Outline your peri-operative management of a patient with ischaemic heart disease having an elective right hemicolectomy.
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
Fleisher, Lee A., et al. "2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines." Journal of the American College of cardiology 64.22 (2014): 2373-2405.