departement hart- en vaatziekten 30/04/2010 - … anesthesie...bradycardia recent diagnosis of vt 4....
TRANSCRIPT
Anesthesie voor
de cardiaal belaste patiënt
Prof. Dr. Carlo Missant, MD, PhD
Departement Cardiovasculaire Wetenschappen – Anesthesie
Universitaire Ziekenhuizen Leuven
Les co-assistenten anesthesie 2014
Referenties
• Clinical Anesthesia (Barash), 6th edition
• Miller's Anesthesia, 7th Edition
• Kaplan’s Cardiac Anesthesia, 6th edition
Inleiding
• Hoge Incidentie Ischemische Hartziekte
– Ouder wordende populatie
– Vaak niet gediagnosticeerd
• Intra-operatieve Myocardischemie = Verhoogd Risico postop MI
• Postoperatief myocardinfarct = Predictor van overleving na
chirurgie
Magnitude of the problem
Trial Patients
(n)
Date Overall
Mortality
Cardiac
Mortality
Myocardial
Infarction
MACCE
Patients at increased cardiac risk
DECREASE
I, II, IV
3893 1996-2008 3.5% (cardiac death, MI)
POISE 8351 2002-2007 2.7% 1.6% 4.4% 6.4% (Cardiovascular death,
non-fatal MI, non-fatal
cardiac arrest)
Sabaté et al. 3387 2007-2008 1.9% 0.6% 4.3% (Cardiiovascular death,
MI, angina, non fatal
cardiac arrest,
arrhythmia, heart
failure, stroke)
Unselected patient population
Lee et al. 4315 > 50J.,
No emergencies
1989-1994 1.5% 0.3% 1.3% 2.5% (Cardiac death, MI,
cardiac arrest, AV III,
pulmonary edema)
Boersma et
al.
108593 1991-2000 1.7% 0.5%
16 mio inhabitants
800.000 non-cardiac surgical
procedures p.a.
15.200 perioperative deaths p.a.
5.000 cardiovascular deaths p.a.
Schouten O.
Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-
risk patients undergoing non-cardiac surgery: Rationale and design of the DECREASE-IV study.
Am Heart J 2004;148:1047–52
Magnitude of the problem
Circulation. 2002;106:2366-2371
Vascular surgery
Anesthesiology 2003; 99:270–4
CABG
Preoperative
evaluation: •Recognition of the patient at
increased cardiac risk
• Risk analysis and
stratification
• Supplemental testing
Outcome
Preoperative
optimisation: • Revascularization
• Antiplatelet therapy
• Statins
• PBB
• α2-Agonists
The patient at increased cardiac risk
European Journal of Anaesthesiology 2010, 27:92–137
Available evidence
Available evidence
Inleiding
• Identification of the patient at risk
• Risk modification strategies:
– Preoperative revascularization
– Pharmacological treatment
• Peroperative medical therapy
• Cardiac preconditioning
• Monitoring
• Anesthesie voor de hartfalen patiënt
Lee’s Revised Cardiac Risk Index
• 6 onafhankelijke risicofactoren
– Hoog risico chirurgie
– VG van ischemische hartziekte
– VG van congestief hartfalen
– VG van CVA
– IDDM
– Serum creatinine > 2 mg/dl
• Aantal risicofactoren ~ kans op majeure cardiale complicatie
– Acuut myocardinfarct
– Longoedeem
– Ventrikelfibrillatie
– Cardiac arrest
0 : 0.5%
1 : 1.3%
2 : 4%
3 of meer : 9%
Circulation 1999;100(10):1043-9
Preoperatieve oppuntstelling
Active cardiac conditions
1. Unstable coronary syndromes
Unstable/severe AP
recent MI (< 30d)
2. Decompensated heart failure
NYHA IV
worsening, new-onset
3. Significant Arrhythmias
AV-block II Mobitz, AV-block III
Symptomat. ventr. Arrhythmias
SV Arrhythmias (HF > 100)
Symptomat. Bradycardia
Recent diagnosis of VT
4. Severe valvular disease
AS (ΔPmean > 40mmHg, AVA < 1cm²,
symptomat.)
MS symptomatic (progressive dyspnea on
exertion, exertional presyncope, or HF)
Unstable cardiac conditions
1) Unstable angina pectoris
2) Acute heart failure
3) Significant cardiac arrhythmias
4) Symptomatic valvular heart disease
5) Recent MI (< 30d)
6) Residual myocardial ischemia
No surgery (unless emergency)
Evaluation and Treatment
before Non-cardiac Surgery
Preoperatieve oppuntstelling
Emergency: 2-5x increased risk
Chirurgisch risico
Chirurgisch risico
Functional capacity 1 MET 40 years, 70kg VO2 = 3.5 ml/kg/min
< 4 MET: Perioperative complications
Climb a flight of stairs? AHA
ESC
Functionele capaciteit
Clinical risk factors
1) IHD
2) Congestive heart failure
3) Cerebrovascular disease
4) Diabetes mellitus (also NIDDM)
5) Renal insufficiency (independent from serum-
creatinine)
Clinical risk factors
1) IHD (angina / MI)
2) Heart failure
3) Stroke / TIA
4) Renal dysfunction (serum creatinine ≥ 2mg/dL or crea-clearance <60mL/min)
5) Diabetes mellitus (IDDM)
Clinical risk factors
12-lead-ECG
Ind.: ≥ 1 risk factor + ≥ intermediate-risk-surgery
No risk factor + vascular surgery
Ind.: ≥1 risk factor + Intermediate/high risk surgery
No risk factor + ≥65 years + ≥ Intermediate-Risk-
Surgery
Noordzij PG et al.
Prognostic Value of Routine Preoperative
Electrocardiography in Patients
Undergoing Noncardiac Surgery.
Am J Cardiol 2006;97:1103–1106
Supplemental testing
Ind.:
Dyspnea of unknown origin
Patients with current or prior HF
with worsening dyspnea or other change in clinical status within 12 months
Echocardiography
Resting LV-Function: not predictive for ischemic events
LVEF < 35%: Sensitivity 50%, Specifity 91% in predicting cardiac death/non-fatal MI
Supplemental testing
Treadmill-ECG, Stress-Echo, Stress-MRI, Myocardial Perfusion Imaging Purpose
Objective assessment of functional capacity
Detection of ischemia
Detection of inducible arrhythmias
Estimation of perioperative cardiac risk
and of long-term prognosis
In general:
Myocardial ischemia at low exercise workloads = high perioperative risk
Extensive ischemic reaction = high perioperative risk
Ind. Vascular surgery: MET < 4 and ≥ 3 RF
Evtl. intermediate risk/vascular surgery: MET < 4 and 1-2 RF
Ind. High risk surgery + > 2 RF + poor exercise tolerance
Evtl. High or intermediate risk surgery + 1-2 RF + poor exercise
Supplemental testing
Peroperatieve strategie
• Pre-operatieve revascularisatie
• Anesthetic approach
• Medicatie
– Betablokkers
– Ace inhibitie
– Statines
– Aspirine
• Preconditioning
• Monitoring
Coronary artery revascularization before
elective major vascular surgery: CARP Trial – Prospective, randomized, multicenter trial
– 510 patients undergoing major vascular surgery
– Angiographycally proven CAD (EF <20% excluded)
– Randomized to preoperative revascularization (59% CABG
and 41% PTCA) or routine medical treatment
2.7 y mortality: 22% vs. 23%
Rate of MI within 30 days after surgery:
12% vs. 14% (n.s.)
NEJM 351:2795-2804, 2004
Pre-operatieve revascularisatie
A Clinical Randomized Trial to Evaluate the Safety of a
Noninvasive Approach in High-Risk Patients Undergoing
Major Vascular Surgery : The DECREASE-V Pilot Study
J Am Coll Cardiol 2007;49(17):1763-9
– Prospective single center randomised trial
– 101 patients: preop. revascularisation vs. medical
treatment
– Revascularization did not improve 30-day outcome p =
0.30
– Also, no benefit during 1-year follow-up p = 0.48
Pre-operatieve revascularisatie
• Indications for coronary revascularization are identical
to those in the non-operative setting
• Revascularization “to get the patient through surgery”
is never indicated
• Timing of subsequent surgery is crucial
• The risk of delaying surgery has to be taken into
account
• CABG vs. PTCA: no prospective randomised trials
Pre-operatieve revascularisatie
Patient met coronaire stent
• Ballondilatatie
• Bare metal stent (BMS)
• Drug eluting stent (DES)
• Aspirine + Clopidogrel:
BMS: 4-6 weeks
DES: 1 year
• Aspirine: Levenslang
Patiënt met coronaire stent
Patient met coronaire stent
Peroperatieve medicatie
• Betablokkers
• Ace inhibitie
• Statines
• Aspirine
London MJ
Perioperative β-Adrenergic Receptor Blockade
Physiologic Foundations and Clinical Controversies
Anesthesiology 2004; 100:170–5
Improvement myocardial O2-balance Antiarrhythmic effects
Optimization of myocardial
metabolism
Anti-inflammatory
Plaque-stabilization
( Shear stress)
Perioperatieve Beta-Blockade
Peri-operatieve beta-blokkers
Mangano et al. N Engl J Med 335:1713-20, 1996
Poldermans et al. N Engl J Med 341:1789-94; 1999
Devereaux PJ et al; Lancet 2008;371:1839-47.
• PeriOperative ISchemic Evaluation trial: POISE trial
• 190 hospitals, 8351 patients
• Start metoprolol 2-4 u voor chirurgie tot 30 d postop
• ↓ MI in metoprolol group vs placebo (4.2 vs 5.7%)
BUT : – ↑ stroke in metoprolol group (1.0 vs 0.5%)
– ↑ mortality in metoprolol group (3.1 vs 2.3%)
• β-blockers ↑ risk, especially in context of anemia +
hypotension
Cardiac
Morbidity Myocardial
Infarction
Stroke
Death
1.) Withdrawal of beta-blockers: NEVER !!!
Shammash JB
Perioperative β-blocker withdrawal and mortality in vascular surgical patients.
Am Heart J 2001;141:148-53
2.) Early start: 30d (or at least 1 week) preop. (ESC);
days to weeks preop. (AHA)
3.) Titration: 60-70/min (ESC); 60-80/min (AHA)
4.) Contraindication: RR < 100mHg (ESC); Hypotonus (AHA)
Beta-blockers: wat is er bewezen?
Beta-blokkers
Ace-inhibitoren
• Inhibitie van angiotensine converting enzyme
• Bloeddrukverlagend effect
• Orgaanpreservatie
– Endotheelfunctie
– Anti-inflammatoire eigenschappen
– Anti-atherogenese
Ace-inhibitoren: QUO VADIS study
• Quinapril vs. Placebo in cardiac surgery
• 4 weeks before untill 1 year after surgery
• Reduction in postoperative cardiovascular events in
quinapril group
• Recent review: conflicting results
Am Heart J 2007; 154:407-14
Ace-inhibitoren
• Perop gebruik gepaard met hypotensie!
– Vooral in combinatie met beta-blokkers
– Ace-inhibitoren = AII receptor blokkers
– Respons op vasopressie beperkt
• Ace-inhibitoren STOP 1 dag preop indien anti-hypertensivum
+ zo snel mogelijk postop herstarten
• Ace-inhibitoren VERDER indien LV systolische dysfunctie en
stabiele klinische toestand
Ace-inhibitoren: ESC guidelines
Geen guidelines
Statines
Statines
Lindenauer PK
Lipid-Lowering Therapy and In-Hospital Mortality Following Major Noncardiac Surgery.
JAMA. 2004;291:2092-2099
NNT: 85
AHA-Indications:
1) Statins should be continued
2) Vascular surgery
3) 1 risk factor + Intermediate Risk Surgery
ESC-Indications:
1) Statins should be continued
2) Statins should be started in high-
risk surgery patients, optimally
between 30 days and at least 1
week before surgery
Statines
Statines
Aspirine
• Aspirin: antithrombotic and anti-inflammatory activity,
particularly relevant in patients with plaque instability
• Widely used, but evidence in perioperative period is limited
• Reduces the incidence of MI, especially in individuals with
serologic evidence of inflammation (Ridker et al. NEJM 336:973-9, 1997)
• Early administration improves outcome following CABG
(Mangano DT. NEJM 347:1307-17, 2002)
• Should not be stopped lightly preoperatively
– In patients at risk for IHD, withdrawal of ASA was associated with 3 fold
risk of adverse cardiac events (OR 3.14) (Eur Heart J 2006; 27:2667-74)
– Bleeding risk >> potential cardiac benefit
Mangano et al NEJM 347:1307-17, 2002
Aspirine
Aspirine: ESC 2014 Guidelines
Cardiaal belaste patiënt
What is really important ?
• Careful evaluation of history / clinical examination
• Estimation of cardiac risk with simple risk factors / scores
• Protocol-based strategy
• Restrictive indications for additional testing
• Preoperative revascularization only in very selected cases
• Structurized management of patients with coronary stents
Myocardprotectie
• Ischemische preconditioning
• Farmacologische preconditioning
• Postconditioning
Ischemische preconditioning
Murry et al. Circulation 1986
Farmacologische preconditioning
Anesthesiology
1999; 91:1437-46
ATP – K kanaal
blokker
Farmacologische preconditioning
Schultz, J. E. J. et al. Circ Res 1996;78:1100-1104
Farmacologische postconditioning
0
10
20
30
40
50
60
Control Isoflurane Desflurane Sevoflurane
Preckel B et al. Br J Anaesth 1998; 81: 905 –
912
* *
Infa
rct siz
e %
Mechanism of preconditioning
inhibition of the
opening of MPTP is
key step in
preconditioning
induced
cardioprotection
Monitoring of peroperative ischemia
• ECG
• PAC
• TEE
ECG
• Inferior: II, III, aVF
• Lateraal: I, aVL, V4-V6
• Septaal: V1,V2
• Anterior: V3,V4
• Anteroseptaal: V1-V3
• Anterolateraal: V1-V6
Transmural infarction
Stop blood supply
Subendocardial ischemia
Subendocardial ischemia
ECG
ECG routine monitoring
• Afleiding II: P-waves -> arrythmie
• Afleiding V5: meest sensitief voor ischemie
• In geval van per-operatieve ischemie:
ST-analyse en 12 lead ECG
Pulmonary artery catheter
• Zie les hemo-
dynamische
monitoring
Pulmonary artery catheter: PCWP
The measurement is obtained when the inflated balloon impacts into a
slightly smaller branch of the pulmonary artery. This is where the arterial
pressure exceeds the venous pressure and the venous pressure exceeds
the alveolar pressure, thereby creating a continuous column of blood from
the catheter tip to the left atrium when the balloon is inflated. Pulmonary
venous pressure is the best indicator of left atrial pressure except when
there is venoocclusive disease. AND ONLY WHEN THE PA CATHETER
IS IN ZONE 3 of the lung.
Transoesophagale echocardiografie
• Fluid and hemodynamic management more
challenging and important than anesthetic
choice/products
• Two major hemodynamic goals
– Preserving cardiac output
– Minimisation of myocardial work
• Consider invasive monitoring including CO for all
major surgery
• Regional versus general anesthesia? Flat position?
Intra – operatief management
General vs. Regional anesthesia
Congest Heart Fail. 1999;5(6):248-253
Anesthetic agents
• No cook book approach
• Removal of sympathetic tone may lead to CV
collapse during anesthetic induction.
• Agents should be chosen to maintain
hemodynamic stability and take into account
coexisting renal or hepatic insufficiency
• High doses of the potent inhalation agents are
poorly tolerated in this population.
1. Preserving cardiac output
– Preload
• Higher than usual central venous pressure
• Tachycardia
• Aggressive treatment of arrhythmias (atrial kick !)
– Afterload
• Avoid acute increase in afterload (dramatic drop in CO)
• Maintain perfusion pressure
– Contractility
• Increased sympathetic tone lost after induction of anesthesia
• Dobutamine / phosphodiesterase inhibitors
2. Minimisation of myocardial work
Major hemodynamic goals
1. Preserving cardiac output
2. Minimise myocardial work / reducing oxygen demand
– Avoid tachycardia
– Avoid hypovolemia
– Avoid hypoxia and hypercapnia
– Avoid anemia
– Reduction afterload – maintain diastolic blood pressure
– Effective postoperative analgesia and PONV prevention
Major hemodynamic goals
Oxygen delivery Oxygen demand
Oxygen carrying
capacity
Coronary blood flow
Diastole
1/HR Perfusion
pressure
Coronary Vascular
Resistance
Heart rate
Contractility
Wall tension
Afterload
Preload
Myocardial oxygen balance
Anesthesie
Zuurstofaanbod Zuurstofverbruik
Zuurstofdragende
capaciteit
Coronaire bloedflow
Diastoleduur
1/HR Perfusiedruk
DABP - LVEDP
Vasculaire weerstand
Hartritme
Contractiliteit
Systolische
wandspanning
Syst
BP
EDV
Daling sympathische activiteit
Milde daling contractiliteit
Afterload reductie
Nitraten: venodilatatie + arteriodilatatie
Zuurstofaanbod Zuurstofverbruik
Zuurstofdragende
capaciteit
Coronaire bloedflow
Diastoleduur
1/HR Perfusiedruk
DABP - LVEDP
Vasculaire weerstand
Hartritme
Contractiliteit
Systolische
wandspanning
Syst
BP
EDV
DOSIS: 0.1 - 7 µg/kg/min
Conclusie
• Hoogrisico patiënten!!
• Pre-operatieve screening
• Peroperatief medicatiebeleid
• Peroperatieve ischemie monitoring
• European Heart Journal (2014) 35, 2383–2431