Question 4

Outline your peri-operative management of a patient with ischaemic heart disease having an elective right hemicolectomy.

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College Answer

Recent  evidence  based  guidelines   published  by  ACC/AHA.     Management   in  concert  with cardiologists and surgeons.  Ideal management often limited by resources.

Pre-operative assessment to determine patient risk.  Based predominantly on exercise tolerance (eg. MET [metabolic] equivalents), history (or not) of recent myocardial infarction, and stability of symptoms.   Standard preoperative  investigations  would include creatinine, urea and electrolytes, full  blood  examination,  ECG  and  CXR.    More  detailed  cardiovascular  investigations  may  be required (eg. exercise test, echocardiography and angiography).  Coronary arterial revascularisation (angiography/stenting/surgery)   may  be  indicated  before  elective  surgery  (balance  with  risk  of delaying  surgery  if  for  malignancy).     Left  ventricular  function  should  be  optimised. Cardiopulmonary  exercise  testing  may  enhance  risk stratification.    Peri-operative  beta-blockade would probably  have already been commenced  but is reasonable  unless contraindicated  (started days before surgery and targeting resting heart rate 50-60).

Intra-operative management (this operation = intermediate cardiac risk) may be aided by invasive monitoring (eg. intra-arterial, pulmonary arterial lines and/or trans-oesophageal echocardiography). ST monitoring is reasonable, as are intravenous nitrates.   Prevention of hypertension/tachycardia and hypotension are expected.  Epidural analgesia dependent on anaesthetic preference.

Post-operative  phase continues intra-operative  stability, and optimises pain relief.   Monitoring of ECG and CKMB/troponin  to determine extent of ischaemic risk (determined by 24 to 48 hours). Early reinstitution of beta-blockade (intravenous if necessary) and heparin/LMW heparin.   Severe cardiac failure may require inotropic support and/or longer period of invasive monitoring and observation (eg. 48 hours).


This 2002 question refers to the "recently published" ACC/AHA guidelines. 
The 2014 reiteration of these guidelines is now available.

I will not make any attempt to summarise this 50page document.

Ok, maybe a little summary.

  • Preoperative assessment
    • Standard preoperative investigations including ECG, CXR, and bloods
    • Risk stratification, based on
      • Exercise tolerance (METs)
      • History of recent ischaemia
      • Stability of cardiac symptoms
    • High risk patients: cardiology referral for angiography and correction of coronary disease
    • Preoperative TTE and optimisation of LV function
  • Preoperative management
    • Control of hypertension
    • Control of arrhythmias
  • Intraoperative management
    • Precautionary invasive monitoring, eg. arterial line / PA catheter
    • Maintenance of normotension
    • Epidural anaesthesia
  • Postoperative management
    • Monitoring in ICU/HDU, and possibly delayed extubation
    • postoperative support with vasopressors and inotropes

The college, in this 2002 model answer, recommended the use of perioperative beta-blockers to reduce the mortality and risk of MI in these patients. Unfortunately, they recommended this on the basis of some work by Don Polderman, which was discredted after he was fired from his academic position for widespread fraud. Later systematic reviews (eg. Wijeysundera et al, 2014), after performing pre- and post-fraud analysis, determined that beta-blockers actual"y increased perioperative mortality after Polderman's work was excluded from the data set. "Perioperative beta blockade started within 1 day or less before noncardiac surgery prevents nonfatal MI but increases risks of stroke, death, hypotension, and bradycardia" they somberly concluded. As such, the current guidelines do not recommend preoperative beta blockade.