Download Geriatric patients for general orthopaedic surgeries.

ANESTHESIA FOR A
GERIATRIC PATIENT WITH
HEART DISEASE
DR.BALAVENKAT,DR.KALYANASUNDARAM,
DR.SUDARSHAN,DR.VENKATACHELLAM,DR.MAHES
H
A 83-year-old, 65 kg man fell down in his yard and
was diagnosed as left femoral neck fracture. The
patient’s 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 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.
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?
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?
Dr.Sudarshan/Dr.Venkatachellam
5.How do we manage his medications?
6.What are the anesthetic concerns in this
case?
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
Dr.Sudarshan/Dr.Kalyanasundaram
9.What postop complications can be
expected in this patient?
10.How should we manage postop pain in
this patient?
Panel discussion
A 83-year-old, 65 kg man fell down in his yard and was diagnosed
as left femoral neck fracture. The patient’s 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 Xray showed cardiomegaly and pulmonary plethora. A transthoracic
echocardiogram showed a decrease in ejection fraction (EF) of 2530% 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
ASA Grading
ACC/ AHA Guidelines 2007
Goldman Risk index
Lee’s modification
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.
GOLDMAN’s 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 >5 premature ventricular contractions per minute
7
Age >70 years
5
Emergency procedure
4
Intra-thoracic, intra-abdominal or aortic surgery
3
Poor general status, metabolic or bedridden
3
>25 – 56% Death,22% severe complications
<26 – 4% Death, 17% severe complications
<6 – 0.2% Death, 0.7% severe complications
Lee’s 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 >2.0 mg/dL
Rate of cardiac death, nonfatal myocardial infarction, and
nonfatal 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 ventricular
fibrillation, pulmonary edema, and/or complete heart block
according to the No.of predictors and use nonuse or of beta blockers
No risk factors - 0.4 to 1.0 percent versus <1 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 - >9 percent versus >3 percent with beta blockers
Detsky and Goldman calculators
http://www.vasgbi.com/riskdetsky.htm
ACC/ AHA Guidelines 2007
“Cardiac Predictors”
MINOR
INTERMEDIATE Predictors
Predictors
Age
Mild angina
MAJOR
Predictors
Unstable coronary
syndromes
Prior MI
Abnormal ECG
Systemic
hypertension
Stroke
Decompensated CHF
Compensated or
prior CHF
Significant
Arrhythmias
Diabetes Mellitus
Renal disease
Severe valvular
disease
TYPE OF SURGERY
HIGH RISK > 5 %
Emergeny major
operations,
especially in elderly
Aortic and other major
vascular procedures
INTERMEDIATE Risk < 5%
Carotid
endarterectomy
Low risk < 1%
– Endoscopic
procedures
Head and neck
– Superficial
procedure
Intraperitoneal &
intrathoracic
– Cataract
Orthopedic
– Breast
Peripheral vascular
procedures
Anticipated prolonged
procedure with large
fluid shift/blood loss
Prostate
Functional Capacity
Step
I
Need for emergency non
cardiac surgery
Perioperative
surveillance & post op
risk stratification and
management
Yes
NO
Step
2
Active Cardiac condition
Yes
Evaluate and treat
as per AHA
guidelines
Consider OT
NO
Step
3
Low risk surgery
Yes
Proceed with planned
surgery
NO
Active Cardiac condition
Step
4
Functional capacity > or
= 4 MET’s without
symptoms
NO or Unknown
Yes
Proceed with planned
surgery
1.Unstable coronary
syndromes
2. Decompensated HF
(NYHA functional class IV;
3. Significant arrhythmias
4. Severe valvular disease
Step
5
History of CAD, or CVA
Pulmonary
STEP
5
Diabetes mellitus
Renal impairment
Hematologic disorders
3 or more risk
factors
Vascular
1 or 2 risk
factors
Intermediate
risk
Vascular
No risk factors
Intermediate
risk
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