Anesthesia for Cardiac Patients for Non Cardiac Surgery Kimberly Westra DNP, MSN, CRNA
Anesthesia for Cardiac Patients for Non Cardiac Surgery Heart Disease is a significant problem in the United States: 84 Million Americans suffer from some form of Cardiovascular Disease 1 in 3 deaths result from cardiovascular disease
Anesthesia for Patients with Cardiac Disease Stagering Statistics: Cardiovascular disease results in approximately 2200 deaths per day that's one every 40 second! Cardiovascular disease kills more death than cancer, chronic lower respiratory and accidents combined!
Identification of Patients with Cardiovascular Disease Patient Preoperative Assessment & Identification: Unstable or stable cardiovascular disease Know, symptomatic cardiac disease Risk Factors
Goals of Cardiac Preoperative Assessment Rarely necessary to provide an intervention rather to offer a risk assessment & suggestions from Cardiologist perspective. Adjunct Tool for Perioperative Care Team: Surgery, Anesthesia & Nursing
Preoperative Assessment: Implantables? Does the patient have an implantable cardiac device? Pacemaker AICD Biventricular Pacer Proximity to Device, Cautery, Bipolar
Cardiac Disease & Co Morbidities Diabetes Renal disease Smoking Dyslipidemia Obesity Hypertension
Optimizing Patients for Surgery Hypertension: Stage 3-- Systolic >180...Diastolic >110 should be controlled before surgery If urgent surgery, IV rapid acting medication may be used. Caution for excessive hypotension.
Valvular Heart Disease Stenotic Valvular Lesions associated with higher perioperative risk, heart failure/shock Regurgitant valve disease is usually better tolerated can be managed.
Myocardial Disease Dilated & Hypertropic cardiomyopathy is associated with increased incidence of Perioperative heart failure Management for valvular disease is promoting perioperative hemodynamic stability.
Anesthesia for Cardiac Disease Patients Surgery results in significant stress due to possible increase in cardiac output, fluid & electrolytes changes/ imbalances, possible anemia Impact of anesthestic agents & medications on homeostatic & cardiovascular system!
Perioperative Cardiac Adverse Events Myocardial infarction & unstable angina are the leading cardiovascular cause of death after surgery Multifactoral issues that lead to increased risk of cardiovasular adverse events
Perioperative Cardiac Adverse Events Contributory events: increased sympathetic tone, inflammatory mediators, plaque rupture, oxygen supply & demand imbalances Multifaced approach to prevention of adverse event should be employed
Anesthesia Care & Approach Preoperative: sound & comprehensive evaluation, risk stratification, careful preparation & setup Intraoperative: smooth induction, maintainence & emergence Postoperative: Careful monitoring, pain management, postoperative follow up Pain management, Cardiac, Hospitalist postoperative
Assessment of Perioperative Risk Goldman Cardiac Risk Index Detsky's modified approach to Goldman Index NYHA Classification Lee's Risk Stratification Criteria Use American Heart Association Guidelines for Evaluation Cardiac Clearance Medical Clearance Coordination of Aftercare
Anesthesia Care & Medications Continue medications for: Antianginal Antihypertensives Beta Blockers Statins Discontinue Diuretics, Anticoagulation meds dependant upon medication, length/ mechanism of action, type of surgery, type of anesthesia needed (regional), expert opinion
Medications: Beta Blockers Myocardial protection from Beta Blockers Heart rate reduction & reduced myocardial oxygen demands Reduced MVO2 with slower HR & stable mean arterial pressure
Beta Blocker Advantage Beta Blockers advantage: reduced myocardial oxygen demand via Reduce HR giving increased diastolic perfusion time Arrythmia suppression Limit production of leukocytes, free radicals, monocyte activiation Release of inflammatory cytokine response, stablizes plaque, reduced expression of aptosis
Beta Blocker Early Data Controversy surrounding early data from DECREASE study 1990s. Lead to further large randomized control trials (RCT) on beta blockers
DECREASE Study Initial study late 1990s. Subsequent studies followed prompted by national organization to promote clincial guidelines Controversy for this study prompted further research...poise
Beta Blockers & Reduced Perioperative Ischemia Risk Extensive studies 1990s to present 2008 POISE Study: Multicenter 8000 patients with metanalysis found significant benefits for non fatal myocardial infarction & myocardial ischemia
Poise Trial 2008 Poise trial continues to suggest perioperative beta blocker started one week prior to surgery, titrated to heart rate especially in high risk patients reduce risk of adverse cardiac event Cardioselective beta blockers are ideal the perioperative setting Imbedded into Anesthesia Metrics & Compliance standards following large research reviews
Anesthesia for Cardiac Patients & Beta Blockers 2008 POISE Study: also found significant perioperative issues such as hypotension, severe bradycardia requiring treatment, stroke, mortality (effect was adverse but not statistically significant)
Anesthesia & Beta Blockers Patients with 3 to 4 cardiac risk factors had significantly lower death risk. Contrarily, 1 to 2 risk factors and beta blockade resulted in increased risk of death.
2009 American Heart Association & American College of Cardiologists suggest: Continue beta blocker for cardiac patients for non cardiac surgery Insufficient data for starting beta blockade started two or more days preoperatively Beta Blockers:
Preoperative Evalutions Diagnostics: EKG ECHO Labs Mets Patient Interview Expert Consult
Intraoperative Considerations EKG Five Lead Blood Pressure frequency Pulse Oximetry Arterial Line Central Line PA Catheter*
Intraoperative Monitoring Five lead EKG monitoring, ST segment analysis, pacer detection settings Arterial Line: beat to beat blood pressure monitoring, early hypotension detection, lab monitoring
Intraoperative Monitoring Considerations: Blood loss with conservative threshold Lab monitoring Hemodynamic instability intolerance Access once positioned for invasives
Intraoperative Monitoring Laboratory Studies: Hemoglobin/HCT Electrolytes Creatinine, Osmolarity Blood Gases Coagulation studies
Intraoperative Monitoring Central Catheter: Fluid status Vasoactive infusions Intravenous fluid and blood products Difficult intravenous access considerations Caution: Pacemakers
Intraoperative Transesphageal Echo Evaluation of regional wall motion abnormalities: suggest ischemia Evaluation of fluid volume/resusitation status Running Echo
Intraoperative Monitoring Temperature: keep normothermic using active and passive warming modalities Avoid hypothermia that can result in significant cardiac stress/shivering* Hypothermia results in left Shift:Oxygen retained at tissue levels
Anesthesia Care for Cardiac Patient in Non Cardiac Surgery Cardiac Disease & Anesthesia Considerations: Valvular Disease Coronary Disease Cardiomyopathy
Anesthesia for Patients with Cardiac Disease Identify Valvular Disease: Tricuspid, Mitral, Aortic Disease Varied types of valvular irregularities Severity of disease, studies available: ECHO, EKG, Expert Report
Anesthesia for Cardiac Patients Preoperative evaluation: expert consultant/report, diagnostic tests, physical exam, patient interview, medications Risk analysis & informed consent with discussion.
Preoperative Evalution & Risk Stratification Recency of coronary revascularization Recency of last favorable cardiac evaluation Comorbidities Functional Status Risk of Proposed Surgery
Major Clinical Predictors Unstable coronary syndromes: Recent MI with evidence for ischemia Unstable or severe angina Decompensated CHF Severe Valvular Disease Significant Arrhythmias: High Grade AV block Symptomatic Ventricular Arrhythmias Supraventricular tachycardia with uncontrolled rate
Intermediate Clinical Predictors Mild angina pectoris Prior MI by history or pathological Q waves Compensated or prior CHF Diabetes Renal Insufficiency
Advanced age Minor Clinical Indicators Abnormal EKG (LVH, LBBB, ST changes Rhythm other than sinus rhythm Low functional capacity History of stroke Uncontrolled Systemic Hypertension
Functional Capacity METs: >10 METs excellent 7-10 METs good 4-7 METs moderate <4 METs poor
MET Scale Used to place patients in their appropriate risk category. MET measure of metabolic unit of capacity A unit is proportional to amount of physical exertion Based on METs person can perform approximation of cardiac status VERY subjective but can act as a quick screening tool for overall cardiac status.
Surgical Risk: High > 5% Emergent major procedures especially with advanced age Aortic & Major Vascular Procedures (TAVR less) Peripheral Vascular Procedures Prolonged Surgery Large Blood loss/fluid shifts
Surgical Risk: High > 5% Emergent major procedures especially with advanced age Aortic & Major Vascular Procedures (TAVR less) Peripheral Vascular Procedures Prolonged Surgery Large Blood loss/fluid shifts
Surgical Risk: Intermediate <5% Carotid endarterectomy Head & Neck Intraperitoneal & Intrathoracic Orthopedic Prostate Surgery
Procedures following Cardiac Revascularizaiton Suggested time to delay non emergent procedures: CABG 2 3 months, sternal healing, infection risk, cardiac risk PCI: Stents, angioplasty 4 6 weeks
Emergent Surgery for Cardiac Patients Risk stratification, optimize monitoring, treatment plan, recovering, vigilent after care Must discuss risks & possible poor outcomes: Death, significant disability.
Conservative Thresholds Close management of labs, monitoring, anesthesia care plan Discussion & coordination of services: postoperative cardiac monitoring/ expert consult
Reflection Questions Perioperative cardiac risk reduction can be achieved by ensuring all patients receive preoperative beta blockers regardless of prior history of beta blocker adminstration as part of the patients routine medical care plan? True or False
Reflection Questions A analysis of METS and physical activity tolerance in the preoperative interview is adequate screening and may mitigate the need for unneccessary sophisticated Cardiac Testing? True or False
Reflection Questions A analysis of METS and physical activity tolerance in the preoperative interview is adequate screening and may mitigate the need for unneccessary sophisticated Cardiac Testing? True or False
Reflection Question Patients with significant cardiac risk for non cardiac surgery may require invasive intra arterial access and possibly a central access catheter to closely assess hemodynamics regardless of the type and length of the surgery? True or False
Summary Increasing number of patients have significant comorbidities including cardiac morbidities Comprehensive reviews for risk stratification, careful planning & safe implementation of anesthesia care is essential No one anesthetic technique is indicated as the safer choice for cardiac patients for non cardiac survery
Questions?