Transcript Perioperative Management of the Cardiac Patient

Perioperative Care of the
Cardiac Surgery Patient
Lars Hegnell, MD
Dept. of Anesthesiology and Perioperative Medicine
OHSU, Portland, Oregon
Learning Objectives
Identify, evaluate, and treat cardiac risk patients
Minimize intraoperative risk for these patients
Address postoperative care problems in an EBM manner
to reduce mortality and morbidity
Challenge in Care Plans
Preoperative
• Evaluation and risk assessment
Intraoperative
• Prevention of acceleration of disease state
• Managing interactions between anesthetic and surgical requirements,
primary disease and co-morbidities
Postoperative
• Prevention and treatment of adverse events following surgery
Goals of Preoperative Evaluation
Assess surgical disease
Assess functional status
Review associated
comorbidities
Explain procedure and
postoperative expectations,
including pain management
Explain expected outcome
Discuss directives in case
of complications
Instruct about preoperative
medication, fasting, and
pain treatment
Minimize risk factors
Full physical examination
Collect and evaluate
cardiac, pulmonary, and/or
vascular examinations
Review medications and
laboratory results
Prevent adverse events
during intra- and
postoperative period
Preoperative Evaluation
Physical, cardiac, and
pulmonary functional
status.
• Use a functional classification
scale like NYHA
• ECG, echo and stress testing
• ABG, CXR, and PFTs
History of previous
surgeries and adverse
events
Allergies
Previous or ongoing
medication with
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antiplatelet therapy
clot lysing agents
Aprotinin within last 6 months*
ß-blockers
nitroglycerin
ACE-inhibitors
digitalis
diuretics
Ca-channel blockers
lipid lowering agents
anti hyperglycemic drugs
* see next slide
Aprotinin
A serine protease inhibitor, decreases inflammatory
response and inhibits plasmin mediated fibrinolysis.
Prior exposure increases risk of allergic response with
peak within the first 6 months post exposure.
Cardiovascular Risk Assessment
Major
• Unstable coronary syndrome
• Acute or recent MI
• Unstable/sever angina
• Decompensated HF
• Significant arrhythmias
• High-grade AV block
• Symptomatic ventricular
arrhythmias with concomitant
heart disease
• Supraventricular arrhythmias
with uncontrolled ventricular
rate
• Severe valvular disease
Intermediate
• Mild angina pectoris
• Previous MI or Q waves
• Compensated/previous heart
failure
• DM (esp. IDDM)
• Renal insufficiency
Cardiovascular Risk Assessment (cont)
Minor
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Advanced age
Abnormal ECG
Rhythm other than SR
Low functional capacity
Previous stroke
Uncontrolled hypertension
These risk factors are
predictors for myocardial
infarction, heart failure,
and death and should be
weighed against surgical
risk (see next slide).
High-risk Surgeries
Aortic and major vascular surgery
Cardiac surgery
Emergency surgical procedures
Prolonged surgery with massive fluid shifts or bleeding
Comorbidities
Diabetes mellitus
Hematological disease
Pulmonary disease
Renal disease
Smoking
Preoperative Medical Treatments with Effect
on Outcome of Surgery
Diabetes
• Poorly regulated blood glucose levels intra- and postop shown to
negatively affect outcome possibly through effect on neutrophil activity.
• Silent ischemia also more likely in diabetic patients.
Hypertension
• Considered risk factor for CAD
• Uncontrolled HTN (stage 3) indication for postponing surgery if possible
Arrhythmias
• Preoperative ß-blockers recommended by ACC/AHA for
supraventricular arrhythmias before cardiac surgery and non-cardiac
surgery
• Amiodarone reduces AF after bypass surgery.
Preoperative Medical Treatments with
Effect on Outcome of Surgery
Hyperlipidemia
• Statins reduce perioperative cardiac complications undergoing vascular
surgery (StaRRS study)
Smoking cessation
• Quitting smoking is associated with a 36% risk reduction of all-cause
mortality among patients with CHD, timeline unclear.
Extended Workup of the Cardiac Patient
Exercise stress test
• If ECG abnormalities, do exercise echo or exercise myocardial
perfusion imaging
Non-exercise stress test
• Dobutamine, not for arrhythmic or severely hypo/hypertensive patients
• Dipyridamole, not for patients with obstructive pulmonary or carotid
disease
• Myocardial perfusion study
Coronary angiogram
• For high-risk patients
Premedication
Opioids
• Sedation, risk of respiratory depression and hypoxia
Benzodiazepines
• Low risk of respiratory depression, good anxiolytic effect, and sedation
Antiemetics
• Sedative, anticholinergic, and antiemetic properties
Alpha-2 agonists
• Decreases stress response, lowers BP, amplifies opiod effect
Goals of Intraoperative Management
Protect brain, heart, lung, and kidney function by
maintaining organ perfusion
Reduce level of stress hormones
Reduce cardiac oxygen consumption
Reduce risk for arrhythmias
Maintain euglycemia, start insulin infusion early!
Implement plan for postoperative pain management
Plan for postoperative organ support if needed
Adjust anesthetic plan for postoperative care
Organ Protection
Maintain tissue perfusion by regulating volume status,
anesthesia depth, and cardiac function through
procedure.
Use Swan-Ganz catheter (not shown to change
outcome), CVP, invasive BP, urine output
measurements, and ABGs to reach your preset goals.
Use ß-blockers intraoperatively to reduce HR (reducing
oxygen consumption and increasing coronary perfusion
time), catecholamine response, and minimize risk for AF.
Methods for Intraoperative Cardiac
Function Measurements
ECG with ST-monitoring
Arterial line
CVP
PA-catheter
TEE
Esophageal Doppler
Partial CO2 rebreathing (NICO) for CO measurement
Goals for Cardiac Optimization
Optimize coronary blood flow by keeping a high arterial
diastolic pressure, low LV diastolic pressure, and a
relative bradycardia, and decrease coronary vascular
resistance (pertinent for CAD but less so for some
valvular lesions like AI):
• Nitrates: vasodilates coronaries, slight to no decrease of diastole,
decrease in preload and afterload
• Ca-blockers: dilates coronaries, increases diastolic time, minimal to light
reduction of preload and reduces afterload
• ß-blockers: increases diastolic time, slightly increase pre- and afterload
(probably not of clinical importance), decreases contractility and HR,
reduces collateral coronary blood flow (metoprolol)
Anesthetics Effect on Cardiac Function
Opioid
• No myocardial depression
• Stable hemodynamics
Volatile agents
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Protects ischemic myocardium
Preconditioning
Suppresses sympathetic response
Myocardial depression
Systemic depression and vascular relaxation
Propofol
• Vasodilator
• Rapid recovery, can be used for postoperative sedation
Anesthetics’ Effect on Cardiac Function
Regional anesthesia
• Epidural: if high (T1-T5), results in cardiac sympathectomy, decreases
oxygen consumption, increases coronary blood flow, and increases LV
function
• Gives excellent analgesia, reduces postoperative stress response, and
facilitates pulmonary function recovery with reduction in mechanical
ventilation and earlier extubation
Benzodiazepines
• Midazolam: decreases myocardial oxygen consumption and coronary
sinus blood flow
• Diazepam: decrease in LVEDP, reduction in oxygen consumption,
increased myocardial blood flow
Anesthetics’ Effect on Cardiac Function
Isoflurane, sevoflurane, and desflurane all cause
coronary vasodilatation
• A hypothesis of “coronary steal” was postulated: Flow change in
coronaries when dilated from normal would reduce flow to poststenotic
dilated poorly perfused areas more than areas with good perfusion
causing aggravated myocardial ischemia. Shown in animal studies, not
a factor in humans if good hemodynamic control is maintained.
Intraoperative Drug Support
Vasopressors
• Dopamine
- α-, β- and dopamine receptor agonist; vasodilator at low doses, impairs NE
release and vasoconstrictor at higher doses
- Increased risk of AF after cardiac surgery
- NO renal protective effect of low-dose dopamine
• Epinephrine
- α- and β- receptor activity; inotropic and chronotropic effect with increase in
afterload, also dromotropic and lusitropic effects (with appropriate use the
effect on afterload is minimal)
- β-adrenergic activity, increases contractility and HR, reduces systemic and
pulmonary vascular resistance
• Norepinephrine
- α- and β1 receptor activity; potent α-effect with increase in vascular
resistance
Intraoperative Drug Support
• Vasopressin
- V1 and V2 (and V3) receptor effect; induces coronary vasodilatation at
low doses followed by vasoconstriction at higher doses, promotes
platelet aggregation, releases factor VIII and vWf, increases hepatic
glycogenolysis, induces mesenteric vasoconstriction, and decreases
CO
- The combined effect of NE and vasopressin infusion on catecholamine
refractory dilatory shock post CABG seems to be advantageous.
Intraoperative Drug Support
Inotropes
• Dobutamine
- “Selective” β agonist; positive inotropic effect, augments coronary blood flow,
reduces afterload and preload more than dopamine
- The increase in CI with dobutamine early after CPB is mostly heart rate, not SV
• Milrinone (Amrinone)
- Phosphodiesterase III inhibitor; positive inotropic effect and dilates pulmonary
and systemic vasculature
Intraoperative Drug Support
Anti-arrhythmic drugs
• Amiodarone
• Minimal effect on LV function, decreases HR
• Magnesium
• Intraoperative magnesium seems to contribute to myocardial recovery and
lessen risk of ventricular arrhythmias postop and reduces AF after cardiac
surgery
Intraoperative Drug Support
Antifibrinolytics - these seem to be clinically equal in
effect on bleeding during CPB surgery, price and side
effects differ
• Aprotinin
• Aminocapric acid
• Tranexamic acid
Postoperative Care of the Cardiac
Surgery Patient
Level of care is dependent on present or anticipated
problems.
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ICU
Step-down unit
Telemetry unit
Ward
Postoperative Care in the ICU
Admission
• Keyword: communication! Direct information from OR
team/anesthesiologist/surgeon to intensivist team on arrival in the unit
about:
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Operation
Complications during op; bleeding, need for transfusion
Responsiveness to volume, inotropes, and drugs
Planned care and expected problems
Initial Review of the Postoperative Patient
ABC
Monitoring
IV lines and sites
Pumps and infusions
Drain catheters and urinary catheter
Temperature
Physical examination
Postoperative Management
CABG patients info of importance for care:
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Time on CPB
Clamp time
Ventilation/oxygenation/airway management
Pressor/inotropic support
Surgical considerations for postop period
Postoperative Management
Ventilation
• CXR for ETT and chest tube placement, SG-catheter position, and
pulmonary pathology
• ABG for ventilation assessment and support
Circulation
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Pressor needs? Inotropes?
CO output and SVR/PVR review
Peripheral perfusion
Kidney function
Coagulation
• Output in chest tube/wound per time unit
• TEG/ACT/PT/APTT/platelet count for coagulation status
• Observe drug effects on platelet function (i.e., milrinone)
Risk Factors for Postoperative Pulmonary
Dysfunction
Age < 2 or > 60
Long CPB time
Amiodarone
Type of oxygenator
COPD
Level of C3a activation in
bypass circuit
Pulmonary hypertension
Congenital pulmonary
pathology
Down’s syndrome
Use of ice for
cardioplegia (damage to
phrenic nerve)
Postoperative Medications
Aspirin
• Start within first 48 (24) h post op. Reduces risk of early occlusion of
grafts
Β-blocker
• Reduces risk of cardiovascular death and AF/arrhythmia
Ca-channel blocker
• Reduced mortality after cardiac surgery, although negative inotropic and
chronotropic effect and platelet inhibitor
Lipid lowering therapy
• Aggressive treatment delays progression of atherosclerosis regardless
of risk factors.
Postoperative Medications (cont)
ACE-inhibitors/ARB
• Reduces risk of stroke, MI and death in diabetic and vascular
patients, unclear effect after cardiac surgery except for quinapril
which reduces risk for ischemic events in postop CAGB patients
Graft Spasm Prevention
Several therapies to maintain graft patency after CABG
has been used, side effects and surgeon preference
decide choice
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Nitroglycerin
Ca2-channel antagonists
Phosphodiesterase inhibitors
α-adrenergic antagonists
Preventable Postoperative Complications
Arrhythmia
• Decreased organ perfusion
• Increased risk for MI or fatal arrhythmia
• Prolonged ICU care and hospital stay
Hyperglycemia
• Increased mortality and morbidity
• Impaired wound healing
• Decreased cardiac function
Hypertension
• Increased risk of stroke and MI
• Increased risk of surgical bleeding
Postoperative Complications
Bleeding
• Surgical?
• Coagulopathy? Lysis? Heparin effect?
Pain
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Secondary hypertension
Reduced pulmonary function
Hyperdynamic circulation
Impaired wound healing
Use multimodal approach: acetaminophen, NSAID, opioid and/or LA
(PainBuster®) from the OR, add opioids in the unit
Postoperative Complications
Coronary ischemia
• Increased risk of MI/arrhythmias/circulatory arrest
Renal failure
• 1 - 2% of CPB patient, associated with high mortality especially if ARF is
associated with dialysis
• Fenoldopam, dopamine – 1 agonist, improves outcome in patients with
low CO?
Prolonged ventilation
• Increased risk of VAP
Problem Directed Management
Hypertension
• Pain?
- PCA, iv/po medications or epidural
• Postoperative stress response?
- ß-blocker if tachycardia and good LV function
- Nicardipine, does not decrease preload, other vasodilators if hypovolemia is
excluded
- Fenoldopam, for patient with renal insufficiency?
• Tachycardia and pronounced hypotension, usefulness in ICU patients
unclear
Problem Directed Management
Hyperglycemia
• Insulin infusion to maintain blood glucose < 110 mg/dl (< 6.1 mmol/l)
has shown to decrease in mortality/morbidity in postoperative ICU
patients.
Problem Directed Management
Arrhythmias
• Amiodarone has good prophylactic effect and shown good rhythm
control on postoperative AF. Secondary effect is reduced morbidity and
cost in the ICU
• ß-blockers should be continued if started, but keep in mind the negative
effect on a “stunned” myo-cardium.
Coagulopathy
Hypothermia?
• Rewarm!
Residual heparin effect?
• Give 50-mg protamine
Intraoperative major bleed?
• Supply missing components – platelets, coagulation factors
• Potentiate vWF and activate platelets with DDAVP
Special Cases
Pacemaker and/or ICD pre-, intra-, and postop.
• Investigate type, function, possibility to turn off during and susceptibility
to cauterization before surgery. Backup needed?
Mechanical support for failing heart postoperatively:
IABP, VAD (L/R/Bi)
• IABP improves coronary circulation during diastole and reduces LV
afterload
• VAD therapy: temporary measurement, bridge-to-transplant or bridgeto-destination
• High complication risk of bleeding and/or infection
Special Cases
Postoperative vasodilatory shock
• Common post CBP and probably exacerbated by preoperative use of
ACE-inhibitor and intraop milrinone.
• CPB appears to stimulate nitric oxide production thru an effect on the
inducible NOS.
• Trend today to use vasopressin infusion, no randomized studies
available comparing NE/E/vasopressin and outcome.
SIRS
• Use of low-dose steroids seems to attenuate cytokine response post
bypass and improve outcome.
Special Cases
Pulmonary hypertension
• PVR increased or RV overload/failure? Use of milrinone, prostaglandin
analogs, nicardipine, diuretics or sildenafil (or combinations) to improve
RV function are treatment modalities currently used.
References
ACC/AHA Guideline 2002. Update on peri-operative cardiovascular evaluation for
noncardiac surgery.
Gunjan YG et al. Intraoperative hyperglycemia and perioperative outcomes in cardiac
surgery patients. Mayo Clin Proc. 2005;80:862-866.
Van den Berghe et al. Intensive insulin therapy in the critically ill patients. N Engl J Med.
200;345(19):1359-67.
Practice Advisory for the Perioperative Management of Patients with Cardiac Rhythm
Management Devices: Pacemakers and Implantable Cardioverter-Defibrillators.
Anesthesiology 2005;103(1).
Louis E Samuels et al. Selective use of amiodarone and early cardioversion for
postoperative atrial fibrillation. Ann Thorac Surg. 2005;79:113-116.
Eugene Chrystal et al. Interventions on prevention of postoperative atrial fibrillation in
patients undergoing heart surgery: a meta analysis. Circulation. 2002;106:75-80.
ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery.
References
(cont)
Erich Kilger et al. Stress doses of hydrocortisone reduce severe systemic inflammatory
response syndrome and improve early outcome in a risk group of patients after
cardiac surgery. Crit Care Med. 2003; 31(4):1068-1074.
Roger JF, Baskett et al. The intraaortic balloon pump in cardiac surgery. Ann Thorac
Surg. 2002;74:1276-87.
Medical Therapy for Pulmonary Arterial Hypertension, ACCP Evidence-Based Clinical
Practice Guidelines. Chest. 2004;126:35S-62S.
O’Neil-Callahan K et al. Statins decrease perioperative cardiac complications in patients
undergoing noncardiac vascular surgery: the statins for risk reduction in surgery
(StaRRS) study. J Am Coll Cardiol. 2005;45:336-42.
Martin W. Dünser et al. Arginine vasopressin in advanced vasodilatory shock: a
prospective, randomized, controlled study. Circulation. 2003;107:2313-2319.
Martin W Dünser et al. The effects of vasopressin on systemic hemodynamics in
catecholamine-resistant septic and postcardiotomy shock: a retrospective analysis.
Anesth Analg. 2001;93:7-13.
Daniel M. Thys et al. Textbook of Cardiothoracic Anesthesiology; McGraw-Hill Companies
ISBN 0-07-079188-0
References (cont)
Dennis T Mangano. Aspirin and mortality from coronary bypass surgery. N Engl J Med.
2002;347(17):1309-1317.
Emile G Daoud, et al. Preoperative amiodarone as prophylaxis against atrial fibrillation
after heart surgery. N Engl J Med. 1997;337:1785-91.
Trevor WR Lee, et al. High spinal anesthesia for cardiac surgery. Anesth. 2003;98:499510.
Stefan G de Hert, et al. Choice of primary anesthetic regimen can influence intensive
care unit length of stay after coronary surgery with cardiopulmonary bypass. Anesth.
2004;101:9-20.
Stefan G De Hert, et al. Cardioprotection with volatile anesthetics: mechanism and
clinical implications. Anesth Analg. 2005;100:1584-93.
PWC ten Broecke, et al. Effect of preoperative ß-blockade on perioperative mortality in
coronary surgery. Br J Anesth. 2003;90 (1): 27-31.
Peter K Lindenauer, et al. Perioperative beta-blocker therapy and mortality after major
noncardiac surgery. N Engl J Med. 2005;353:349-360.
Cardiac Surgery. Kirkland/Barratt-Boyes 2003; Churchill, Livingstone: New York, NY
References
(cont)
S Miller, at al. Effects of magnesium on atrial fibrillation after cardiac surgery: a metaanalysis. Heart. 2005;91:618-623.
A Thompson, et al. Perioperative cardiac arrhythmias. Brit J Anesth. 2004;93(1):86-94.
B Erstad. Antifibrinolytic agents and desmopressin as hemostatic agents in cardiac
surgery. Ann Pharmacother. 2001;1075-84.
S Mussa, et al. Radial artery conduits for coronary artery bypass grafting: current
perspective. J Thorac Cardiovasc Surg. 2005;129:250-253.
Case 1
59-year-old male presents to emergency dept. with chest
discomfort. Hx. of smoking, hypertension, and
hyperlipidemia. Newly prescribed nitroglycerin for
intermittent chest pain that started 3 months ago. Now
chest pain during night that resolved after nitro. Meds:
atenolol, ASA, lisinopril, lovastatin, and nitroglycerin.
ECG: SR, 70 Hz, no ST/T changes. Troponin 0.02.
Admitted to Obs. Unit for follow up. Second ECG
showed T-inversions in aVL, V4-5. Second troponin 0.02,
no chest pain.
What next?
Case 1
(cont)
Patient sent for exercise treadmill test: Chest pain, ST
depression in II, III, aVF, V5, and V6. Chest pain and
ECG resolved.
What now?
Cardiac cath lab: EF 45%, severe multivessel CAD,
referred to CT surgeon for surgery
Which medications do you continue with or start?
Case 1
(cont)
Patient started on heparin until surgery. ASA, metoprolol,
lisinopril, and lovastatin cont’d.
Day 2: CABG x 5, intraop CBG 98-177, started on insulin
infusion. Anesthesia with isoflurane/fentanyl/pancuronium.
CPB 109 minutes, clamp time 85 minutes. Postop
sedation with dexmedetomidine.
Admitted to ICU, initial review showed bibasilar
atelectasis and minimal left pleural effusion on CXR,
stable circulatory values, normal SVR/PVR and SvO2 and
ABG: 7.23,56,126,-5.3,22. Good UO and temp 35.7º C.
What do you do now?
Case 1 (cont)
Decision to “fast track” patient to extubation; patient
extubated after 2 hours in ICU. ABG pre-extubation:
7.37/40/123/-1.6/23 after some volume replacement.
Minimal pain issues postop, continued on opioids and
acetaminophen.
Day 3: Stable patient. No chest drain output, stable
circulation and respiration. Chest tubes and S-G catheter
d’ced and patient moved to floor unit.
Day 5: Discharged home.