Dr.

Kanchan Chauhan
Associate Professor in
Anaesthesiology
 INTRODUCTION


 Stress due to surgery leads to an increase in cardiac output which can be

achieved easily by normal patients, but which results in substantial morbidity
and mortality in those with cardiac disease.

 Most suitable anaesthetic can be given by understanding different cardiac

disease.

 The skill with which the anaesthetic is selected and delivered is more
important than the drugs used.

 No. of patients with cardiac disease are increasing. due to the fact that the
surgery is being performed on older patients in whom the incidence of
coronary artery disease (CAD) is higher, and secondly, recent advances in
diagnostic technology have allowed us to detect CAD in asymptomatic or
mildly symptomatic patients.

 With increased awareness and improved cardiac surgical results,

 patients who have undergone corrective cardiac surgery are also presenting
for noncardiac surgery.
What Should be our Approach ?
 Preoperative –
 Pre anaesthetic evaluation,
 Risk stratification and
 preparation
 Intraoperative –
 Smooth induction ,
 Smooth recovery ,
 Smooth monitoring
 Postoperatively –
 Cont. monitoring and vigilance
Pre anaesthetic evaluation

ASSESSMENT OF PERIOPERATIVE RISK

 Goldman Cardiac Risk Index.
 Lee’s risk stratification criterion
 Detsky’smodified approach to Goldman index
 NYHA Classification
 Canadian Cardiovascular Society Classification

 Follow AHA ( American Heart Association)

guidelines for perioperative cardiovascular
evaluation
Medications : Keep in Mind
 Continue all antianginals, anti hypertensives
 Continue anti arrythmics
 Continue Beta blockers and Statins
 Continue Aspirin (not in some institue)

 Discontinue Diuretics, Digitalis, Oral

hypoglycemics, ACE inhibitors
O T Preparation
 Ready Emergency cardiovascular drugs
 (iv beta blockers, NTG, SNP, Inotropes,
Ephedrine, Phenylephrine, CCB, anti arrythmics
etc.

 Cardiac equipments :Defibrillator, Pacemakers,

Syringe pump
Monitoring
ECG
Blood Pressure
Temperature
Pulse oximetry
End tidal CO2
Arterial Catheter

Beat to beat blood pressure

monitoring
ABGs
Early detection of hypotension
Laboratory studies
HGB & HCT
Electrolytes
Liver function studies
Creatine clearance
Osmolality
PA catheter
Assessment of LV Function
Early detection of ischemia
“v” waves
Increased PCWP
More accuracy than CVP
Intravascular volume problems
Especially in patients with severe lung
disease
Transesophageal
Echocardiography
Demonstrates regional wall motion
abnormalities
Suggestive of ischemia
Most accurate measure of left
ventricular volume
Non-invasive Continuous
Cardiac Output Monitors

Transesophageal Doppler
Thoracic impedance
Limited
Accuracy is controversial
No information about systemic vascular resistance
Measure CVP

Invasive Monitoring
Temperature
Keep warm
Decreasing temperature
Shift Oxygen dissociation curve to left
Hemoglobin retains oxygen at tissue level
Prevent alkalosis

02/07/13 WE Ellis 13
Preoperative Preparation
Angina
Medications to control it
Blood pressure controlled
Diastolic < 95 mm hg
Congestive heart failure treated
Diuretics
Afterload reduction
Bedrest if indicated
Control diabetes
 Our Approach 2012 for beta
blockers
 Continue beta blockers for those already receiving
 Initiate beta blockers prior to surgery (cautiously) for
patients who would otherwise need them -

 Begin low dose as early as possible- >1 week - not day of surgery
 Titrate to heart rate (60-70) and BP

 Carefully follow those on beta blockers in the postoperative

period
 Hypotension
 Bradycardia
 Postoperative tachycardia: look first for a treatable cause
(hypovolemia, anemia) rather than just increasing beta blocker dose.
Anesthesia
 Goal
 Does technique make a
difference?
 Laryngoscopy
 Maintenance
 Regional anesthesia

02/07/13 WE Ellis 16
Anesthetic Technique
Goals of Anesthesia
loss of conciousness
amnesia
analgesia
suppression of reflexes (endocrine and
autonomic)
muscle relaxation
Anesthetic Management
Anaesthetic techniques –
Local anaesthesia
Regional anaesthesia
Combined Regional – General anaesthesia
General anaesthesia

Anesthetic management skills more important than technique.

Safest technique is the one the practitioner does best.

Anaesthetic technique must be based on the type of surgery

and the desired haemodynamic goals during anaesthesia.
Role of Local
Anaesthesia
 LA should be with appropriate IV sedation

 Large doses of anaesthetic should be avoided -

 cardiac toxicity - dysrrhythmias and myocardial
depression.

 Epinephrine with LA - tachycardia, which is undesirable

and should be avoided.

 Monitored with an ECG, BP and a pulse oxymeter.

Supplemental oxygen therapy

 Regular verbal contact with patient are important.

 Regional Anaesthesia
 Intraoperative adverse cardiac events do not differ when
general or regional anaesthesia is used.(study shows)

 Certain procedures have shown better outcome under RA.

 E.g.-
 McLaren et al found no mortality under spinal anaesthesia
for fracture neck femur, versus 25%mortality after
 GA.
 Patients with prior MI undergoing transurethral resection of
prostate had <1% reinfarction rate after spinal versus 2-8%
after GA.
Regional Anaesthesia
 RA - loss of sympathetic efferent tone - rapid
haemodynamic deterioration
 contraindicated in severe aortic stenosis or
hypertrophic obstructive cardiomyopathy.

 In a patient with a failing heart who is dependent on

sympathetic tone –


 central neural blockade can

precipitate cardiac arrest.
Monitor patient more accurately
Control sympathetic responses
Combined Regional-
General Anaesthesia
 Requires a lot of experience on the part of anaesthesiologist.

 E.g. - For lower abdominal surgery, a combination of lumbar

epidural analgesia and GA can be considered when long
surgical procedure, large blood loss or marked hypothermia
is anticipated.
 The combination of thoracic epidural and GA can be used for
upper abdominal, thoracic and major vascular surgery.

 The main advantages of epidural blockade are superior

postoperative analgesia and less diminution of vital capacity.
 Epidural analgesia by suppressing pain improves transmural
distribution of regional myocardial blood flow and thus
minimizing myocardial ischaemia.

General
anesthesia
 Most common anaesthetic technique used for cardiac
patients undergoing noncardiac surgery.
 Avoids sympathectomy

Risks with intubation

Sympathetic stimulation
Hypoxia
Increased catecholamines
Loss of subjective monitor
Chest pain
Ischemia
 General Anesthesia
required
I. Pre-anaesthetic medication
 Integral part of anaesthetic practice ( particularly in
patients with CAD and hypertension.)
Benzodiazepines –
Quell anxiety
Hemodynamic stability
Extended duration of action
Potential for hypoxia
 Intravenous narcotics (e.g. Fentanyl)
Effective control of catecholamines
Respiratory depression
Prolonged ventilation
Opioids
Advantages
Excellent analgesia
Hemodynamic stability
Blunt reflexes

Disadvantages
May not block hemodynamic and hormonal
responses in patients with good LV function
Do not ensure amnesia
Chest wall rigidity
Respiratory depression
Inductions Agents
Avoid Ketamine
Hypertension
Tachycardia
Use in trauma
Etomidate
Painful to inject
More Cardiovascular stability
Barbiturate
Direct depressant
Extended duration of activity
Smaller doses
1-2 mg/kg
Add benzodiazepines and narcotic

Propofol
Outpatient anaesthesia (quick recovery)
Benzodiazepines
Laryngoscopy and intubation
 Adequate depth of anaesthesia should be ensured prior to
intubation.

 Fentanyl
 5-8 mgm/kg can be given to blunt the sympathetic
responses to laryngoscopy and intubation.

Lidocaine
Blunt effects of intubation
1.5 - 2 mg/kg 4-6 minutes prior to intubation

Esmolol i.v. – 0.5 to 1mg/kg 90 sec before intubation

Muscle Relaxants
 Succinylcholine is notorious - producing arrhythmias.
 Avoid pancuronium
Tachycardia
ST segment changes consistent with ischemia
 (Pancuronium may be used in patients with CAD who have a
 slow heart rate)
 Vecuronium provides minimal haemodynamic alterations.
 Doxacurium -cardiovascular stable.
 Rocuronium should be considered during rapid sequence induction
technique.
Avoid Histamine releasing drugs
Curare
Atracurium
Mivacurium <15 mcg/kg
- Hypotension ,Tachycardia
Nitrous Oxide
increased PVR
depression of myocardial contractility
mild increase in SVR
air expansion
Constricts coronary arteries
Aggravates myocardial ischemia
High FiO2 recommended
 Maintain saturation at 95-100%

 N2O - Detrimental effects in patients with CHF, pulmonary

hypertension and regional myocardial ischaemia
Inhalation Agents
Advantages
Myocardial oxygen balance altered favorably by
reductions in contractility and afterload
Easily titratable
Can be administered via CPB machine
Rapidly eliminated
Disadvantages
Significant hemodynamic variability
May cause tachycardia or alter sinus node function
Possibility of “coronary steal syndrome”
Inhalation Agents
 Depress myocardium,
 Cause arterial and venous dilation and
 decrease sympathetic nervous activity.

 decrease in BP and CO, and thus decrease in

myocardial oxygen consumption.
 (advantageous in patients with CAD, may produce
cardiovascular collapse in patients with poor myocardial
reserve.)
 Potential for coronary steal - isoflurane
Alters coronary autoregulation
Alters regional blood flow
Little influence on outcome
Coronary Steal
Arteriolar dilation of normal vessels diverts blood
away from stenotic areas

Commonly associated with adenosine,

dipyridamole, and SNP

Isoflurane causes steal and new ST-T segment

depression

May not be important since Isoflurane reduces

SVR, depresses the myocardium yet maintains
CO
Intraoperative predictors
Choice of Anesthetic
No significant hypotension
No significant tachycardia
Site of Surgery
Thoracic and upper abdominal
2-3 X’s risk of extremity procedures
Duration of Anesthetic
> 3 hours > risk of morbidity & mortality
Emergency Surgery
2 - 5 X’s greater risk than nonemergent
surgery
Cardioactive drugs
Nitroglycerin
Lower LVEDP , Vasodilator
Esmolol
Control heart rate and blood pressure
Labetalol
Control hypertension , Heart rate management
Clonidine
Less hypertension , Decreased anesthesia
requirements
Nifedipine
 Controlling hypertension
 Manage coronary artery spasm
Coronary Artery Disease
Major Goal
Balance Supply and Demand

Primary Determinants of Myocardial Oxygen Demand

Wall tension and Contractility

Factors modifying coronary blood flow

diastolic time
perfusion pressure
coronary vascular tone
intraluminal obstruction
Hemodynamic Goals for
the Patient with CAD
Preload - keep the heart small, decrease wall
tension, increase perfusion pressure
Afterload - maintain, hypertension better than
hypotension
Contractility - depression is beneficial when LV
function is adequate
H R - slow
Rhythm - usually sinus
MVO2 - control of demand frequently not enough,
monitor for and treat ischemia
Monitored Anaesthesia Care
 Employed in CAD patients

 Patients carrying the highest risk are selected

 Minimum anaesthetic interference
 Adequate analgesia is mandatory

 Failure to suppress the stress response

 Highest incidence of 30 day mortality

 (isacon 2008)
 HEART FAILURE
 Inability of the heart to pump enough blood to match tissue requirements.
 Commonest cause
 ischaemic heart disease.
 Other causes include hypertension, valvular heart disease and
cardiomyopathies.

 Note that with an increase in contractility there is a greater cardiac output

for the same ventricular end- diastolic volume.
 .
 Drug treatments may include ACE (angiotensin converting enzyme)
inhibitors, diuretics and nitrates.

 Echocardiogram to assess ejection fraction - values of less than 30%

equate to severe heart failure.
Anaesthesia
consideration
 Preload can be reduced with diuretics and nitrates, and both
central venous and pulmonary artery pressures can be
monitored.
 Trans-oesophageal echocardiography, if available, is a
useful tool to visualize overall cardiac performance.

 Maintenance of myocardial contractility - in particular

inotropes may be needed to oppose the cardiodepressant
action of anaesthetic agents.

 Reduction of afterload by vasodilation, for example as a

secondary effect of spinal or epidural anaesthesia. This not
only reduces myocardial work, but helps maintain cardiac
output. However, the benefit of such actions may be limited
by falls in blood pressure which can compromise blood flow
to vital organs such as the brain and kidneys. So balance
should be there
Valvular Heart Disease

Aortic Stenosis Mitral Stenosis

Aortic Insufficiency Mitral regurgitation

Mitral Stenosis
Characterized by:
Normal ventricular function

Obstruction to left atrial emptying decreases

cardiac output

Pulmonary congestion from elevations in LA

and pulmonary venous pressure

Pulmonary hypertension and RVH over time

Hemodynamic Goals for the
Patient with MS
Preload - Enough to maintain flow across stenotic
valve so to maintain ventricular feeling, excess
fluid may cause pulmonary edema

Afterload – SVR should be maintained,avoid

decrease in SVR
Avoid increased RV afterload (PVR)

Contractility - LV usually ok until after CPB, with

longstanding PHTN, RV may be impaired

HR -keep slow to allow time for ventricular filling,

AVOID SINUS TACHYCARDIA
Hemodynamic Goals for
the Patient with MS
Rhythm - Often atrial fibrillation, control ventricular
response

MVO2 - Not a problem

CPB - Vasodilators may help post-CPB RV failure,

control of ventricular response may be difficult

epidural preffered over spinal

phenylephrine preffered over ephedrine
Mitral Regurgitation
Characterized by:

Chronic volume overload similar to AI

Increased ventricular compliance without

change in LVEDP

May mask signs of impaired ventricular

function
Hemodynamic Goals for
the Patient with MI
Preload – maintain or slightly increase ;an elevated preload
may cause increase in regurgitant flow and low preload
may cause inadequate cardiac output Usually pretty full,
may need to keep that way
Afterload - Decreases are beneficial, increases augment
regurgitant flow, avoid sudden increase in SVR
Contractility - Unrecognized myocardial depression
possible, titrate myocardial depressants carefully,
maintain or increase to decrease left ventricular volume
HR – maintain or increase , avoid bradycardia which
worsens regurgitant flow
Hemodynamic Goals for
the Patient with MI
Rhythm - Atrial fibrillation is occasionally a problem

MVO2 - only if associated with CAD, then caution!

CPB - New valve will increase afterload, unmasking

impaired ventricle

Spinal and epidural well tolerated but avoid

bradychardia
Mitral valve prolapse-
anaesthesia consideration
 Aboid decrease in preload

 Continue antiarrhythmic drugs

 Same consideration as for MI

Aortic Stenosis
Characterized by:
Obstruction to LV outflow

Intraventricular systolic pressure and wall

tension increase

Concentric hypertrophy

Decreased LV compliance

Reliance on atrial contribution

Hemodynamic Goals for
the Patient with AS
Preload - full, adequate intravascular volume to fill
noncompliant ventricle and to maintain BP

Afterload - already elevated but relatively fixed,

coronary perfusion pressure must be maintained,

Contractility - usually not a problem, inotropes may

be helpful preinduction in end-stage AS with
hypotension
Watch out for vasodilation
Treat hypotension with phenylephrine
Hemodynamic Goals for
the Patient with AS
Rate - not too slow (decrease CO), not too fast
(ischemia)
Rhythm - Sinus!! Cardioversion if hemodynamic
instability from SV dysrhythmias
MVO2 - Ischemia is an ever present risk, Avoid
tachycardia and hypotension
Mild to moderate may tolerate spinal and epidural
(epidual preferred)
spinal and epidural contraindicated in severe AS
High risk of myocardial ischaemia
Aortic Insufficiency
Characterized by:

Chronic volume overload

Ventricular dilatation
Eccentric hypertrophy

Forward stroke volume higher than normal

causing increased systolic pressure

Regurgitation across the valve causes

diastolic pressure to be lower than
normal
Hemodynamic Goals for
the Patient with AI
Preload - normal to slightly increased to maximize
forward cardiac output and maintain BP
Afterload - Reduction beneficial with anesthetics or
vasodilators,increases augment regurgitant flow,
avoid sudden increase in afterload
Contractility - usually adequate
Rate - Modest tachycardia shortens diastolic phase
decreases regurgitant fraction and increases
cardiac output
Most patient tolerate spinal or epidural provided
intravascular volume is maintained
Aortic Insufficiency
 Once asymptomatic death can occur with in 5 yrs
unless lesion is surgically repaired

 Digitalis , Diuretics and afterload reduction (ACE

inhibitors) for chronic cond. (eventual surgical
repair)

 Inotropes (dopamine,dobutamine) and

vasodilators for severe,chronic aortic regurgitation
(requires surgery)
Hemodynamic Goals for
the Patient with AI
Rhythm - usually sinus, not a problem

MVO2 - Not usually a problem

CPB - observe for ventricular distention (decreased

HR, increased ventricular filling pressure) when
going onto bypass
Hypertension – Anaesthesia
consideration
 HTN (defined as a diastolic BP>90mmHg or a systolic BP>140mmHg in
adults) is the most common of all the cardiovascular diseases.

 Most patients are under adequate control preoperatively and their

medication should be continued till the day of surgery.

 Poorly controlled or uncontrolled hypertensives are at increased risk of

perioperative complications such as ischaemia, MI, arrhythmias and
cerebrovascular accidents (CVA).

 In mild hypertensive patients a single dose of long acting beta-blocker

may reduce the risk of myocardial ischaemia during stressful periods.
 However, in patients with moderate to severe HTN, cardiology
consultation should be obtained and BP brought under control prior to
elective surgery.
Coronary Artery Revascularization
Prophylaxis Trial (CARP)

 Coronary revascularization prior to vascular

surgery is not of benefit in the patient with
stable CAD if treated with beta blockers,
aspirin, statins in the absence of:
unstable coronary disease
left main coronary disease
aortic stenosis
severe left ventricular dysfunction
Elective vascular surgery in high risk patients.
101 patients
3 or more cardiac risk factors
All with extensive inducible ischemia by stress test
43% with LVEF < 35%
75% with Left main or 3-vd
All received beta blocker titrated to HR 60-65
Antiplatelet agents continued in perioperative period

No benefit of prophylactic coronary revascularization

How about the patient who has
already received a stent and
requires noncardiac surgery ?
Drug eluting stent related issues

 Stent thrombosis
ASA + clopidogrel
 Hemorrhage
ASA + clopidogrel
Joint Advisory Recommendations
and Noncardiac Surgery
 Consider bare metal stent if patient requires PCI and is
likely to require invasive or surgical procedure within next
12 months.

 Educate patient prior to discharge re: risk of premature

antiplatelet discontinuation

Instruct patient to contact treating cardiologist before

antiplatelet discontinuation

 Healthcare providers who perform surgical or invasive procedures

must be made aware of catastrophic risks of premature antiplatelet
discontinuation and should contact the treating cardiologist to discuss
optimal management strategy
 Joint Advisory Recommendations
and Noncardiac Surgery
 Defer elective procedures for which there is bleeding risk
until completion of antiplatelet course
 1 month bare metal stent
 12 months drug eluting stent

 For patient with drug eluting stent who are to undergo

procedures that mandate discontinuation of thienopyridine
(eg, clopidogrel), continue aspirin if at all possible and
restart thienopyridine as soon as possible

 No evidence for “bridging therapy” with antithrombins,

warfarin, or glycoprotein IIb/IIIa agents
Postoperative predictors
Ischemia does occur most commonly in
the postoperative period

Persists for 48 hours or longer following

non-cardiac surgery

Predictor value is unknown

Goldman, L., (1983) Cardiac Risk and Complications of noncardiac

surgery, Annals of Internal Medicine. 98:504-513
Postoperative
Management
Maintain analgesia
Balance supply and demand
Supplemental oxygen
Continue monitoring into
postoperative period
Early transfusion
 Key Points
 Clearance. Perform evaluation and make recommendations
that will relate to perioperative and long – term issues.

 Tests only if likely to influence treatment.

 Preoperative coronary revascularization if independently

indicated.

 Selective use of beta blockers. (beware bradycardia)

 Statins
 Beware of premature antiplatelet discontinuation in the
patient post PTCA stent.

 Continue beta blocker, aspirin, statins,

Summary
 Patients with cardiac disease present for
anaesthesia every day.

 Since their perioperative courses are associated

with greater morbidity and mortality, it is important
to provide a haemodynamically stable anaesthetic

 This requires knowledge of the pathophysiology of

the disease, and of the drugs and procedures and
their effects on the patient.
THANKS