Valvular heart disease patient for non cardiac surgery

Symptoms & signs Anatomical and physiological changes Anaesthetic considerations Antibiotics Preop drugs Premed Regional Induction Art.Line CVP PA TEE Maintainence Special considerations Extubation Post op ICU

A.S.

Syncope. Angina. Dyspnoea.

Concentric L.V. Hypertrophy, Diastoloic dysfunction, LA dialation

Maintain sinus Rhythm,Avoid tachy, Maintain preload & SVR

Not recommende d

No atropin, Light premed.

Epidural is preferred. Invasive monitoring with vasoconstrictor therapy should be available.

Avoid Propofol,Pentothal, ketamine & pancuronium. Opioids, midazolam, etomidate, cisatracurium are preffered drugs.

Strongly indicated before induction

Helpful for Fluid monitoring and pressor infusions.

Can be considered but no class IIa advantage. indicatio H.R 60-70. PCWP n uderestimate s LV preload.

Maintain Avoid reversal if hemodynamics Hemodynamically unstable possible. Topical / &Analgesia. ECG SVT/Arrhythmia: prompt I.V.lidocaine reduces monitoring II & V for cardioversion. Hypotension tube stress during ischemia detection is must be identified early and emergence from strongly treated with fluid and anaesthesia. recommended vasopressors.(Phenylephrin Preemptive throught out the e is drug of choice). analgesia is strongly surgery and post op recommended. period.

A.I

Angina. Shock. Dyspnoea.

Non concentric LVH, LV systolic dysfunction, LA enlargment

Avoid bradycardia,high Not AntiSVR,hypotension. recommende hypertensives ( Fast,full, d are continued. vasodialated)

Atropine & good sedation is well tolersted.

Epidural preferred.

Propofol,Thiopental,Pa ncuronium can be safely used.Ketamine with aution.With Suxamethonum observe brady and use atropine

Minor surgery : no need of invasive monitoring. Severe & Should be symptomatic considered in AI :Art.Line major surgery. Strongly recommende d before induction.

Severe AI and CCF : PA helps but class IIa PCWP indicatio overestimate n s LV filling pressure.

Higher normal heart rates .Full and vasodialated. volatile agents, neuromuscular blockers, and opioids are acceptable. LV dysfunction : dobutamine drug of choice.

Special care should be taken during laryngoscopy, intubation, and other periods of stimulation to minimize increases in afterload.

Reversal tolerated .Preemptive analgesia to avoid hypertension.

Avoid Hypertension, Maintain hemodynamics by voulme and if required Dobutamine.

M.S.

Dyspoea, Palpitation, Syncope

L.A dialatation,A.Fib, L.A thrombus,Systemic embolisation,PAH,RVF

B.blockers, Ca.channel blockers,diureti Avoid tachy,Maintain Not cs,anticoagulan preload,SVR.Meticulou recommende ts and s fluid.Avoid PHT,RVF d pulmonary vasodialators to be continued

No atropin, Light Epidural is premedicatio preferred. n

Avoid Propofol,Pentothal and ketamine. Etomidate / opioids preferred.Adequate depth before intubation,Beta blockers available,Defeb pads on patient.

strongly indicated before induction

Hypotension=Phenylnephrin Recommended . Is useful and Ensure adequate class IIa e PHT & RVF Observe trends can be depth,avoid indicatio =NO and Milrinoe rather than considered in hypoxia,hypercar n (Dobutamine with caution) absolute value. PHT & RVF bia ,hypothermia No adrenaline

Reversal with Sugameddex preffered .Topical lidocaine reduces tube stress during emergence from anaesthesia. Preemptive analgesia is strongly recommended.

Maintain hemodynamics &Analgesia. Donot discontinue NO abruptly. Start anticoagulant early once bleeding risk is minimised.

M.R.

Dyspnoea ,Palpitation

Functional & Organic MR. LV & LA dialatation, PHT Depressed LV function.A.F.

Organic:Reduce afterload ,maintain high normal heart rates to increase forward flow. Functional:Maintain afteroad and low normal H.R.to avoid ischemia despite high regurgitant volume

B.blockers, Ca.channel blockers, diuretics,antico Not agulants and recommende pulmonary d for isolated vasodialators M.R. to be continued. No need to discontinue ACE inhibitors

Sedation and anxiolyitics well tolerated in the abscence Epidural of PHT and preferred RVF. Avoid Atropin in Functional M.R.

Avoid propofol,pentothal( in PHT & RVF) and ketamine.Etomidate/ opioids are recommended.

should be considered in moderate or severe disease and Should be in underlying considered . coronary Follow trends artery disease, PHT, or ventricular dysfunction

Is usefull and can be considered in PHT & RVF. But in class IIa isolated M.R. indicatio Lt. Heart CO n by thermodilutio n is overestimate d.

Tolerates Reversal well except in Ischemic MR .In ischemic M.R. Avoid Hypotension=ephidrne Ensure adequate tachy Topical PHT & RVF =NO & depth,avoid lidocaine reduces Milrinone. hypoxia,hypercar tube stress during Functional MR deterioration bia ,hypothermia emergence from = IABP anaesthesia. Preemptive analgesia is strongly recommended.

Avoid Hypertension, hypoxia and hypercarbia in immediate post op period to avoid precipitation of PHT & RVF

A.S = Aortic Stenosis,A.I =Aortic Insufficiency,M.S = Mitral Stenosis,M.R.= Mitral Regurgitation,L.V.H.= Left ventricular hypertrophy,LA=Left Atrium,CCF= congestive cardiac failure,PCWP= pulmonary capilary wedge pressure,PHT= Pulmonary Hypertension,RVF= Right ventricular failure