1.preoperative cardiac assessment and management (1).ppt

Cardiac Anaesthesiology assessment

2. EVALUATION AND EXAMINATION OF CVS: RISK
ASSESSMENT IN CARDIAC SURGERY & MONITORING
DURING PRE-OPERATIVE PERIOD
DR. P.SELVAKUMAR
DIRECTOR OF ANAESTHESIA AND
INTENSIVE CARE SERVICES
VELAMMAL HOSPITALS -- MADURAI

3. •The size of the problem is substantial , chiefly due to the
prevalence of coronary artery disease (CAD), with its attendant
risk and complications.
•Peri operative myocardial infarction continues to have a high
mortality , it is often silent and significant greatest cause of
death following non cardiac surgery.
•As the proportion of surgical patients presenting cardiac risk
grows it becomes increasingly necessary to design protocol for
evaluation of these patients preoperatively in clinically efficient
and cost effective way.

4. •Evaluation of other cardiac pathology , such as cardiomyopathy is
based on a greater degree on expert opinion.
•The ultimate aim of pre operative cardiac assessment is to reduce peri
operative cardiac morbidity and mortality (PCM) .
•This is achieved by identification of high risk patient and using the
information to modify peri operative management or to prompt further
investigation .
•Irreversible major outcomes such as peri operative myocardial
infarction and cardiac death are hard outcome measures. Reversible or
transient outcomes such as peri operative ST depression, non fatal
arrhythmias or cardiac failure occur more commonly than hard
outcomes and are less strictly defined. These are termed as benign
outcomes.

5. Department of Cardiac AnaesthesiaDepartment of Cardiac Anaesthesia
VELAMMAL HOSPITALS- Madurai VELAMMAL HOSPITALS- Madurai
Pre Operative Assessment
•Pt.Name : Date of Surgery:
•Age/Gender: Ht.: Cm / Wt.: Kg.
•IP No. : Blood Group:
•D.O.B. :
•Diagnosis: Investigations
Hb :
Urea :
•Surgery : Creatinine :
•Grafts Recommended: Other Investigation:
•Physical Examination : Coagulation Profile:
•Air way : Electrolytes :
•C.V.S : History :
•Res Sys : M.I :
DM :
HTN :
Asthma :
•Other systems : Renal :
•E.C.G. : Jaundice :
•Echo : Thyroid :
C.V.A :
•Angio : Allergics :
•Comments: H/O Previous Anaesthesia:
•X-Ray : Drugs :
•Carotid : Smoking :
•PFT : Cehttiar :
•Obesity :
Signature

6. In 1977, Goldman et at published the first multifactorial index of
cardiac risk which was updated by Detsky et at in 1986.
VariablesVariables PointsPoints
Myocardial infarction within last 6 months 10
Myocardial infarction more than 6 months ago 5
Canadian Cardiovascular Society angina- Class 3
- Class 4
10
20
Unstable angina in previous 3 months 10
Alveolar pulmonary oedema within – 1 week
- Ever
10
05
Suspected critical aortic stenosis 20
Sinus plus atrial premature beats or rhythm other than sinus or last preoperative
ECG
05
More than 5 ventricular premature beats per minutes at any time prior to surgery 05
Poor general medical condition (ABG,Urea, Creatinine, Sr.electolytes)
























































































05
Age over 70 years 05
Emergency operation 10
Class I-0-15,ClassII-20-30,ClassIII ->30

7. History
In addition to a general medical and anesthetic history ,
questioning should elucidate history and symptoms
related to other systems.
1.Renal
2.CNS
3.Endocrine
4.Haemotology
5.Dental
6.Medication -Continue β-Blockers and other drugs till surgery
to prevent rebound hypertension and myo cardial ischemia
Cont..

8. 7. Smoking
8. IHD
9. Arrythmias
10. HT
11. DM
12. Functional ability
This has been formally classified by the Duke
functional status index in to M&T equivalent
1- M∑T = Basal O
2
consumption at rest)
4 M∑T’s = Heavy House work/ Climbing stairs.
<1 M∑T’s = Poor Cardio respiratory reserve.
Peri –Operative risk

9. Clinical ExaminationClinical Examination
1.General - Pallor, Cyanosis, Dyspnoea at rest
2.Blood pressure
3.Pulse - Regularity , rate, Peripheral Pulse
4.Character and volume of Carotid Pulse.
5.Any evidence of peripheral vascular disease
6.Pre cordial auscultation
7.Lung field auscultation

10. TestTest
Routine Non Invasive
Routine:
Blood – Urea,Creatinine,Electrolytes, Coagulation profile.
X-Ray – Cardiomegaly, Calcified aorta, Pulmonary Congestion,
Position of Pace maker.
ECG – i) Rhythm other than sinus
ii) Atrial Fibrillation
iii) Pathological ‘Q’ waves ,LVH -> MI
iv) PVC’s
v) Conduction Abnormality
Non Invasive test
This group of tests represents the second line of
investigation used in a defined group of patients.

11. To reduce false positive rate and to constrain costs , these
tests are only applied for higher underlying prevalence
of Cardiac risk
Static Function (Resting tests)
a)Resting trans thoracic echo (Murmurs, Valve, Vegetations,
effusion and chamber enlargement)
Resting EF and ventricular function.
b)Multigated radio nuclide ventriculography (MUGA SCAN) is
used to measure Ventricular ejection fraction.
Normal > 50%
< 35% -> Adverse outcome.
“ Not a Cost effective pre operative test.”
Dynamic Function (Stress Tests)
The most useful second line of investigation as they asses
the performance of the heart and coronary circulation under
the condition of stress (Exercise or Pharmacological) thus
giving a measure of functional reserve

12. Exercise Stress Testing
DescriptionUsually a staged exercise protocol on a
treadmill or bicycle with continuous ECG and
intermittent Blood Pressure monitoring
Indication of
Myocardial
Ischemia
ST Segment depression
Ventricular ectopics
Typical chest pain
Disadvantage
of test
Many exclusive criteria e,g abnormal baseline
ECG (Digoxin effect,Left bundle branch
block,Pacemaker).
Poor position, predictive value for
perioperative cardiac events
Advantages of
test
Widely available.

13. Radio Nuclide Myocardial Perfusion imaging with
Pharmacological Stress
Description intravenous injection of Radionuclide (taken by Perfused
myocardium) after IV injection of Pharmacological stress
or images obtained from Gamma camera over chest
images repeated 4hrsly after wards without stress
Indication of
Myocardial
Ischemia
Reversible perfusion defects (fixed perfusion defects
represents old infarcts) developing after stress and
resolving on subsequent images.
Transient left ventricular dilation under stress indicates a
very large area of induceble ischemia.
Indication of
Poor LV
function
Increased lung uptake of isotope.
Disadvantage
s of test
Specialised equipment means test is confined to centers
with nuclear medicine facilities.
Advantages
of Cardiac
test
Good negative predictor values for peri operative event.

14. Stress Echocardiography ( Stress may be
Pharmacological ,e.g. Peripheral IV Dobutamine
Infusion or Exercise
DescriptionTrans thoracic echocardiography.
Indication of
Myocardial
Ischemia
New areas of dyskinetic wall motion developing during
the test (Pre excisting areas generally represent old
infarcts).
Indication of
Poor LV
function
Transient left Ventricular dilation under stress.
Disadvantage
s of test
Although protocols are evolving results remain to same
extent of operator dependent.
Advantages
of Cardiac
test
•Very good negative predictine value for peri-operative
cardiac events.
•Potentially available in all centers with access to
echocardiograph facilities.
•Value function can also be evaluated

15. Continuous ambulatory ECG (Usually 24Hrs)
Description Various monitoring systems are available to
monitor the electrocardiograph of an
ambulant patient continuously processing of
the trace may be manual or automated on line
or retrospective.
Indication of MIST-segment depression
Indication of Poor
LV function
No indicator
Disadvantages
of test
Not useful with abnormal baseline ECG
Advantages of
Cardiac test
•Detecting silent ischemia in patients with
peripheral vascular disease
Test Negative•Patient becomes Low risk
Test positiveHigh risk. Position Predictive Value (PPV) for
major peri-operative event.

16. Which Investigation is best?Which Investigation is best?
Static
(Resting Echo resting MVGH)
“Do not give an indication of how the heart and coronary
anatomy will behave under stress”
Dynamic:
Usually depends on local cardiology practice and
facilities.
Most centre do not have direct access to nuclear
medicine facilities but exercise test is widely available.
Dobutamine stress echo could be extended to all
centers but extra trained technicians are required.

17. AHA and ACP – both sets of guidelines follow broadly similar
steps , a preliminary screening step followed by further
investigation where necessary.
Three broad group of Patients
High riskHigh risk Intermediate Intermediate
riskrisk
Low riskLow risk
•Unstable Angina
•Tight A.S
•CCF –
Decompensated
•Recent MI <30 days
•SVT with uncontrolled
Ventricular rate
•High grade AV block
Stable Angina
Previous MI
H/O CCF
Chronic DM
H/O Stroke
Old MI
LVH

Abnormal
ECG
BBB

18. AHAAHA
Low Risk Proceed to Surgery.
Intermediate Risk Assess Functional status
Good Poor
Proceed Non invasive testing
High Risk Detsky Class II and Class III
Modifiable risk Non Modifiable risk
Proceed Cancel

19. Intra operative risk related to type of SurgeryIntra operative risk related to type of Surgery
•Low risk surgery (PCM< 1%) -> Cataract
Breast surgery
Endoscopic surgery
•Intermediate risk (PCM < 5%)-> Carotid surgery
Head and neck
Ortho ,Abdominal and
Thoracic
•High risk (PCM>5%)->
Major ,Emergency ,Vascular ,Prolonged surgery >3Hrs

20. Pre-operative Factors for Post operative Pre-operative Factors for Post operative
organ failureorgan failure
•Severe cardio - resp illness
•Severe multiple trauma (e.g.) massive blood loss
•Septicemia
•Shock
•Acute abdomen with shock
•Acute renal failure
•Prolonged Surgery

21. Intra operative Monitoring
1.12 Lead ECG
2.NIBP
3.IBP
4.PA PRESSURE / CVP
5.ETCO2
6.SP02
7.Temperature
8.Continuous Cardiac Output
9.TEE

22. ManagementManagement
Myocardial O
2
Supply O
2
demand
1.Coronary Blood flow
a) CPP
b) CVR
c) Diastole
2.Arterial O
2 content
DECREASED
1.HR
2.After Load
3.Pre Load
4.MC
INCREASED
1.Tachycardia
2.Diastolic Pressure
3.LVEDP
4. O
2
1.Tachycardia
2. After Load
3. Pre Load
4. MC

23. Post OP ManagementPost OP Management
1.O
2
2.Temperature
3.Fluid
4.Pain control
5.Ischaemic Medication

24. MESSAGEMESSAGE
•Coronary artery disease and its consequences
are by far the most common cause of cardiac
disease.
•Coronary artery disease is associated with the
majority of peri operative mortality and serious
morbidity
•Adequate dynamic cardiac reserve can be
measured by stressing the heart with exercise or
pharmacologically seems to be the most
reassuring pre-operative predictor of good cardiac
out come.

25. MESSAGEMESSAGE
•Most serious PCM occurs in the early post
operative period when baseline heart rate is
elevated from pre operative levels.
•B-Blockade has been shown to decrease PCM
in patients at risk.
•Active Cardiac failure significant aortic stenosis
and unstable angina pose unacceptably high
peri-operative e risk and should be managed in
their own right prior to elective non – cardiac
surgery.