
with ischemic risk .
• In patients with coronary stents, aspirin is best to continued during
surgery and should be reinitiated as soon can be done safely if
stopped
• Surgery can be done in patients on anticoagulant if INR is less than
1.5 .
• Routine Echo is not recommended preoperatively however is
reasonable in patients with high risk surgery heart failure Or
unexplained dyspnoea.