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PACEMAKERS:
Q) 56 years old man scheduled for elective hernia repair. He has an implant PPM.
A) TYPES OF PACEMAKER:
1. Temporary:
a) Single pacing
b) Dual pacing.
2. Permanent:
a) Asynchronies (AOO, VOO, DOO)
b) Single chamber demand pacing (VVI, AAI)
c) Dual chamber AV sequential pacing (DDD)
VVI and DDD are most commonly used
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7. If PPM malfunctions intra-operatively, it should generally be converted to an
asynchronous mode.
8. Myocardial ischemia, infarction or scarring can also cause failure of
ventricular capture.
9. All anesthetic agents can be used safely in pacemaker patients
10.LA with light I/V sedation usually needed for placement of pacemaker
D) VVI pacemakers:
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a) What are the risks factors involved?
b) What measures would you take to minimize the risk?
Ans. a)
RISK FACTORS
Cardiac:
Major
1. Recent MI < 1 month to planned surgery
2. USA (unstable angina)
3. DHF (decompensated heart failure)
4. Significant arrhythmias
5. Severe valvular disease (AS/MS)
6. CABG/ PTCA < 6 weeks
Intermediate:
1. Prior MI > 1month to planned surgery
2. Stable mild angina
3. Compensated heart failure
4. DM
5. Renal insufficiency
Minor:
1. Advance age
2. Abnormal ECG
3. Rhythm other than sinus e.g. AF
4. Low functional capacity
5. H/O stroke.
6. Uncontrolled systemic HTN.
Surgical:
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Intermediate risk (cardiac risk < 5%)
1. Carotid endarterectomy
2. Head and neck surgery.
3. Intra-peritoneal and intra-thoracic surgery
4. Orthopedic surgery.
5. Prostate surgery.
FUNCTIONAL CAPACITY:
Exercise tolerance expressed in METS
(Duke Activity Status Index) (DASI)
1-4 METS Minor exercise (dress change) slow walk
4.10 ETS Moderate exercise (climb on stares) Play golf
>10 METS Vigorous exercise (swimming)
MANAGEMENT OF IHD:
OBEJETIVES: To maintain a balanced myocardial oxygen supply-demand relationship
PREOP MANAGEMENT:
History is of prime importance in IHD
Ask about symptoms, treatment, complications and results of previous evaluations
provide enough estimates of disease severity and ventricular function.
Functional class, activity level (walking, climbing stairs)
Medications, allergies, smoking, previous anesthetics
General physical examination:
Airway assessment (MD, TM distance, loose teeth, artificial dentures etc)
Investigations:
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Prophylactic -blockers have shown to reduce incidence of intraoperative and
postoperative ischemia complications.
INTRAOP MANAGEMENT:
POSTOP MANAGEMET:
HTN
Long standing uncontrolled hypertension accelerates atherosclerosis and
hypertensive organ damage.
HTN is a major risk factor for cardiac, cerebral, renal and vascular diseases.
Complications: MI, CHF, stroke, renal failure, peripheral occlusive disease and aortic
dissection
Definition: Consistently elevated diastolic BP > 90-95 mmHg and a systolic pressure
> 140-160 mmHg
CLASSIFICATION:
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Category of BP Systolic B.P Diastolic BP
Normal _________________ <130 ___________ <85
High normal _____________ 130-139 __________ 85-89
Stage 1 mild _____________ 140-159 __________ 90-99
Stage 2 moderate ________ 160-179 __________ 100-109
Stage3 sever ____________ 180-209 __________ 110-119
Stage4 very sever ________ >210 __________ >120
Malignant HTN ___________ Medical Emergency
ACE inhibitor or ARB 1st line choice pts with hyperlipidemia, CKD and DM
-Blocker 1st line choice pts with CAD
In black patients diuretic or Ca+ channel blocker.
In elderly patients diuretic with or without -Blocker or Ca + channel blocker alone.
Pts with moderate to severe HTN requires 2nd or 3rd drugs Diuretics, -Blocker,
ACE-inhibitors.
MANAGEMENT OF HTN:
OBJECTIVES: To maintain an appropriate stable blood pressure range within 10-20%
of baseline level
PREOP MANAGEMENT:
1. Antihypertensive drug therapy should continue till surgery
2. Surgery should be postponed until DBP < 110, particularly those with
evidence of end organ damage.
3. History Ask about severity and duration, drugs, complications functional
class, edema, syncope and claudication.
4. Physical examination: Ophthalmoscopy most useful examination after BP
readings. S4 gallop common in pts with LVH.
5. Measure BP in both supine and standing positions.
6. Preoperative fluid administration prevents severe hypotension @ induction
7. Airway assessment
8. Investigations:
a.) ECG. d.) Cr. & BUN. c.) ECHO (for LVH)
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b.) CXR (boot shape). e.) UCE (hypokalemia should be
corrected)
9. Premedication: reduces anxiety and is highly desirable in hypertensives
Mild to moderate HTN anxiolytic agent midazolam
Antihypertensive continue till surgery.
INTRAOP MANAGEMENT:
1. Arterial blood pressures should generally be kept within 10-20 % of
preoperative levels. If severe HTN > 180/120 is present then kept within high
normal range 150-140/90-80 mmHg to maintain CBF in longstanding HTN.
2. Standard monitoring with intra arterial monitoring reserved for major
procedures associated with rapid or marked changes in cardiac preload and
after load. Other include ECG, Urine Output
3. Several techniques may be used before intubation to attenuate the
hypertensive response:
a.) Deep anesthesia with a patent volatile agent for 5-10 minutes
b.) The duration of laryngoscopy should be as short as possible.
c.) Administer a bolus of an opioid e.g. fentanyl 5 g/kg
d.) Administering lidocaine 1.5mg /kg I/v
e.) -adrenergic blockade with esmolol, propranolol or labetalol.
f.) Using topical airway anesthesia e.g. lidocaine 4mg spray.
Ketamine is contraindicated sympathetic stimulation HTN, Parkinsonism and
vasopressors used very cautiously.
Intraoperative hypertension not responding to anesthetic depth can be treated
with parenteral antihypertensive e.g. GTN, SNP, labetalol, hydralazine etc.
Reversible causes such as inadequate depth of anesthesia, hypoxemia or
Hypercapnia should always be excluded before starting antihypertensives.
POSTOP MANAGEMENT:
Postoperative HTN is common and anticipated in pts having uncontrolled HTN
Close BP monitoring in recovery.
Sustained HTN can cause formation of wound hematomas and disruption of
vascular sutures line.
HTN could be enhanced by respiratory abnormalities, pain, volume overload or
bladder distension Treat the cause.
Parenteral antihypertensive like labetalol given if necessary
When patient resumes oral intake, preoperative medications restarted.
MYOCARDIAL OXYGEN SUPPLY-DEMAND BALANCE
Q.45, years old gentleman had major MI 8 weeks ago. He requires an urgent
laparotomy
a) Write down factors governing myocardial O2 supply demand?
b) How will you evaluate and prepare this patient?
c) What problems do you anticipate intra/ postop?
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Ans a) FACTORS AFFECTING MYOCARDIAL OXYGEN SUPPLY-DEMAND BALANCE
SUPPLY:
1. Heart rate (diastolic time)
2. Coronary perfusion pressure (aortic diastolic BP, Ventricular EDP)
3. Arterial oxygen content (arterial oxygen tension, Hb. concentration)
4. Coronary vessel diameter.
DEMAND:
1. Basal requirement
2. Heart rate
3. Wall tension (Preload, Afterload)
4. Contractility
Ans b) Cardiac risk factors and surgical risk factors for evaluation /assess
preoperative management of IHD for preparation.
Ans c)
INTRAOP PROBLEMS
Sympathetic stimulation due to
1. Light anesthesia 5. Blood loss
2. Inadequate analgesia 6. Hypoxia
3. Surgical stimulus 7. Hypercarbia
4. Large fluid shifts 8. Hypovolaemia
These all can provoke HR and hypertension, which then increase demand and
decrease supply deteriorating myocardial oxygen balance.
TOP PROBLEMS
1. Tachycardia due to inadequate analgesia, emergence and Hb < 9 gm. /dl.
2. myocardial ischemia during emergence and extubation.
3. Hypotension ECG Ischemia.
4. Respiratory abnormalities like hypoxia and Hypercarbia.
5. Fluid overload.
All these factors can also influence and deteriorate myocardial oxygen supply-
demand balance.
MITRAL STENOSIS:
Q. A 20 year old female pt. presents with # shaft of femur as a result of RTA; ORIF is
planned. She is diagnosed case of MS for last 5 years.
a) What is pathophysiology of MS?
b) Write down pre anesthetic evaluation?
c) Write down anesthetic technique with special reference to hemodynamic
goals?
d) Write down normal MV area?
e) Complications of MS during anesthesia and how will you prevent them?
Ans.a) PATHOPHYSIOLOGY OF MS
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1. MS almost always occurs as a delayed complication of acute rheumatic fever.
2. Rheumatic process causes valve leaflets to thicken, calcify and become
funnel shaped. Annular calcification also present.
3. Mitral commissure fuses.
4. Chordae tendineae fuses and shorten
5. Valve cusp become rigid valve leaflets typically display bowing or doming
during diastole on echo.
6. Significant restrictions of blood flow through mitral valve results in higher
trans-valvular pressure gradients.
7. LA dilates and promotes SVT particularly AF and thrombus in LA appendage
8. LA pressures pulmonary edema PVR and pulmonary HTN.
9. Lung compliance and WOB (work of breathing) chronic dyspnea.
10.RVH TR & PR (pulmonary valve regurgitation)
11.Incidence of pulmonary emboli, infarction, hemoptysis and recurrent
bronchitis
12.LA compression of left recurrent laryngeal nerve hoarseness.
13.LV function normal, but is small and poorly filled.
History: Ask about exercise tolerance, fatigability, SOB, dyspnea, orthopnea, PND.
NYHA functional class is useful for grading severity of HF.
Chest pain, neurological Sx, and prior procedures like valvotomy or valve
replacement
Review of medications, especially digoxin for its toxicity.
PHYSICAL EXAMINATION:
Mitral facies Malar flush on cheeks.
Peripheral cyanosis
Signs of RHF (JVP, hepatosplenomegaly, ascites, pedal edema)
Tapping apex beat (loud S1, opening snap, diastolic murmur)
INVESTIGATIONS:
ECG: P mitral, AF, Notched P wave if SR
CXR: Calcification, LA, kerley-B line.
ECHO:Pressure gradients/ valvular areas
LFTs: assessing hepatic function
ABGs: If significant pulmonary Sx
Coagulation profile: PT, APTT, INR.
ANESTHETIC TECHNIQUE:
Because surgery of lower extremity is planned, the delivered anesthetic technique is
Epidural anesthesia because more gradual onset of sympathetic blockade then
spinal.
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GOALS (HAEMODYNAMIC)
The principal hemodynamic goals are to maintain a SR sinus rhythm (if present
preoperatively) and to avoid tachycardia, large increase in CO and both
hypovolaemia and fluid overload by judicious fluid therapy. Adequate preload, high
normal SVR
Avoid hypoxia, Hypercarbia and acidosis exacerbation PHTN.
CAUSES:
PREOPRATIVE:
1. Pre-existing cardiac disease.
2. CHB (complete heart block)
3. Drugs (-Blocker, CCB Calcium channel blockers, Digoxin)
4. Hypothyroidism
5. ICP
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6. IOP
7. Myocardial ischemia
8. Hypothermia
INTRAOPERATIVE:
1. Deep anesthesia
2. Repeated dose of Suxamethonium
3. Rapid acting opioids
4. Halothane
5. Propofol
6. Surgical stimulation (eye ball traction, cervical/ anal dilatation)
7. Hyperkalemia
8. Low dose atropine
9. Sick sinus syndrome
10.ICP
POSTOPERATIVE:
1. Hypoxia
2. Hypothermia
3. Intraoperative use of -blocker/CCB
4. High spinal
5. Inadvertent intravascular injection of local anesthesia during epidural
3. Investigations:
1. ECG (long lead II)
2. Holter monitoring
3. ECHO
4. Electrophysiological study
5. CXR
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6. Cardiac enzymes
7. Electrolytes
8. Thyroid fx test
9. Serum digoxin level
TREATMENT:
1. Treat the cause (hypoxemia) (stop surgical shunt)
2. Anticholinergics (atropine, glycopyrrolate)
3. Epinephrine
4. If refractory TPM/PPM
PEA
Q. What is pulseless electrical activity?
Q. What causes it? Algorithm for PEA
Cause:
1. Severe hypovolaemia 6. Profound hypoxemia
2. Cardiac tamponade 7. Severe acidosis
3. Ventricular rupture 8. Pulmonary embolism
4. Dissecting aortic aneurysm 9. Drugs related after prolong CPR
5. Tension Pneumothorax atropine induced
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ALGORITHM
FOR PEA
1-Pulse less
electrical activity
(PEA = rhythm on monitor, without detectable pulse)
2-Primary ABCD survey
Focus: basic CPR and defibrillation.
Check responsiveness
Activate- emergency response system
Call- for defibrillator
a- Airway open the airway
b- Breathing provide positive pressure ventilations
c- Circulation give chest compression
d- Defibrillation assess +shock for VF/VT
3-Secondary ABCD survey
Focus: more advanced assessment and treatments
a) Airway place airway device ASAP
b) Breathing confirm and secure airway device.
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c) Breathing confirm effective oxygenation and ventilation.
d) Circulation-establish IV access.
e) Circulation identify rhythm-monitor.
f) Circulation administer drugs appropriate for rhythm & conduction
monitor
g) Circulation assess for occult blood flow
h) D/D search for and treat identified reversible causes
4-Review For Most Frequent Causes
6-Atropine 1mg IV
Repeat every 3 to 5 min as needed to a total dose of 0.04mg/kg.
ASYSTOLE
Q. a) List the causes of cardiac arrest during operation?
b) Write down algorithm for pulse less VT?
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14 High spinal
15 Total spinal
Cardiac arrest can only be diagnosed clinically by palpating carotid artery (absent
pulse)
CAUSES OF VT:
1 IHD
2 Ventricular scarring after MI or previous cardiac surgery.
3 Right ventricular failure
4 Electrolyte abnormalities in pts with prolong QT interval
(TCA, antihistamines, phenothiazines or Brugada syndrome)
5 SVT e.g. WPW syndrome may cause a broad complex tachycardia
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PULSELESS VT
Ans b)
ALGORYTHM FOR PULSELESS VT
If not already done, give O2 and establish IV access
Pulse No use VF protocol
yes
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Adverse signs
SBP<90
Chest pain
Heart failure
Rate > 150bpm
No yes
or
Lidocaine 50mg IV over Amiodarone 150mg I in 10min
2 min repeated every 5 min
To a maximum of 200 mg
Further cardio version as necessary
Synchronized DC shock
100-200-360J
Signs
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No of life yes
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ADULS ALS ALGORYTHM
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Unresponsive
Open airway
Look for signs of life
Call rescue team
CPR 30:2
Until defib/monitor attached
Assess rhythm
Immediately resume
CPR 30:2
For 2min
Reversible cause:
1. Hypoxia 5. Tension pneumothorax
2. Hypovolaemia 6. Tamponade, cardiac
3. Hypo/hyperkalemia 7. Toxins (drug )
4. Hypothermia 8. Thrombosis coronary and pulmonary.
SYNCOPE
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Q. a) why should anesthesiologist be concerned about H/O syncope?
b) Causes of syncope?
Ans. a)
A history of syncope in elderly patients should always raise the possibility of
arrhythmias and underlying organic heart disease.
Cardiac syncope results form an abrupt arrhythmia that suddenly
compromises CO and impairs cerebral perfusion.
Both Brady and tachyarrhythmias can produce syncope.
b). Causes:
Cardiac:
1. Tachyarrhythmias >180 b/min 7. Primary pulmonary HTN
2. Brady-arrhythmias < 40 b/min 8. Pulmonary embolism.
3. Aortic stenosis. 9. Cardiac tamponade.
4. Hypertrophic cardiomyopathy.
5. Massive MI
6. TOF
Non cardiac
1. Vasovagal (vasodepressor reflex) 6. Autonomic dysfunction
2. Carotid sinus hypersensitivity 7. Sustained valsalva maneuver
3. Neuralgias 8. Seizures
4. Hypovolaemia 9. Metabolic (-Hypoxia,
5. Sympathectomy -Hypocapnia
-Hypoglycemia)
CARDIAC CYCLE
7 Phases
1 Atrial systole
2 Isovolumetric ventricular contraction
3 Rapid ventricular ejection
4 Reduced ventricular ejection
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5 Isovolumetric ventricular relaxation.
6 Rapid ventricular filling
Reduced ventricular filling.
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Integrated post cardiac arrest care
A strong chain of survival can improve chance of survival and recovery for victims of
heart attack, stroke and other emergencies
CARDIOVERSION
Q.) A 55 years old man with new onset AF is scheduled for elective cardioversion
A) What are the indications and complications of cardioversion?
B) How would you evaluate this patient?
C) What minimum monitors and anesthetic equipment required.
c) MINIMUM MONITORING
ECG, BP & pulse oximetry,
Precordial stethoscope breath sounds,
Conscious level continuous verbal contact
EQUPMENTS
DC fibrillator
Transcutaneous pacing
Reliable IV access
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A functional bag-mask device capable of delivering 100% O 2
An Oxygen source (from pipeline or cylinder)
Airway trolley (laryngoscopes, ETT, LMA, bougie, Guedel airway
A functioning suction apparatus
Anesthetic drug kit
Crash cart that includes all necessary drugs and equipment for CPR
PAIN PATHWAY
Thalamus
3rd order neuron
Postcentral gyrus of parietal cortex & sylvian fissure
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Psychological evaluation: Minnesota multiphasic Personality Inventory MMPI
and Beck depression inventory
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