Noncardiovascular Surgery for the Cardiac Patient

Wayne E. Ellis, Ph.D., CRNA

Preoperative Assessment

History Physical exam Laboratory findings and other tests

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History - Do a good one!!!

Stability of angina
NYHA
Class I: Mild angina without impairment Class IV: Angina at rest

Exercise tolerance! Ventricular function Associated cardiovascular diseases Medication

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Recent Myocardial Infarction

Less than three months Patient < 70 years of age Location of surgery Duration of surgery Poor LV function CHF Enlarged heart Arrhythmias Increased risk of morbidity and MORTALITY
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Perioperative Predictors
Recent MI
< 6 months Current CHF

Only consistent predictors of perioperative outcome

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Challenge of anesthesia
Adequately evaluate the patient Provide adequate anesthesia Prevent myocardial injury Maximize postoperative pain management

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RISK FACTORS
genetic predisposition age gender obesity hyperlipedemia diabetes mellitus hypertension stress, tobacco, and smoking

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Smoking
Increases the risk of an initial cardiac event and doubles the rate of subsequent infarction and death. Risk rapidly declines after stopping and by 3 years reaches that of survivors who have never smoked.

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Assessment of risk factors

Cigarette smoking Hypertension Diabetes Family history May have a normal physical

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Perioperative estimation of cardiac risk

Recent preoperative MI
average 8% reinfarction if within 3 months
Optimal preparation Invasive Monitoring

Without monitoring
> 30%

Age
> 70
10 fold increased risk

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Coronary Artery Disease

Most common cause of premature death for males between 35-45years of age. Each year 1.5 million MIs occur in the U.S. 280,000 OHS every year in the U.S. $60 billion spent annually to treat CAD OHS represents 80% of the total adult operations performed at most medical centers in the U.S.

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Atheroscelerosis
begins as crystals of cholesterol adheres to the intima. These crystals then form a larger matrix that stimulates surrounding fibrous and smooth muscle tissue growth to create additional layers i.e.) larger plaques can grow

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Atheroscelerosis
Larger plaques then develop into total obstructive lesions, resulting in sclerosis(fibrosis) Atherosclerosis lesions become symptomatic with 75% stenosis of one or more coronary vessels = ischemia, which depresses the myocardial function, causes chest pain (angina pectoris).

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CAD
Modulated by 3 factors
1) Myocardial oxygen demand 2) Myocardial oxygen supply 3) Coronary blood flow

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Myocardial Oxygen Demand (MvO2)

Heart extracts more 02 than any other organ, 50-70% at rest BP and HR provides a basic guideline for Mv02 contractility and myocardial wall tension are primary determinants of Mv02 wall tension can be lowered by decreasing preload contractility can be lowered by beta blockers or pain management relief
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Determinants of Oxygen Supply

Degree of muscular contractility
Frank Startling Principle The more stretch placed on a muscle fiber before contraction, the more forceful the contraction. Ventricular preload

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Wall tension of the left ventricle

Afterload With increased resistance Hypertrophy Increased muscle mass Maintain normal wall tension

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Heart rate
The faster the rate the more oxygen required The faster the rate there is less time for tissue oxygenation

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Myocardial Oxygen Supply

Any increase in myocardial oxygen requirements can be met only by raising coronary blood flow Maintaing the bloods oxygen carrying capacity is the secondary objective for cardiovascular perfusion

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Myocardial Oxygen Supply

Oxygen content = Ca02 CaO2 = (hgb x 1.34) x Sa02 + (Pa02 x 0.0003) 1.34 = milliliters of 02 per gm of hgb Sa02 = % of oxyhemoglobin of total hemoglobin(fractional saturation) 0.003 = oxygen solubility in plasma

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Influences affecting oxygen supply

Coronary blood flow Left ventricle during diastole With increased heart rate diastole is shortened Coronary perfusion pressure Diastolic pressure minus left ventricular end diastolic pressure CPP = DP-LVEDP

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Oxygen Supply
With coronary stenosis Improve CPP Increase systemic pressure Lower elevated LVEDP Nitroglycerin Hgb Level Oxygen saturation

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Myocardial Oxygen Supply

Any increase in myocardial oxygen requirements can be met only by raising coronary blood flow Maintaing the bloods oxygen carrying capacity is the secondary objective for cardiovascular perfusion

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Coronary blood flow

Perfusion of the left ventricle takes place almost entirely during diastole, whereas the right ventricle occurs mostly with systole. Not only is diastole important, but the length of diastole is critical in determining the volume of left ventricular subendocardial flow

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Coronary blood flow

Coronary perfusion psi = aortic diastolic pressure(AoDp) - LVEDP Note hypotension is more likely to produce ischemia than hypertension

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Temperature
Keep warm Decreasing temperature
Shift Oxygen dissociation curve to left Hgb retains oxygen at tissue level

Prevent alkalosis

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Evaluation
Select patients at highest risk of difficulty Reinfarction in 1st 6 months post MI high High fatality rate CABG or Angioplasty first Choice of monitoring

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Physical exam: Not a lot here

Vital signs Cardiac exam PMI Gallops S4: HTN, S3: increased LVEDP Apical systolic murmur Papillary muscle dysfunction Precordial bulge Other signs of LV function JVD, pulmonary signs
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Physical Examination
Cardiovascular
JVD Carotid Bruits Murmurs S3, S4, Click, Rub Pitting Edema Pulses Vascular Access
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Physical Examination
Pulmonary
Wheezes Rales Rhonchi A-P Diameter

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ECG
How many msec after the J point?? How many mm?? A resting 12 lead is not a whole lot of good for detecting ischemia

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Chest X-Ray
Cardiomegaly Signs of ventricular dysfunction

Edema, effusions
Complicating diseases

Calcification of vessels, valves Pulmonary disease

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Blood tests
CK, other cardiac enzymes
R/O after surgery: Usually an MB of about 57% of total CK

Triponin >7 positive

Diabetes, thyroid disease

Associated diseases

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Primary Treatment
Antiplatelet agents(abciximab,eptifibatide, tirofiban, integullin) GPIIb-IIIa antagonists inhibit platelet function by blocking the GPIIb-IIIa receptor, the final pathway of platelet aggregation thereby decreasing thrombi development and prevents arterial vessel occlusion

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Percutaneous Coronary Intervention

Advantages include: higher recanulazation rates improved blood flow through the infarctrelated vessel improved LV function lower in-hospital mortality rates

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Normal Hemodynamic Measurements

RA (mean) RV (mean) PA (sys/dys) LA or wedge (mean) LV (sys/dys) Systemic arterial (sys/dys) 2-8 15 - 30/2 - 8 15 - 30/4 - 12 2 - 10 100 - 140/3 - 12 100 - 140/60 - 90

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Monitoring
Routine
Pulse Oximetry PNS Capnography Temperature
Core and peripheral

ECG
Leads V5 and II

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Monitors of Cardiac Performance

Arterial Line
Standard of Care Site selection

Pulmonary Artery Catheter

Provides means for assessing filling pressures Reliable site for drug administration

Transesophageal Echocardiography

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Physical signs
Jugular distention Chest sounds Rales Extra heart sounds

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Preoperative Evaluation
History Physical assessment EKG evaluation Exercise tolerance Chest X-ray Lab studies

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Preoperative Evaluation
Current Medication
Beta-blockers Calcium Channel Blockers Antidysrhythmia agents Nitrates Diuretics Antihypertensive agents

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Dyspnea
Activity Rest What starts it How long lasts

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Dynamic Predictors
Acute imbalances in myocardial oxygen supply and demand may produce ischemia that may result in irreversible cardiac morbidity Hypertension Hypotension Tachycardia

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Dynamic Predictors
Hypertension
No conclusive correlation
Intraoperative Hypertension MI

Acute Hypertension
Precedes intraoperative ischemic events 50% of time

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Dynamic Predictors
Hypotension
25 % of ischemic events associated with > 20 % decrease in systolic blood pressure 6 % decrease in MAP Important predictor of PCM
Higher reinfarction rate 15.2 % vs. 3.2 % Intraoperative hypotension
> 30% decrease in systolic BP > 10 minutes duration

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Dynamic Predictors
Tachycardia
Combination with hypotension Ominous Significant indicator of PCM

Myocardial Ischemia
ST changes
Not a clear indicator of PCM

TEE
Most sensitive, earlier indices of ischemia Before ST segment changes
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Treatment of ischemia
Is it real? Optimize oxygenation and hemodynamics IV NTG SL Nifedipine Diltiazem Intra-aortic Ballon Pump

Improves systolic run off Provides diastolic augmentation

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Anesthesia Goals
Balance supply and demand Control heart rate Normal to slow range Maintain CPP Prevent hypotension Prevent increased LVEDP Optimize arterial oxygen and carbon dioxide status Keep patient normothermic Higher threshold for transfusion
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Anesthesia
Goal Does technique make a difference? Laryngoscopy Maintenance Regional anesthesia

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Preoperative Preparation
Angina
Medications to control it

Blood pressure controlled

Diastolic < 95 torr

Congestive heart failure treated

Diuretics Afterload reduction Bedrest if indicated

Control diabetes

Preoperative Medications
Sedation Prevent tachycardia Hypertension Prepared for hypoxia Supplemental oxygen Calcium channel blockers not protective of perioperative ischemia Antihypertensives continue on day of surgery Stop Diuretics

Antianginal medications
Beta-blockers Calcium Channel Blockers Nitrates Nitropaste morning of surgery

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Beta Blockers
Negative inotropic effects Withdrawal following stoppage of beta blocker
Unstable angina Myocardial infarction

Monitoring
EKG 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

Noninvasive beat to beat analysis

Finapress Ohmeda

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

Improved outcomes
Aggressive monitoring & treatment Vasoactive drugs Reduced intraoperative ischemia MI < 6 months has better survival rate Occurrence reduced from 30-5% Multi-institution study over last 10 years 5000 patients Continued for 3 days post-operatively

Decision to use Invasive Monitoring

Patients with severe inoperable CAD Chronic stable angina undergoing significant abdominal or thoracic surgery Large blood loss History of remote MI with stable angina
Not necessary to use invasive monitors

Anesthetic Management
Regional vs general Anesthetic management skills more important than technique Safest technique is the one the practitioner does best

General anesthesia
Avoids sympathectomy Risks with intubation
Sympathetic stimulation Hypoxia Increased catecholamines

Loss of subjective monitor

Chest pain Ischemia

General Anesthesia required

Narcotics
Effective control of catecholamines Respiratory depression Prolonged ventilation

Avoid Ketamine
Hypertension Tachycardia Use in trauma

Etomidate
Painful to inject More CV stability

Barbiturate
Direct depressant Extended duration of activity Smaller doses
1-2 mg/kg Add benzodiazepines and narcotic

Benzodiazepines
Quell anxiety Hemodynamic stability Extended duration of action Potential for hypoxia Lidocaine Esmolol

Muscle Relaxants
Avoid pancuronium
Tachycardia ST segment changes consistent with ischemia

Doxacurium
Duration similar to pancuronium No cardiovascular effects

Avoid Histamine releasing drugs

Curare Atracurium Mivacurium <15 mcg/kg Hypotension Tachycardia

Inhalation Agents
Potential for coronary steal Alters coronary autoregulation Alters regional blood flow Little influence on outcome

Nitrous Oxide
Constricts coronary arteries Aggravates myocardial ischemia High FiO2 recommended
Maintain saturation at 95-100%

Regional Anesthesia
Monitor patient more accurately Control sympathetic responses
Fluids Esmolol

Intraoperative predictors
Choice of anesthetic Site of surgery Duration of Anesthesia Emergency Surgery

Intraoperative predictors
Choice of Anesthetic
No difference in infarction rate GETA vs. Regional
No significant hypotension No significant tachycardia

TURP
Regional decreased risk post MI Reinfarction rate
SAB < 1% GETA 2-8%

Intraoperative predictors
Choice of Anesthetic
Patient with CHF will benefit from regional technique
Sympathectomy Decreased preload

Coronary Steal
Potent inhalation agents vs. narcotics

Intraoperative predictors
Site of Surgery
Thoracic and upper abdominal
2-3 Xs risk of extremity procedures

Duration of Anesthetic
> 3 hours > risk of morbidity & mortality

Emergency Surgery
2 - 5 Xs greater risk than nonemergent surgery

Cardioactive drugs
Nitroglycerin
Lower LVEDP Vasodilator Poor ventricular function

Esmolol
Control heart rate and blood pressure Induction Emergence

Labetalol
Mixed alpha and beta Control hypertension Heart rate management

Lidocaine

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

Clonidine
Less hypertension Decreased anesthesia requirements

Nifedipine

Controlling hypertension Manage coronary artery spasm

Postoperative Management
Maintain analgesia Balance supply and demand Supplemental oxygen Continue monitoring into postoperative period Early transfusion

Coronary Artery Disease

Major Goal
Balance Supply and Demand

Primary Determinants of Myocardial Oxygen Demand

Wall tension and Contractility

Coronary Artery Disease

Factors modifying coronary blood flow
diastolic time perfusion pressure coronary vascular tone intraluminal obstruction

Coronary Artery Disease

Myocardial O2 Extraction
infrequently the cause of ischemia intraoperatively

Arterial O2 Content
Correction of anemia High FiO2

Hemodynamic Goals for the Patient with CAD

P - keep the heart small, decrease wall tension, increase perfusion pressure A - maintain, hypertension better than hypotension C - depression is beneficial when LV function is adequate R - slow, slow, slow

Hemodynamic Goals for the patient with CAD

Rhythm - usually sinus MVO2 - control of demand frequently not enough, monitor for and treat supply ischemia CPB - elevated ventricular filling pressure usually not needed after CABG

Anesthetic Technique
Goals of Anesthesia
loss of conciousness amnesia analgesia suppression of reflexes (endocrine and autonomic) muscle relaxation

Inhalation Agents
Advantages
Myocardial oxygen balance altered favorably by reductions in contractility and afterload Easily titratable Can be administered via CPB machine Rapidly eliminated

Inhalation Agents
Disadvantages
Significant hemodynamic variability May cause tachycardia or alter sinus node function Possibility of coronary steal syndrome

Coronary Steal
Arteriolar dilation of normal vessels diverts blood away from stenotic areas Commonly associated with adenosine, dipyridamole, and SNP Forane causes steal and new ST-T segment depression May not be important since Forane reduces SVR, depresses the myocardium yet maintains CO

Opioids
Advantages
Excellent analgesia Hemodynamic stability Blunt reflexes Can use 100% oxygen

Opioids
Disadvantages
May not block hemodynamic and hormonal responses in patients with good LV function Do not ensure amnesia Chest wall rigidity Respiratory depression

Induction Drugs
Barbiturates Benzodiazepines Ketamine Etomidate

Nitrous Oxide
Rarely used due to:
increased PVR depression of myocardial contractility mild increase in SVR air expansion

Muscle Relaxants
Used to:
facilitate intubation prevent shivering attenuate skeletal muscle contraction during defibrillation

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

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