1. The evaluation of jeopardy factors, is for planning the anesthetic control, and will be of no exercise in predicting the outcome.
2. There is nay justification for performing revascularisation purely to facilitate elective non cardiac surgery.
3. M.I. in the compass of the last 6 weeks, class iii-iv angina, decompensated organ of circulation failure, malignant arrhythmias, severe valvular affection disease, CABG/PTCA within the final 6 weeks constitute major Cardio Vascular expose to danger factors for surgery.
4. Previous M.I. (>6weeks), rank i-ii angina, compensated heart failure, T2 DM fix intermediate C. V. risk factors.
5. Age > 70 years, uncontrolled systemic hypertension, arrhythmias, lineage h/o CAD, dyslipidemia, smoking, renal dysfunction, ECG abnormalities (LVH, RBBB/LBBB, ST portion anomalies) constitute minor C. V. peril factors.
6. Only emergency, life sparing procedures should be performed during the first 6 weeks after a myocardial infarction (M. I.) and ~wards CABG/PTCA with or without a coronary stent. The determination between 6 weeks and 3 months are considered at the same time that a period of intermediate risk, at the time that non urgent elective surgery should be postponed.
7. SURGICAL PREDICTORS OF INCREASED PERIOPERATIVE CARDIOVASCULAR RISK
(i) HIGH RISK (confusion rate >5%)
#Emergency major to intermediate surgery, especially in elderly patients
#Aortic & major and also peripheral vascular surgery
#Procedures involving: hem
dynamic instability, long duration or ample fluid/blood loss
(ii) INTERMEDIATE RISK (entanglement rate 1-5%)
#Head & neck surgery
(iii)LOW RISK (combination rate <1%)
#Breast and superficial surgery
8. ACE inhibitors are withheld in spite of 24 hours by some anesthetists.
9. Perioperative beta stop up. should be continued for 72 hours postoperatively.
10. The gold pennon for detecting intraoperative ischemia and assessing quantity status & valvular function is TEE.
11. Most perioperative myocardial infarctions occur in the foremost 3 days postoperatively. Patients at jeopard for M.I. require effective analgesia and humidified oxygen therapy instead of atleast 72 hours after major surgery.
12. Severe hypertension (grade 3) has been associated with each increased incidence of perioperative hemodynamic instability, quiet m.i. and arrhythmias; but testimony of a clinically significant increase in untoward outcome is lacking. The presence of endorgan injury due to hypertension is more important than the blood pressure per se.
13. Ideally the vital fluid pressure should be maintained within 20% of the best estimate of preoperative pressure.
14. The handling of arrhythmias produced by WPW syndrome includes Flecainide, Disopyramide, Procainamide and Amiodarone. Dgoxin and Verapamil are contraindicated.
15. There is no evidence to suggest that, frequent ventricular ectopics or asymptomatic non sustained ventricuar tachycardia is associated through an increased incidence of perioperative m.i..
16. Sick opening syndrome is associated with a haughty ris of thromboemboism and may have ~ing anticoaguated. If the patient is not having a enduring pacemaker, he/she needs a, evanescent pacing wire inserted preoperatively.
17. Complete core block, type ii second degree A-V make steady and lesser degrees of heart close, in the presence of symptoms or cardiac failure requires preoperative insertion of continuing or temporary insertion of pacemaker. Vlatile agents continue lengthen in time cardiac conduction and can worsen inclination block. Atropine, Isoprenaline and facilities ~ the sake of external pacing should be kept ready.
18. ATRIOVENTRICULAR BLOCKS
(i) First remove block: P-R interval > 0.2 sec
(ii)Second station block
Type I: progressive lengthening of PR period, until conduction fails and a ~ing is dropped.
Type II: intermittent failure of AV carrying without preceding PR prolongation.
(iii) Third order block
Complete dissociation of atria and ventricles for example atrial impulses fails to be transmitted.
19. CHECKLIST FOR A PATIENT WITH PACEMAKER
a. Indication ~ the sake of pacemaker insertion
b. Mode of part of pacemaker
c. Functional status
d. Consider conversion of rate responsive pacemakers to fixed asperse in the perioperative period.
e. Ensure exercise of only bipolar diathermy
f. If unipolar diathermy be required to be used, then the ground layer should be placed on the corresponding; of like kind site as the operating site, at the same time that far away from the pacemaker while possible. The frequency and duration of application should be minimised and the lowest potential current used.
g. MRI is contraindicated
h. Magnets should not subsist placed over pacemakers during surgery, during the time that they have an unpredictable effect on the programming of modern pacemakers.
i. A backup amble system, atropine, adrenaline, isoprenaline and a backup pace system should be available, in condition of pacemaker failure.
20. Anesthesia constitutes a weighty risk in Hypertrophic Obstructive Cardiomyopathy. Patients wish be having dynamic left ventricular flow tract obstruction, often with secondary MR. They are apt to arrhythmias and sudden cardiac debt of nature. Look for an Ejection systolic complaint in auscultation and LVH in ecg. Confirmation is ~ means of ECHO. Avoid hypovolemia, vasodilatation and the employment of catecholamines
21. Constrictive pericarditis meanly tolerate vasodilatation; especially at induction.
22. In valvular passion disease, antibiotic prophylaxis is especially required beneficial to dental surgeries and those involving instrumentation of upper respiratory quarter and genitourinary system.
23. AORTIC STENOSIS
# Even ~y ejection systolic murmur in an asymptomatic resigned also warrants careful preoperative examination/ ECHO, viewed like symptoms tend to appear late in the distemper only.
# Promptly treat tachycardia and AF.
# Maintain ventricular filling ~ dint of. avoiding hypovolemia and maintaining SVR.
# Vasodilatation may be derived in profound hypotension–> subendocardial ischemia and just sudden death.
# Aggressive treatment of hypotension is preceptive to prevent cardiogenic shock and/or cordial arrest. Cardiopulmonary resuscitation is unlikely to subsist effective in patients with aortic stenosis inasmuch as it is difficult, if not out of the question, to create an adequate stroke compass across a stenotic aortic valve through cardiac compression.
24. AORTIC REGURGITATION
# Avoid vasoconstriction and bradycardia which increases the degree of regurgitation
# A suave tachycardia, moderate fluid loading, a stage of vasodilatation and avoidence of myocardial vitiation can improve the forward flow.
# Acute AR is a surgical unforeseen occasion and may respond poorly to vasodilatation.
25. MITRAL STENOSIS
# Patients are sloping to develop CCF and Pulmonary Edema.
# Atrial fibrillation is a trigger instead of acute deterioration; so should be treated preoperatively
# Avoid tachycardia, myocardial ~ of spirits and excessive vasodilatation
# Hypovolemia compromises ventricular filling
# Fluid overburden can easily precipitate pulmonary edema
# PCWP choose be inaccurate in the presence of pulmonic hyperension. Avoid Nitrous oxide if in that place is evidence of pulmonary hypertension.
26. MITRAL REGURGITATION
# A soothing tachycardia, a slight reduction in SVR and avoidance of myocardial ~ of spirits are desirable.
# Avoid hypovolemia
27. There is small degree evidence that GA in ADULTS with URTI is associated with an increased put to hazard of adverse respiratory events, although upper airway reactivity may exist increased
28. In children with URTI, a higher incidence of contrary respiratory events have been demonstrated, yet few of these adverse events issue in postoperative sequelae. It has been suggested that surgery be in want of not necessarily be postponed in children with mild URTI. Increased airway reactivity may endure for 4-6 weeks and whether surgery is postponed, it should be for a period of at in the smallest degree 6 weeks.
29. In COPD, suppose that the patient is having copious secretions, improvement to avoid anticholinergics, as it resoluteness impair the ability to clear secretions.
30. Even granting regional anesthesia has the advantage of avoiding respiratory complications of GA, ~ numerous patients, even those with quite relentless COPD may be managed safely inferior to carefully c
31. Pressure Controlled Ventilation through a low respiratory rate and prolonged expiratory aspect is suitable in COPD patients.
32. Epidural analgesia has been shown to subside the incidence of postoperative pulmonary complications in thoracic and upper abdomnal surgery.
33. In patients with bronchial asthma, good depth of anesthesia, competent muscle relaxation and i. v. Lidocaine be able to reduce the incidence of bronchospasm during intubation; topical lidocaine spray is not sufficient and may induce bronchoconstriction in some patients.
34. Circulatory disturbance during anesthesia and surgery may affect the absorption of subcutaneous insulin.
As the spasms are in my back it be possible to make breathing really painful.