Cardiac Surgical Patient

Question 1

Why is there perioperative risks?

Answer 1

• Major hemodynamic stress
• Changes in cholinergic activity
• Changes in catecholamine activity
• Body temperature fluctuations
• Fluid shifts
• Pain

Question 2

Risks of anesthesia?

Answer 2

• Decrease systemic vascular resistance

- Decrease Stroke Volume

Question 3

What does induction of general anesthesia do to your systemic arterial pressure?

Answer 3

• Lowers by 20-30 %

- Anesthetic agents lower cardiac output by 15%

Question 4

What does tracheal intubation to do your blood pressure?

Answer 4

-Increases by 20-30mmHg

Question 5

Many anesthetic lower CO by what percent?

Answer 5

10-15%

Question 6

In addition to identifying the presence of pre-existing manifested heart disease it is essential to define disease _________, _________, and _______ _________.

Answer 6

Severity, stability, and prior therapy

Question 7

What is the main factor that can help you determine cardiac risk?

Answer 7

Functional Capacity

Question 8

What type of surgical procedures are considered higher risk?

Answer 8

Vascular procedures and prolonged, complicated thoracic, abdomen, and head and neck procedures

Question 9

The presence of _______ maybe also place a patient at a higher perioperative risk

Answer 9

Anemia

Question 10

In addition to CAD and CHF, a history of what co-morbidities increases perioperative cardiac morbidity?

Answer 10

Cerebrovascular Disease, preop elevated creatinine greater than 2mg per deciliter, insulin treatment for DM, and high risk surgery

Question 11

What are the 4 cornerstones of preoperative cardiac evaluation?

Answer 11

• review of history
• physical examination
• diagnostic tests
• knowledge of the planned surgical procedure

Question 12

Evaluation of Cardiac Risk

Answer 12

See Slide 13

Question 13

What is included in evaluation of cardiac risk- valvular heart disease

Answer 13

• Dyspnea, Orthopnea, PND
• Embolic Events
• Hemoptysis
• Heart Failure, Palpitations

Question 14

What would you look for in the general appearance of the physical exam that would be concerning?

Answer 14

Cyanosis, pallor, dyspnea during conversation or minimal activity, nutritional status, obesity, skeletal deformities, tremor and anxiousness

Question 15

What is included in a detailed cardiac exam?

Answer 15

• JVD, Pedal edema
• Capillary Refill
• Displaced apical impulse (cardiomegaly)
• S3 Gallop (increased LVEDP)
• S4 (decreases compliance)
• Presence of murmurs
• Pulmonary Edema

Question 16

What is a MET or metabolic equivalent defined as?

Answer 16

The ratio of a person’s working metabolic rate relative to the resting metabolic rate

Question 17

T/F: one MET represents the oxygen consumption of a resting adult (3.5ml/kg/min)

Answer 17

True

Question 18

If patients reduce exertion because of cardiac symptoms but still meet a 4-MET threshold clinicians will under or over estimate risk?

Answer 18

Underestimate

Question 19

Non cardiac functional limitations (ex: knee or back pain) may falsely over or under estimate cardiac risk?

Answer 19

Overestimate

Question 20

What range is considered poor, moderate and good for METS.

Answer 20

Poor <4 METS
Moderate 4-7 METS
Good >7-10 METS

Question 21

Measurements on a treadmill inducing ischemia at low-level exercise (<5 MET) or heart rate <100/min identifies what

Answer 21

A high risk group

Question 22

The achievement of more than 7 MET (or heart rate >130/min) without ischemia identifies what?

Answer 22

A low-risk group

Question 23

The presence of abnormalities on ECG such as Q waves and non sinus rhythms have been shown to correlate with that?

Answer 23

Adverse Postoperative Cardiac Events

Question 24

What can alter an ECG tracing?

Answer 24

• Metabolic
• Electrolyte Disturbances
• Medications
• intracranial disease
• Pulmonary disease

Question 25

What is considered the gold standard for risk indices?

Answer 25

ACC/AHA

Question 26

What are considered major disease processes?

Answer 26

- Unstable coronary Syndromes - Decompensated Heart Failure - Significatn Arrhythmias - Severe Valvular Disease * see slide 26

Question 27

What are considered intermediate disease processes?

Answer 27

- Mild angina - History of MI, pathologic Q’s - Compensated our prior CHF - Diabetes Mellitus - Renal Insufficiency(CKD)

Question 28

What disease processes are considered minor?

Answer 28

- Advances age - Abnormal ECG (LVH, LBBB, ST-T abnormalities) - Rhythms other than sinus (AF) - Low functional capacity - History of stroke - Uncontrolled systemic hypertension

Question 29

High risk surgeries (5% risk of perioperative death or MI) include:

Answer 29

Emergent major surgery, peripheral vascular or aortic surgery, prolonged surgery involving excessive blood loss

Question 30

Moderate risk surgeries (1-5% risk of perioperative death or MI) include:

Answer 30

Carotid endarterectomy, urologic, ortho, uncomplicated abdominal, head, neck or thoracic operations

Question 31

Low risk surgeries (<1% risk of perioperative death or MI) include:

Answer 31

Cataract removal, endoscopy, superficial procedure, cosmetic procedures, and breast surgery

Question 32

Indications for preoperative cardiac testing

Answer 32

- patients with intermediate clinical predictors - prognostic assessment of patients undergoing initial eval for suspected or proven CAD - Eval of patients with a change in clinical status - Eval of adequacy of medical treatment - Prognostic assessment after acute coronary syndrome

Question 33

Noninvasive cardiac tests

Answer 33

1. Transthoracic ECHO 2. Exercise tests and pharmacologic tests 3. Exercise stress test 4. Dobutamine stress ECHO 5. Adenosine stress test 6. Ambulatory ECG monitoring

Question 34

What are some strategies to reduce risks?

Answer 34

- General vs Regional anesthesia - Temperature Monitoring - Invasive monitoring: PAC, TEE - Laparoscopic vs Open - Endovascular

Question 35

What are some medical management ways to reduce risk?

Answer 35

- use of beta blockers - Other anti-ischemic medications - Lipid lowering agents

Question 36

Class I: preoperative coronary angiogram/coronary intervention

Answer 36

See slide 40

Question 37

Evidence based practice parameters: Classes

Answer 37

``` Class 1: benefits greatly outweigh the risks Class 2a: reasonable to consider Class 2b: may be reasonable to consider Class 3: not indicated Level A: highest level of evidence Level C: lowest level of evidence ```