Surgery in a patient with IHD (RCS 65,66,374BL258) {Phase A Written}


Introduction
Coronary artery disease /IHD is the commonest cardiac disease and associated with the majotity of perioperative mortality and morbidity.
High risk procedures:
1.      Major emergency operation: especially in the elderly
2.      Major vascular surgery including peripheral vascular
3.      Prolonged surgery (>3hours) with major fluid shifts
Risk of MI with time:
Time since infarct                     incidence of further infarct after surgery (%)
0-6 month                                55
1-2 years                                  22
2-3 years                                  6
>3 years                                   1
No nfarct                                 0.66  

Preoperative evaluation:
a)     History- breathlessness, palpitation, exercise intolerance, chest discomfort, chest pain, radiation, syncopal attack, history of DM, HTN, hyperlipidemia.
b)    Physical examination: pulse, BP, heart sound, added sound, murmurs
c)     Investigation: ECG, ECHO (EF <30 angiography.="" associated="" br="" chest="" coronary="" is="" outcome="" patient="" poor="" radiograph="" scintigraphy="" style="mso-special-character: line-break;" test="" thallium="" treadmill="" with="">
Aim of management:
Optimizing myocardial O2 supply and demand ratio to minimize the risk of myocardial ischemia developing
Preoperative preparation:
1.     Cessation of smoking at least 12 hours before operation
2.     Stop aspirin / clopidogrel 7/14 days preoperatively
3.     Postponed surgery if recent MI within 6 months
4.     Continue Beta blocker and antianginal drugs up to the time of surgery
5.     In patient with coronary stents, delay elective surgery after stoppage of dual antiplatelet- 6 weeks for bare metal stent insertion, 12 months for drug eluting stent insertion
6.     In patient underwent PTCA, elective surgery after 4-6 weeks
7.     Blood pressure should be controlled to near 160/90 mm of Hg                      

Per-operative care:
1.      Anesthetist should avoid any condition that increase myocardial O2 demand or reduce O2 supply- tachycardia, systolic HTN, Diastolic hypotension
2.      Blood loss must be accurately maintained and Hb maintained at a level suitable for the patient’s cardiac risk patient
3.      Avoid atropine as anesthetic premedication
4.      Use halothane during anesthesia

Post-operative care:
1.     Admission to a HDU
2.     Supplemental O2 therapy continue for 3-4 days (for 24 hours and overnight for first 4 post-operative days) [RCS 26]
3.     Ensure effective postoperative analgesia
4.     Institute invasive monitoring for the first 24-36 hours as the risk of MI is high.
5.     Regular serial ECG and cardiac monitoring
6.     Post-operative beta blocker may reduce cardiac complication   
Conclusion
Patients with IHD should be managed jointly along with cardiologist, anesthetist and intensivist.                                                                                                                                                                                                  

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