1. Anaesthesia for ischemic heart
disease patient
Dr.Prabhu M.S

5. • 55 yrs old male patient
• 4 months old MI
• CA stomach – subtotal gatrectomy
• On T.Aspirin 75 mg OD
T.Clopidogrel 75 mg OD
T.Enalapril 2.5 mg BD
T.Metoprolol 25 mg OD
T.Atorvastatin 10 mg HS
• Blood investigation – WNL
• ECG – ST and T V3-V6
• ECHO – moderate LV sys dys
EF 40 %

6. Risk stratification
• GOLDMAN CARDIAC INDEX
HISTORY
CLASS
AGE > 70 yrs CARDIAC DEATH (%) LIFE THREATANING
5
Myocardial infarction in preceding 6 months COMPLICATIONS
10
(%)
PHYSICAL EXAMINATION
0-5 0.2 0.7
Third heart sound or gallop rhythm 11
Aortic stenosis 3
ECG 6-12 2 5
Rhythm other than sinus 7
13-25
5 ventricular ectopic / mt 2 11 7
POOR GENERAL STATUS 3
SURGERY >26 56 22
Intraperitoneal, intrathoracic, aortic 3
Emergency 4

7. • All factors contribute equally to the index (with 1 point each), and the
incidence of major cardiac complications is estimated at 0.4, 0.9, 7
and 11% in patients with an index of 0, 1, 2, and 3 points,
respectively.

8. • T.Aspirin 75 mg OD
T.Clopidogrel 75 mg OD
T.Enalapril 2.5 mg BD
T.Metoprolol 25 mg OD
T.Atorvastatin 10 mg HS

9. ANAESTHETIC GOALS
• MAINTAINING MYOCARDIAL OXYGEN SUPPLY AND DEMAND
• FACTORS DECREASING OXYGEN SUPPLY :
– DECREASED CORONARY BLOOD FLOW
– TACHYCARDIA (LOW DIASTOLIC PERFUSION TIME)
– HYPOTENSION
– INCREASED PRELOAD
– HYPOCAPNIA (CORONARY VASOCONSTRICTION)
– CORONARY ARTERY VASOSPSM
– DECREASED OXYGEN CONTENT AND AVAILABILITY
– ANAEMIA
– HYPOXEMIA
– REDUCED OXYGEN RELEASE FROM HEMOGLOBULIN
(pH, 2-3 DBG, temp)

10. ANAESTHETIC GOALS
• FACTORS INCREASING OXYGEN DEMAND :
– Tachycardia
– Increased wall tension
– Increased preload
– Increased afterload
– Increased myocardial contractility

11. HISTORY
• Exercise tolerance
• Angina pectoris – symptomatic manifestation of myocardial ischemia
evoked by physical exertion and relieved by nitrates
• Myocardial infarction
according to Tarhan et al perioperative re infarction
37 % - MI < 3 months
16 % - MI 4-6 months
5 % - > 6 months
• Co existing disease
• Current medication
• Cardiac failure

12. EXAMINATION
• Pallor, cyanosis, clubbing, odema, lymphadenopathy
• Pulse rate and rhythm
• Blood pressure
• Jugular venous pulse
• CVS - murmur, heart sounds
• RS - any added sound
• Other system examination.

13. INVESTIGATION
• Complete blood picture
• RFT
• Serum electrolytes
• Platelet function analysis
• Coagulation profile
• ECG
• ECHO
• Stress test
• angiography

14. ASSESSMENT
• ASA III
• All drugs to be continued (except clopidogrel to be stopped 1 wk
prior)
• ACEI to be continued
• Aspirin to be continued
• Preop night sedation
• Antacid prophylaxis

15. IN THEATRE
• MONITORS :
NON INVASIVE :
ECG (computerized ST analysis ), NIBP, SPO2, ETCO2, Temp,
urine output
INVASIVE :
arterial BP, vigileo, CVP monitor
• Lead V4, V5 – 90 % sensitivity
• Lead II, V4, V5 – 96 % sensitivity
• CM5 , CB5 leads

16. IN THEATRE
• MONITORS :
role of TEE

17. GENERAL ANAESTHESIA
• INTRAVENOUS ANAESTHESIA /
HIGH OPIOID ANAESTHESIA
Premed : glycopyrrolate 5 mcg / kg (if required)
midazolam 0.05 mg/kg
morphine 0.1 – 0.2 mg/kg / fentanyl 2- 5 mcg/kg
Preoxy : 100 % O2 – 3 mts
Induction : etomidate 0.2 – 0.3 mg/ kg

18. GENERAL ANAESTHESIA
• INTRAVENOUS ANAESTHESIA /
HIGH OPIOID ANAESTHESIA
Morphine 0.5 – 1 mg/kg
(or)
Fentanyl 20 – 40 mcg/kg
+
Midazolam 0.05 – 0.15 mg/kg

19. GENERAL ANAESTHESIA
• Muscle relaxant :
Vecuronium 0.1 – 0.2 mg/ kg
Rocuronium 0.6 – 1 mg/kg
• Maintenance
N2O : O2 – 4:2
Volatile anaesthetics :

20. • VOLATILE ANAESTHTICS
Ischemic preconditioning
XENON :
non inflammable, non pungent, odorless
B/G : 0.14
MAC : 0.71
no myocardial depression

21. INTRA OP PERIOD
• Fluid management according to CVP and SVV
• Blood loss to be taken care of – anaemia can cause critical
reduction in myocardial oxygen supply in IHD pt.
• Avoid hyperventilation
• Maintain normothermia

22. INTRA OP PERIOD
PERIOPERATIVE HYPOTHERMIA COMPLICATION
Cardiac arrhythmia & ischemia
Increased peripheral vascular resistance
Platelet dysfunction
Left ODC
PREVENTION
Minimizing redistribution of heat
cutaneous warming
internal warming

23. INTRA OP PERIOD
• Intraoperative ischemia :
Hemodynamically stable
BB
NTG
Heparin after consulting with surgeon.
Hemodynamically unstable
Inotropic support
IABP
Plan earliest possible cardiac catheterization.

24. INTRA OP PERIOD
• Intraoperative arrhythmia : hemodynamically stable
IV amiodarone
ventricular tachycardia
hemodynamically unstable
cardioversion
supraventricular tachy carotid massage
BB, CCB

25. POST OP PAIN RELIEF
• Epidural analgesia
• USG guided TAP block
• IV opioid.

26. CARE IN POST OP PERIOD
• Continuous ECG monitoring
• Continuation or institution of beta blockade
• Temperature control
• Provision of supplemental O2
• Adequate post op pain relief
• Maintain hemodynamics with IV fluids
• DVT prophylaxis.