ANESTHETIC MANAGEMENT OF IHD PATIENT WITH FRACTURE NECK FEMUR FOR ORIF.

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• ANESTHETIC MANAGEMENT OF IHD PATIENTWITH
  FRACTURE NECK FEMUR FOR ORIF.
• Dr. Kolli S.Chalam, MD PDCC.
• HOD Anesthesiology Critical Care Medicine, Sri
  Sathya Sai Institute of Higher Medical sciences,
  Whitefield, Bangalore-66.

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1.

• WHAT ARE THE ANESTHETIC
• GOALS ?

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ANESTHETIC GOALS

• Avoid new onset myocardial Ischaemia/MI
• Improving myocardial O2 supply/demand
• Controlling hemodynamics
• Detect treat myo. ischaemia

2.

• MYOCARDIAL O2 BALANCE

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MYOCARDIAL O2 BALANCE

• OXYGEN SUPPLY
• oxygen content of
• arterial blood
• CBF
• ARTEIAL o2
• coronary blood flow.
• -cpp, vasc. Tone
• - time available- DPTI
• Severity of intra luminal obst.
• Collateral circulation

• OXYGEN DEMAND
• wall stress P xR/2h
• CONTRACTILITY
• PRELOAD
• AFTERLOAD
• HEART RATE

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How would you prepare this patient?
3.
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PRE- OPERATIVE PREPARATION

• Management of Anesthesia for Hypertensive Pts
• Preoperative Evaluation
• Determine adequacy of BP control
• Review pharmacology of drugs
• Evaluate for evidence of end-organ damage
• Continue drugs used for control of BP
• Induction and Maintenance of Anesthesia
• Anticipate exaggerated BP response to
• anesthetic drugs
• Limit duration of direct laryngoscopy
• Administer a balanced anesthetic to blunt
• hypertensive responses
• Consider placement of invasive hemodynamic
• monitors
• Monitor for myocardial ischemia
• Postoperative Management
• Anticipate periods of systemic hypertension
• Maintain monitoring of end-organ function .

• BP 180/90 mmHg
• Labs Hb 8 g 10/30 rule.
• AABB Guideline .
• Other Labs N.

Carson JL, Grossman BJ, Kleinman S, et al. Red
blood cell transfusion a clinical practice
guideline of the AABB. Ann Intern Med 2012 157
49-58. No recommendation hospitalized stable
pts with ACS.
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How would you premedicate this patient?
4.
Is there a role for alpha 2 agonists in
premedication?
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PREMEDICATION

• Sedation / Anxiolysis
• anxiety ? tachycardia /HTN ? Ischemia
• Anxiolysis Psychological pharmacological
• Avoid significant circulatory or ventilatory
  depression 1. Benzodiazepines
• 2. Alpha 2 agonists Clonidine, Dexemed,
  Mivazerol
• (Naloxone / Flumazenil /Atipamazole (reversal
  agents)
• Analgesia Pain ? symp.stimulation ? Ischemia.
• H2 Receptor Blockers Coronary artery
  vasoconstriction,with unopposed action of H1
  receptors
• Antibiotc Prophylaxis against infective
  endocarditis In the presence of valvular HD
  (MR)

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• Would you discontinue any medication before
  surgery?

5.
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MEDICATIONS TO CONTINUE/DISCONTINUE

• All drugs esp. BB POISE study better cardiac
• out-comes ? mortality.
• Sudden withdrawal of anti-anginal drugs may
• produce rebound tachycardia and HTN ? ppt.
  
• acute ischemia or MI
• STATINS decrease trial
• ASPIRIN bleed risk 1.5 vs 3times of MACE
• Anti hypertensives ACE inhibitors / AR
• blockers(D/C)

caution post induction Hypotension less
responsive to conventional vasopressors e.g
ephedrine/PE Rx.vasopressin or terlipressin
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6.

• How would you monitor the patient in the
  operating room?

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Monitoring - Necessity
operative procedure, severity of IHD
- Goal early detection of myocardial ischemia

• Non Invasive
• Pulse oximetry
• BP NIBP
• Capnography (GA)
• Oxygen analyser(GA)
• Semi Invasive
• Oesophageal/bladder temp probe
• Urine output Foleys
• Invasive

ECG
TEE
PAC/CVP
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• ECG -MONITORING
• Traditional Two leads, II / V5
• ST segment depression or elevation of at least
  1 mm.
• T-wave inversion and R-wave changes
• Degree of ST-segment depression parallels
  severity of ischemia
• Lead II is also useful for analysis of cardiac
  rhythm disturbances
• Multiple lead ? Ability to detect ischemia -
  II,V3,V4,V5
• II/V5 detection 80, II/V4,V5 96
• Lead of the ECG anatomic distribution of
  diseased coronary artery correlate

ECG Lead Coronary Artery Responsible for Ischemia Area of Myocardium That May Be Involved
II, III, aVF Right coronary artery Right atrium, Right ventricle S A node Infesior aspect of left ventricle AV node
I, aVL Circumflex coronary artery Lateral aspect of L V
V3V5 Left anterior descending coronary artery Anterolateral aspect of LV
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PULMONARY ARTERY CATHETER

• insensitive monitor for myocardial ischemia ,
• not shown to be associated with improved
  outcomes

• Shah MR, Hasselblad V, Stevenson L, et al. Impact
  of pulmonary artery catheter in critically ill
  patients meta-analysis of randomized control
  trials. JAMA. 2005294(13)16641670.

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INTRA OP AND PERIOPERATIVE TEE

• Very sensitive for new onset ischemia,
• not useful for perfusion assessment
• Fat Embolism - Long bone surgery
• Practice guidelines IIa by ASA/SCA
  Anesthesiology 2010112(5)10841096.

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Is regional anesthesia better than GA for
patients with IHD?
7.
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REGIONAL SA,EA,CSE VERSUS GA

• No distinct advantage is apparent between them
  when considering PCM and mortality
• optimize graft patency if the regional technique
• Rapid return bowl function
• incidence of thrombo-embolic complications
• MASTER trial improved pulmonary outcomes.
• Possible to continue for post op Analgesia
• current guidelines recommends that choice of
  anesthesia is best left to the discretion of
  anesthesia care team.

Gilbert TB et al.Spinal anesthesia versus GA
for hip fracture repair a observation of 741
elderly patients during 2-yr follow-up.Am J
Orthop 2000 Jan29(1)25-35.
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How would you induce general anesthesia?

• 8.

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GENERAL ANESTHESIA- INDUCTION

• PREOXIGENATION
• INTRAVENOUS
• Reduced doses of thiopentone/ propofol /
  etomidate
• Fentanyl 5 ?g/kg.with preoxygenation, with
  increments of one of the
• following agents
• Etomidate
• Better hemodynamic profile in CAD best at
  0.2 to 0.3 mg per kg.
• min. changes in HR ,Stroke vol. or C O. BP
  may decrease upto 15.
• (Problems of suppresed A C function,myoclonus)
  
• Thiopentone Can ? HR by 10 -36 ,.....dangerous
  
• Propofol ? Intubation responses
• x Ketamine ? HR and BP transiently ?
  myocardial O2 requirements

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MUSCLE RELAXANTS

• Tracheal intubation
• Succinylcholine or a cardio stable NDMR
  vecuronium
• / Rocuronium /cisatracurium
• Laryngoscopy / Intubation or Lighterplanes
  sympathetic nervous system stimulation
  tachycardia and hypertension Myocardial
  ischemia
• AVOID BY
• Short-duration laryngoscopy (15 seconds)
• If duration is likely to be longer, or if
  hypertension already exists
• Drugs Laryngotracheal lignocaine, IV
  lignocaine, esmolol, fentanyl(propofol induction)

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POSITION AND FLUIDS

• Head down /Trendelenberg position Venous
  return, Risk of failure / Pul. Congestion
• Fluids Maintenance crystalloid fluids
• Blood replacement/
• Transfusion

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GA MAINTENANCE

• INHALATION AGENT IIa
• Possess ischemic preconditioning even in non
  cardiac surgeries.
• Isoflurane Most potent cor.vasodilator,tachyc
  ardia
• - may predispose to coronary steal syndrome
• - NO evidence that this drug? incidence of
  intra-operative myocardial ischemia
• - Isoflurane Desflurane depress CO less
• - H R ? most with desflurane
• - Halothane BRADYCARDIA, Junctional Rhythm
• - Sevoflurane
• OPIOIDS
• - Morphine Fentanyl - minimal CV effects in
  N. doses Both produce Bradycardia
• - preferred anesthetic technique will be a
  balanced anesthetic approach opioids, with
  low/moderate doses of volatile anesthet-ics and
  benzodiazepines

• ENIGMA II Trial Nitrous Oxide Anaesthesia and
  Cardiac Morbidity After Major
• Surgery- 7K PATIENTS

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How would you treat intra-operative myocardial
ischemia?
9.
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Management of ischemia new 3-mm ST-segment
depression in lead V 5

• ? HR HTN ? depth of Anesthesia
• use of beta-blockers.
• If contraindicated use-. CCB drug of choice if
  coronary spasm
• Avoidance of hypotension use of vasopressors
  to sustain CPP
• use of nitrates- if not compromise CPP,
• decrease myocardial oxygen demand by decreasing
  preload, intracavitary pressure, myocardial
  tension.
• NTG ? ratio of endocardial to epicardial blood
  flow
• Oxygen delivery correcting anemia(Blood)/ ?
  fio2
• correction of hypothermia and/or shivering, if
  present. Secondary therapies aspirin. use of
  heparin .
• Fleisher et al.ACC/AHA Task Force on Practice
  Guidelines. Circulation. 2009120e169276.

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WHAT IS THE SIGNIFICANCE OF TIGHT CONTROL OF
HEART RATE INTRAOPERATIVELY
10.
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TIGHT CONTROL OF HEART RATE

• Intra-op Tachy Myocardial Ischemia
• Duration of tachy elevated troponin levels
• Use of beta Blockers
• Maintain HRlt 60/min or 20 below Ischemia
  threshold
• slogoffS, Keats A. MYOCARDIAL ISCHEMIA
  REVISITED. Anesthesiology 2006 105214-216.

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How fast does a Humming bird's Heart Beat?

1. 300 BPM
2. 580 BPM
3. 1,260 BPM
4. 2,410 BPM

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What could you do to prevent hypertension and
tachycardia during extubation and emergence?
11.
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Extubation and Emergence

• Extubated when patient is fully awake, breathing
  adequately,
• Neuromuscular blockade is fully reversed
• With Neostigmine Glycopyrrolate
• Reduce sympathetic response of emergence and
  extubation
• with1 mg per kg of lidocaine or esmolol, or
  0.015 to 0.03 mg per kg of nicardipine, or 0.1 mg
  per kg of labetalol, diltiazem, or verapamil.

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How would you control postoperative pain?
12.
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POST OPERATIVE PAIN CONTROL

• Stressful due to pain
• temp changes, alteration of resp. function.
• Marked changes in plasma catecholamine
  concentration, hemodynamics, ventricular function
  coagulation MACE
• MODALITIES PCA or PCEA
• Pain relief reduces _ postoperative
  catecholamine surges and hyper-coagulability

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13.

• How would you diagnosis manage PMI
  (Peri-operative myocardial infarction)?

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How would you make diagnosis of PMI ?

• WHO definition triad
• Clinical symptoms (mostly asymptomatic),
• Posst OP ECG changes ( nonQ wave in nature),
• ? MB fraction of creatine kinase (CK-MB
• Cardiac-specific enzyme troponin I (cTn I),
  troponin T (cTn T)
• Biochemical dia. of a PMI( sensitivity
  specificity )

Clinicians need to be sensitive to redundancy in
testing AHA advises for High Risk Group.
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How would you manage PMI (Peri-operative
myocardial infarction)?

• Lack of control evidence regarding Rx. of PMI in
  postsurgical patient.
• PMI 3 clinical scenarios/diagnosis unstable
  angina (UA), NSTEMI, STEMI.
• MONA Morphine,Oxygen,NTG, Aspirin
• Surgical/Cardiac Consultations
• PCI/stent/CABG if STEMI

Landesberg G, Beattie WS, Mosseri M, et al.
Perioperative myocardial infarction.
Circulation. 200911929362944.
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IntraVascularUltraSound (IVUS)
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SRI SATHYA SAI INSTITUTE OF HIGHER MEDICAL
SCIENCES, WHITEFIELD, BANGALORE-66
SSSIHMS
Duty without love is deplorable Duty with love is
desirable Love without duty is divine-
BABA. THANK YOU