ANESTHESIA FOR A GERIATRIC PATIENT WITH HEART DISEASE

1
ANESTHESIA FOR A GERIATRIC PATIENT WITH HEART
DISEASE

• DR.BALAVENKAT,DR.KALYANASUNDARAM,
• DR.SUDARSHAN,DR.VENKATACHELLAM,DR.MAHESH

2

• A 83-year-old, 65 kg man fell down in his yard
  and was diagnosed as left femoral neck fracture.
  The patients medical history includes coronary
  artery disease, for which he had undergone
  4-vessel coronary artery bypass grafting nine
  years prior to this admission hypertension, a
  history of stroke one year earlier
  insulin-dependent diabetes and benign prostatic
  hypertrophy. His medications at home included
  Nitroglycerin 0.4 mg daily, Metoprolol 25 mg
  twice daily, Lisinopril 20 mg daily, Aspirin with
  Clopidogrel daily, Insulin injection 20 units
  daily, Metformin 400 mg twice daily, Finasteride
  5 mg daily.

3

• His ECG has ST depression in Lead I and aVL. He
  has Q waves in II, III and aVF. He has occasional
  ventricular ectopics. His chest X-ray showed
  cardiomegaly and pulmonary plethora. A
  transthoracic echocardiogram showed a decrease in
  ejection fraction . EF is 25-30 as compared to
  his baseline EF of 40-45. His S.Creatinine is
  1.8mg/dl. His random Bld sugar is 225mg/dl. His
  coagulation is normal. He is posted for early
  fracture repair and arthroplasty.

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• Dr.Sudarshan/Dr.Venkatachellam
• 1.What is the risk involved in this case? High
  or moderate ?
• 2.How do we stratify the risk in old age? Do they
  have an increased risk than their younger
  counterparts with same risk factors?

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• Dr.Kalyanasundaram/Dr.Balavenkat
• 3.Should we have to optimize him before taking
  him up for surgery?
• 4.What more information is needed? What should be
  done for optimization of his risk?

6

• Dr.Sudarshan/Dr.Venkatachellam
• 5.How do we manage his medications?
• 6.What are the anesthetic concerns in this case?

7

• Dr.Balavenkat/Dr.Venkatachellam
• 7.What kind of anesthetic is preferred? Regional
  or General? Does the type of anesthesia influence
  the outcomes?
• 8.Does the degree of monitoring influence the
  outcomes in this patient

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• Dr.Sudarshan/Dr.Kalyanasundaram
• 9.What postop complications can be expected in
  this patient?
• 10.How should we manage postop pain in this
  patient?

9
Panel discussion
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• A 83-year-old, 65 kg man fell down in his yard
  and was diagnosed as left femoral neck fracture.
  The patients medical history includes coronary
  artery disease, for which he had undergone
  4-vessel coronary artery bypass grafting nine
  years prior to this admission hypertension, a
  history of stroke one year earlier
  insulin-dependent diabetes and benign prostatic
  hypertrophy.
• His medications at home included Nitroglycerin
  0.4 mg daily, Metoprolol 25 mg twice daily,
  Lisinopril 20 mg daily, Aspirin with Clopidogrel
  daily, Insulin injection 20 units daily,
  Metformin 400 mg twice daily, Finasteride 5 mg
  daily.
• His ECG has ST depression in Lead I and aVL. He
  has Q waves in II, III and aVF. He has occasional
  ventricular ectopics. His chest X-ray showed
  cardiomegaly and pulmonary plethora. A
  transthoracic echocardiogram showed a decrease in
  ejection fraction (EF) of 25-30 as compared to
  his baseline EF of 40-45. His S.Creatinine is
  1.8mg/dl. His random Bld sugar  is 225mg/dl. His
  coagulation is normal. He is posted for early
  fracture repair and arthroplasty

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• ASA Grading
• ACC/ AHA Guidelines 2007
• Goldman Risk index
• Lees modification

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ASA GRADING

• Grade I A normal healthy patient
• Grade II A patient with mild systemic illness
• Grade III A patient with severe systemic disease,
  that limits function, but is not
  incapacitating.
• Grade IV A patient with severe systemic disease
  that is a constant threat to life.
• Grade V A moribund patient who is not expected to
  survive without the operation.
• Grade VI A declared brain dead patient whose
  organs are being removed for donor purposes.

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GOLDMANs Risk Index

• Third heart sound (S3) 11  Elevated
  jugulovenous pressure 11  Myocardial
  infarction in past 6 months 10  ECG
  premature arterial contractions or any rhythm
  other than sinus 7  ECG shows gt5 premature
  ventricular contractions per minute 7  Age gt70
  years 5  Emergency procedure
  4  Intra-thoracic, intra-abdominal or
  aortic surgery 3
• Poor general status, metabolic or bedridden
  3

gt25 56 Death,22 severe complications lt26
4 Death, 17 severe complications lt6 0.2
Death, 0.7 severe complications
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Lees Revised Goldman cardiac risk index

• Six independent predictors of major cardiac
  complications
• High risk type of surgery
• H/o. IHD
• History of HF
• History of cerebrovascular disease
• Diabetes mellitus requiring treatment with
  insulin
• Preoperative serum creatinine gt2.0 mg/dL

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Rate of cardiac death, nonfatal myocardial
infarction, andnonfatal cardiac arrest according
to the number of predictors

• No risk factors - 0.4 percent (95 CI 0.1-0.8
  percent)
• One risk factor - 1.0 percent (95 CI 0.5-1.4
  percent)
• Two risk factors - 2.4 percent (95 CI 1.3-3.5
  percent)
• Three or more risk factors - 5.4 percent

Rate of cardiac death nonfatal MI, cardiac
arrest or ventricularfibrillation, pulmonary
edema, and/or complete heart blockaccording to
the No.of predictors and use nonuse or of beta
blockers

• No risk factors - 0.4 to 1.0 percent versus lt1
  percent with beta blockers
• One to two risk factors - 2.2 to 6.6 percent
  versus 0.8 to 1.6 percent with beta blockers
• Three or more risk factors - gt9 percent versus gt3
  percent with beta blockers

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Detsky and Goldman calculators

• http//www.vasgbi.com/riskdetsky.htm

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ACC/ AHA Guidelines 2007
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Cardiac Predictors

• MAJOR
• Predictors
• Unstable coronary syndromes
• Decompensated CHF
• Significant Arrhythmias
• Severe valvular disease

• MINOR
• Predictors
• Age
• Abnormal ECG
• Systemic hypertension
• Stroke

• INTERMEDIATE Predictors
• Mild angina
• Prior MI
• Compensated or prior CHF
• Diabetes Mellitus
• Renal disease

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TYPE OF SURGERY

• Low risk lt 1
• Endoscopic procedures
• Superficial procedure
• Cataract
• Breast

• HIGH RISK gt 5
• Emergeny major operations, especially in elderly
• Aortic and other major vascular procedures
• Peripheral vascular procedures
• Anticipated prolonged procedure with large fluid
  shift/blood loss

• INTERMEDIATE Risk lt 5
• Carotid endarterectomy
• Head and neck
• Intraperitoneal intrathoracic
• Orthopedic
• Prostate

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Functional Capacity
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Step I
Perioperative surveillance post op risk
stratification and management
Need for emergency non cardiac surgery
OT
Yes
NO
Step 2
Evaluate and treat as per AHA guidelines
Consider OT
Yes
Active Cardiac condition
NO
Step 3
Proceed with planned surgery
Yes
Low risk surgery
NO
Active Cardiac condition
Step 4
Proceed with planned surgery
1.Unstable coronary syndromes 2. Decompensated HF
(NYHA functional class IV 3. Significant
arrhythmias 4. Severe valvular disease
Functional capacity gt or 4 METs without
symptoms
Yes
NO or Unknown
Step 5
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History of CAD, or CVA Pulmonary Diabetes
mellitus Renal impairment Hematologic disorders
STEP 5
3 or more risk factors
1 or 2 risk factors
No risk factors
Vascular
Intermediate risk
Intermediate risk
Vascular
Proceed with the planned surgery
Consider testing if it will change management
Proceed with planned surgery with HR Control or
consider non invasive testing if it will change
the management