ANESTHESIA FOR A GERIATRIC PATIENT WITH HEART DISEASE DR.BALAVENKAT,DR.KALYANASUNDARAM, DR.SUDARSHAN,DR.VENKATACHELLAM,DR.MAHES H.

ANESTHESIA FOR A ANESTHESIA FOR A GERIATRIC PATIENT WITH GERIATRIC PATIENT WITH

HEART DISEASEHEART DISEASEDR.BALAVENKAT,DR.KALYANASUNDARAM,DR.BALAVENKAT,DR.KALYANASUNDARAM,

DR.SUDARSHAN,DR.VENKATACHELLAM,DR.MAHESDR.SUDARSHAN,DR.VENKATACHELLAM,DR.MAHESHH

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

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

Dr.Sudarshan/Dr.VenkatachellamDr.Sudarshan/Dr.Venkatachellam

1.What is the risk involved in this case? 1.What is the risk involved in this case? High or moderate ?High or moderate ?

2.How do we stratify the risk in old age? 2.How do we stratify the risk in old age? Do they have an increased risk than their Do they have an increased risk than their younger counterparts with same risk younger counterparts with same risk factors?factors?

Dr.Kalyanasundaram/Dr.BalavenkatDr.Kalyanasundaram/Dr.Balavenkat

3.Should we have to optimize him before 3.Should we have to optimize him before taking him up for surgery?taking him up for surgery?

4.What more information is needed? What 4.What more information is needed? What should be done for optimization of his risk?should be done for optimization of his risk?

Dr.Sudarshan/Dr.VenkatachellamDr.Sudarshan/Dr.Venkatachellam

5.How do we manage his medications?5.How do we manage his medications?

6.What are the anesthetic concerns in this 6.What are the anesthetic concerns in this case?case?

Dr.Balavenkat/Dr.VenkatachellamDr.Balavenkat/Dr.Venkatachellam

7.What kind of anesthetic is preferred? 7.What kind of anesthetic is preferred? Regional or General? Does the type of Regional or General? Does the type of anesthesia influence the outcomes?anesthesia influence the outcomes?

8.Does the degree of monitoring influence 8.Does the degree of monitoring influence the outcomes in this patientthe outcomes in this patient

Dr.Sudarshan/Dr.KalyanasundaramDr.Sudarshan/Dr.Kalyanasundaram

9.What postop complications can be 9.What postop complications can be expected in this patient?expected in this patient?

10.How should we manage postop pain in 10.How should we manage postop pain in this patient?this patient?

Panel discussionPanel discussion

A A 83-year-old83-year-old, 65 kg man fell down in his yard and was diagnosed , 65 kg man fell down in his yard and was diagnosed as left femoral neck fracture. The patient’s medical history includes as left femoral neck fracture. The patient’s medical history includes coronary artery diseasecoronary artery disease, for which he had undergone , for which he had undergone 4-vessel 4-vessel coronary artery bypass grafting nine yearscoronary artery bypass grafting nine years prior to this admission; prior to this admission; hypertensionhypertension, a history of , a history of stroke one yearstroke one year earlier; earlier; insulin-dependent insulin-dependent diabetesdiabetes and benign prostatic hypertrophy. and benign prostatic hypertrophy.

His medications at home included Nitroglycerin 0.4 mg daily, His medications at home included Nitroglycerin 0.4 mg daily, Metoprolol 25 mg twice daily, Lisinopril 20 mg daily, Aspirin with Metoprolol 25 mg twice daily, Lisinopril 20 mg daily, Aspirin with Clopidogrel daily, Insulin injection 20 units daily, Metformin 400 mg Clopidogrel daily, Insulin injection 20 units daily, Metformin 400 mg twice daily, Finasteride 5 mg daily.twice daily, Finasteride 5 mg daily.

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

ASA GradingASA Grading

ACC/ AHA Guidelines 2007ACC/ AHA Guidelines 2007

Goldman Risk indexGoldman Risk index

Lee’s modificationLee’s modification

ASA GRADINGASA GRADING

Grade IGrade I A normal healthy patientA normal healthy patient

Grade IIGrade II A patient with mild systemic illnessA patient with mild systemic illness

Grade IIIGrade III A patient with severe systemic disease, that A patient with severe systemic disease, that limits function, but is not incapacitating.limits function, but is not incapacitating.

Grade IVGrade IV A patient with severe systemic disease that is A patient with severe systemic disease that is

a constant threat to life.a constant threat to life. Grade VGrade V A moribund patient who is not expected to A moribund patient who is not expected to

survive without the operation.survive without the operation. Grade VIGrade VI A declared brain dead patient whose organs A declared brain dead patient whose organs

are being removed for donor purposes. are being removed for donor purposes.

GOLDMAN’s Risk IndexGOLDMAN’s Risk Index

Third heart sound (S3) Third heart sound (S3) 1111   Elevated jugulovenous pressure  Elevated jugulovenous pressure 1111   Myocardial infarction in past 6 months  Myocardial infarction in past 6 months 1010   ECG: premature arterial contractions or any rhythm other than sinus 7 ECG: premature arterial contractions or any rhythm other than sinus 7   ECG shows >5 premature ventricular contractions per minute  ECG shows >5 premature ventricular contractions per minute 77    Age >70 years Age >70 years 55   Emergency procedure  Emergency procedure 44   Intra-thoracic, intra-abdominal or aortic surgery  Intra-thoracic, intra-abdominal or aortic surgery 33

Poor general status, metabolic or bedridden Poor general status, metabolic or bedridden 33

>25 – 56% Death,22% severe complications

<26 – 4% Death, 17% severe complications

<6 – 0.2% Death, 0.7% severe complications

Lee’sLee’s Revised Goldman cardiac risk indexRevised 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 Preoperative serum creatinine >2.0 mg/dL

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

No risk factors - 0.4 percent (95% CI 0.1-0.8 percent)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)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)Two risk factors - 2.4 percent (95% CI 1.3-3.5 percent)

Three or more risk factors - 5.4 percentThree or more risk factors - 5.4 percent

Rate of cardiac death & nonfatal MI, cardiac arrest or ventricularRate of cardiac death & nonfatal MI, cardiac arrest or ventricularfibrillation, pulmonary edema, and/or complete heart blockfibrillation, pulmonary edema, and/or complete heart block

according to the No.of predictors and use nonuse or of beta blockersaccording 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 blockersNo 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 One to two risk factors - 2.2 to 6.6 percent versus 0.8 to 1.6 percent with beta blockersbeta blockers

Three or more risk factors - >9 percent versus >3 percent with beta blockersThree or more risk factors - >9 percent versus >3 percent with beta blockers

Detsky and Goldman calculatorsDetsky and Goldman calculators

http://www.vasgbi.com/riskdetsky.htmhttp://www.vasgbi.com/riskdetsky.htm

ACC/ AHA Guidelines 2007ACC/ AHA Guidelines 2007

““Cardiac Predictors”Cardiac Predictors”MINORMINOR

PredictorsPredictors

AgeAge

Abnormal ECGAbnormal ECG

Systemic Systemic hypertensionhypertension

StrokeStroke

INTERMEDIATE INTERMEDIATE PredictorsPredictors

Mild anginaMild angina

Prior MIPrior MI

Compensated or Compensated or prior CHFprior CHF

Diabetes MellitusDiabetes Mellitus

Renal diseaseRenal disease

MAJOR MAJOR PredictorsPredictors

Unstable coronary Unstable coronary syndromessyndromes

Decompensated CHFDecompensated CHF

Significant Significant ArrhythmiasArrhythmias

Severe valvular Severe valvular diseasedisease

TYPE OF SURGERYTYPE OF SURGERY

HIGH RISK > 5 %HIGH RISK > 5 %

Emergeny major Emergeny major operations, operations, especially in elderlyespecially in elderly

Aortic and other major Aortic and other major vascular proceduresvascular procedures

Peripheral vascular Peripheral vascular proceduresprocedures

Anticipated prolonged Anticipated prolonged procedure with large procedure with large fluid shift/blood lossfluid shift/blood loss

INTERMEDIATE Risk < 5%INTERMEDIATE Risk < 5%

Carotid Carotid endarterectomyendarterectomy

Head and neckHead and neck

Intraperitoneal & Intraperitoneal & intrathoracicintrathoracic

OrthopedicOrthopedic

ProstateProstate

Low risk < 1%Low risk < 1%

– Endoscopic Endoscopic proceduresprocedures

– Superficial Superficial procedureprocedure

– CataractCataract

– BreastBreast

Functional CapacityFunctional Capacity

Need for emergency non cardiac surgery

Yes

OT

Perioperative surveillance & post op risk stratification and management

Step I

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

Step 4

Functional capacity > or = 4 MET’s without

symptoms

YesProceed with planned

surgery

Step 5

NO or Unknown

1.Unstable coronary syndromes

2. Decompensated HF (NYHA functional class IV;

3. Significant arrhythmias

4. Severe valvular disease

Active Cardiac condition

STEP5

3 or more risk factors

Vascular Intermediate risk

1 or 2 risk factors

No risk factors

VascularIntermediate risk

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

Proceed with the planned surgery

History of CAD, or CVA

Pulmonary

Diabetes mellitus

Renal impairment

Hematologic disorders