Peri-operative Nursing Pre-operative Clients PN 111 lab 2007.
Peri -Operative Cardiac Risk Reduction, A-fib/MI Management
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Jason E. Davis, MD PERI-OPERATIVE CARDIAC RISK REDUCTION, A-FIB/MI MANAGEMENT
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Peri -Operative Cardiac Risk Reduction, A-fib/MI Management. Jason E. Davis, MD. Surgery as a Controlled Injury. ~27 million non-cardiac surgeries per year 1 – 1.5 million for pt’s w/ known cardiac disease - PowerPoint PPT Presentation
Transcript of Peri -Operative Cardiac Risk Reduction, A-fib/MI Management
Jason E. Davis, MD
PERI-OPERATIVE CARDIAC RISK
REDUCTION, A-FIB/MI MANAGEMENT
~27 million non-cardiac surgeries per year1 – 1.5 million for pt’s w/ known cardiac disease3 – 4 million for pt’s with 3 or more risk factors for coronary
artery disease (DM, smoking, etc)Past 50 years in surgery
Dramatic changes in procedures Improvements to survival
SURGERY AS A CONTROLLED INJURY
Predictable responses Body doesn’t differentiate surgery from injury
Fight or flight, mobilization of energy stores
“Physiological Narrowing” 20 years old and healthy generally tolerates stressors better than
pt 80 years oldGraded neuro-endocrine response
Bigger surgery, bigger response
SURGERY AS A CONTROLLED INJURY
• Anterior Pituitary– ACTH– Growth hormone– Prolactin– Endorphin
• Posterior Pituitary– Arginine vasopressin
• Adrenals– Cortisol– Epinephrine (rises until 3 hrs)– Norepinephrine (until 3 days)
PREDICTABLE RESPONSES
AnalgesiaHypercoagulability (control of blood loss)Mobilization of metabolic substrates (glucose)Conservation of fluid, electrolytes
POST-INJURY/SURGERY DEFENSES
• Altered hemodynamics– Hypertension– Fluid and metabolite shifts– Tachycardia– Hypercoagulability– DVT, pulmonary embolus–Myocardial Ischemia– Congestive heart failure– Tachyarrhythmia• Hypokalemia• Hypomagnesemia• Immune suppression• Infectious complications• Hyperglycemia
CONSEQUENCES & COMPLICATIONS
Defining overall riskPMH = Opportunity to Prevent, Plan, AdaptHighest risk for complications
First 3 days post-operatively Corresponds to injury + response
SEQUENCE OF EVENTS
American Society of Anesthesiologists risk stratification and classification scheme Class 1: Normal healthy patient Class 2: Patient with mild systemic disease Class 3: Severe systemic disease, limits function Class 4: Incapacitating, constant threat to life Class 5: Moribund, unlikely to survive +/- surgery Class 6: Brain-dead organ donor
PATIENT SELECTION
American Society of Anesthesiologists risk stratification and classification scheme Class 1: Mortality 0 – 2% Class 2: Mortality 0.5 – 3% Class 3: Mortality 5 – 10% Class 4: Mortality 75%
Elective vs. Emergent: 2 – 3x riskAlso: Magnitude, Duration…
PATIENT SELECTION
High Risk factors Acute/recent MI Unstable coronary dx De-compensated CHF Significant arrhythmias Severe valvular disease
EAGLE’S CARDIAC RISK ASSESSMENT HTTP://WWW.FPNOTEBOOK.COM/CV/SURGERY/EGLSCRDCRSKASMNT.HTM
Intermediate Risk factors Mild angina History of MI, compensated CHF Renal insufficiency, DM
Minor Risk Factors Advanced age Abnormal EKG Low functional capacity
EAGLE’S CARDIAC RISK ASSESSMENT HTTP://WWW.FPNOTEBOOK.COM/CV/SURGERY/EGLSCRDCRSKASMNT.HTM
• Eagle’s cardiac risk assessment–>70 years age– History of angina– History of ventricular dysfunction– Diabetes on therapy– Abnormal Q-waves on EKG
• ACC-AHA Criteria– Functional Capacity (I – IV)– Graded by “Metabolic Equivalents” (>4 METS = lower risk)
• Detsky’s Modified risk index• Goldman criteria
FURTHER PRE-OP PLANNINGHTTP://WWW.FPNOTEBOOK.COM/CV/SURGERY/ACAHPRPRTVCRDCRSKASMNT.HT
M
• Beta-Blockers– Chronic users (AM w/ sip of water)– High risk non-users prescribed pre-op• Remember neuro-endocrine response
• Anticoagulants – soon as outweighs bleeding– Coumadin• Interim heparin
– Aspirin, Plavix
• Statins – mixed literature
CONTINUATION OF MEDICATIONS
• Pre-operative– Pre-emptive anesthesia (local, systemic)– Appreciate pt’s entire risk -- not just surgical!
• Intra-operative– Product of underlying problems x surgical stress
• Post-operative– Pain control– Fluid balance, early mobilization– Tx co-morbid conditions
ATTENUATION OF STRESS RESPONSE
• Anesthetic selection– Local +/- sedation– Regional (epidural, spinal, etc)– General
• Temperature control– National initiatives to 37C• Improved bloodflow• Decreased neuro-endocrine
ANESTHETIC FACTORS(COLLABORATIVELY ADDRESSED WITH ANESTHESIA
COLLEAGUES)
• Recognition– Irreg rhythm, tachycardia +/- CP, SOB, hypotension
• Diagnosis– EKG, new onset often secondary to ischemia
• Treatments– Attempt to normalize• B-blocker > Diltiazem > Digoxin
– Rate control (often same meds)– Anticoagulation soon as poss• Prevent propagation thrombus
ATRIAL FIBRILLATION
Recognition Tachycardia, hypotension, chest pain, new onset a-fib, shortness
of breath, mental status changeDiagnosis
EKG, Troponin/CKMb, CXR (assess alt causes)Treatment
B-blocker, nitrates, heparin, morphine, asa, statins Cardiology consult PRN
MYOCARDIAL ISCHEMIA
Lehigh Valley Heart Specialists Nurse available on-call Contact:
Lehigh Valley Heart Care Group Fellow available on-call Contact:
LVHN CARDIOLOGY CONSULTS
Consider whole pt Surgery (controlled injury) + co-morbidities
Risk reduction Pt stratification Clearance, medications Coordination of care
MI: dx, decrease work, decrease pain, +O2A-fib: ‘break’, rate, anticoag.
SUMMARY
THANK YOU.
