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Anaesthesia for the cardiac patient for non-cardiac surgery Preoperative assessment János Gál

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Page 1: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Anaesthesia for the cardiac patient for

non-cardiac surgery

Preoperative assessment

János Gál

Page 2: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

The role of the anaesthesiologist

(1846-2013)

http://www.braceface.com/medical/Civil_War_Surgeons_swords_and_images/Civil War Images/PJ stereoview surgery.jpg
http://www.braceface.com/medical/Civil_War_Surgeons_swords_and_images/Civil War Images/PJ stereoview surgery.jpg
Page 3: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Consequences of incorrect preoperative risk

assessment

• 6x increase in mortality!

• Australian Incident Monitoring Study (AIMS-

2000)

– Inadequate risk stratification 11,6% (478/6271)

– Complications 3,1 % (197)

– Major morbidity 23, death 7

– >50% definitely, further 21% probably avoidable

Page 4: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Mosaics of the lecture

• Cardiac risk stratification

• Screening tools

• Preoperative PCI???

• Problems with patients with

stents

• Pharmacological risk reduction

• Patients with PM/ICD

Page 5: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Risks of anaesthesia of cardiac patients in

non-cardiac surgery

• 60% of patients due to anesthesia has some kind of heart

disease (80% above age of 60)

• Periop. cardiac complication develops in 4%

• 17-74% of coronary disease patients suffers myocardial

ischemia

Mangano DT. Anesthesiology 1990; 72: 153-184

Page 6: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Risks of anaesthesia of cardiac patients in

non-cardiac surgery

• Myocardial infarction accounts for 10–40% of postoperative

fatalities, it is the major determinant of perioperative

mortality associated with non-cardiac surgery

• Nonfatal MI in the periop. period is associated with a 20-

fold increased risk of late mortality

Landesberg G. J Cardiothorac Vasc Anesth 2003; 17:90–100

Raby K. N Engl J Med 1989; 321:1296–300

Page 7: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Devereaux PJ. CMAJ 2005;173(6):627-34

Page 8: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Cardiac risk stratification

• Lee’s revised Cardiac risk index

• MET (metabolic equivalent)

• Risk of surgical procedure

• Localization of operation

• Further perioperative tests if needed

– Myocardial perfusion scintigraphy

– Dobutamine stress echocardiography

Flood C. Am Fam Physician 2007;75:656-65

Page 9: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Flood C. Am Fam Physician 2007;75:656-65

Page 10: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Metabolic equivalent

Freeman WK. Mayo Clin Proc. 2009;84(1):79:90

Page 11: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

The surgical procedure

Flood C. Am Fam Physician 2007;75:656-65

Page 12: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Sensitivity of preoperative tests regarding cardiac death

and non-fatal MI (major vascular surgery)

Kertai MD. Progress in Cardiovascular Diseases 2005;47(4):240-257

Page 13: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Effect on survival of elective

preoperative coronary revascularisation

McFalls EO. N Engl J Med 2004;351:2795-2804

Page 14: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Perioperative management of patients with

stent (PCI, BMS, DES)

• 1990’: increasing periop. morbidity/mortality in patients

with PCI going for non-cardiac surgery

• 90% of patients going for PCI get one or several stent/s

• 5% will have non-cardiosurgical intervention within 1 year!

• Periop. dilemma: bleeding or coagulation?

• 63% of anesthesiologists do not know the guideline!

Vicenzi MN et al. Br J Anaesth 2006;96:686-93

Patterson L et al. Can J Anesthesiol 2005;52:440-1

Page 15: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Overview: prevention of periop.stent thrombosis

• Avoid preop. coronary stenting

• Stent selection (BMS-DES)

• Delay surgery

• There is no bridge therapy for PCI

patients, timing is crucial

• Education, interdisciplinary teamwork

• Surgery only where PCI is available

Brilakis et al. JACC 2007;49,22:2145-50

Page 16: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Preoperative pharmacological risk reduction

• β-blockers

• Statins

• Remember there is indirect β-blocking

– Choose proper mode of anaesthesia, EDA

– Avoiding hypothermia

– Avoiding anaemia

– PM, ICD (switch off frequency enhancing and

antitachycadia programs temporarily)

Gal J et al. EJA 2006, 23(8):641-648.

Page 17: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Targets: blood pressure, pulse, endothel

• Elective operation BP <180/110 mmHg, P<70/min

• Effective by evidence: β-blocker and statins

• Effective risk reduction takes 6-8 weeks!

– Vascular/endothel changes/pleiotropic effect

– Risk/benefit

• Intraop. low BP is more dangerous than hypertension!

• diuretics?, Ca channel blockers, (ACEI ?)

Howel SJ. Br J Anaesth 2004;92:570-583

Page 18: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Effects of statins

Chan YC. Vascular Health and Risk Management 2008;4(1):75-81

It takes time! ~ 30 days

Page 19: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Effect of haematocrit on major

postoperative cardiac events

Page 20: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

PM, ICD: preoperative management

• Consider the underlying disease

• Check the setting and the memory of the device-

specialist!

• Switch off frequency enhancer programs

• Optimizing DO2 : frequency adaptation

• Switch off ICD anti-tachycardia therapy

Page 21: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

PM, ICD: intraoperative management

• Caution: Magnet???

– Different effects: depending on the type of the device

• Bipolar>monopolar electrocauter

• Current must not flow through the generator-heart circuit

• Pulse wave monitoring

Page 22: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

PM, ICD: postoperative management

• Postoperative check/modification

• Frequency setting (CO, DO2)

• Antitachycardia therapy must be enabled, until then close

monitoring!

• Frequency enhancer programs should be enabled

Page 23: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

Summary

• Plaque fissure plays an important role in

perioperative MI

• Risk stratification is important

• Indication of preoperative PCI is limited

• Beta-blockers, statins, mode of anaesthesia may

improve outcome

• Stent, PM, ICD patients need special management

Page 24: Anesthesia of the cardiac patient for non-cardiac …...fatalities, it is the major determinant of perioperative mortality associated with non-cardiac surgery • Nonfatal MI in the

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