Care of the Critically Ill Surgical Patient

Cardiac disorders lecture

CCrISP® Australasia Edition 4

 Objectives
By the end of this session, you will be able to:

• Anticipate common cardiac problems in the surgical

patient by identifying cardiac risk factors
• Take steps to prevent and manage common cardiac
problems
• Detect cardiac complications
– Acute ischaemic events
– Impaired cardiac function

CCrISP® Australasia Edition 4

 Scenario 1
A 71-year-old woman, painful arthritic hips, due for right
total hip replacement, STEMI 3 weeks ago – bare metal
coronary stent, medications – aspirin, metoprolol,
clopidogrel, ACE inhibitor, Atorvastatin, NSAID

What issues need to be considered?

CCrISP® Australasia Edition 4

 Issues to consider
• Timing of surgery

• Cardiac function (LV)

• Risk of further ischaemia

• Management of medications

• Further cardiac assessment and advice

CCrISP® Australasia Edition 4

 Scenario 2
Pre-admission clinic, 69-year-old man with laryngeal
carcinoma for neck dissection, history of angina,
paroxysmal AF, heart failure, medications – aspirin,
warfarin, atenolol, frusemide, ACE inhibitor.

How would you assess his peri-operative cardiac risk

factors?

CCrISP® Australasia Edition 4

 Major risk factors for
peri-operative cardiac mortality
Patient factors
• Recent MI (< 3 months)
• Unstable angina
• Decompensated LVF
Operative factors
• Vascular surgery
• Major intra-abdominal
surgery

• Severe aortic or mitral valve • Major intrathoracic surgery

stenosis
• Recent coronary stent
(< 1 month)

CCrISP® Australasia Edition 4

 Cardiac risks
Additional risk factors for acute peri-operative
coronary event

• Previous MI
• Previous heart failure

• Previous stroke
• Diabetes, on therapy
• Renal dysfunction (creatinine > 170)
• High-risk surgery

CCrISP® Australasia Edition 4

 Quantifying risk

Non-emergency, inpatient, non- Up to 2%

cardiac surgery, > 45-year-old major cardiac event

Patients with known or high risk of Up to 10%

cardiac disease major cardiac event

Acute MI post-non-cardiac surgery Up to 25%

hospital mortality

CCrISP® Australasia Edition 4

 Quantifying risk
• Predicting risk allows informed decision making; may
influence patient’s/surgeon’s choices
• Complex testing for selected individuals only
• What should be done if increased cardiac risk is
identified?
– If cardiac risks outweigh operative risks, defer or withhold
surgery, consider alternative to surgery, consider optimising
cardiac function, talk to patient

CCrISP® Australasia Edition 4

 Pre-operative optimisation
• You should:
– Continue statins, aspirin and -blocker
– Delay surgery > 4 weeks after stenting, if possible
– Get LVF under optimal control

• Risk/benefit balance for ACE inhibitors is uncertain

• Limited role for non-invasive testing
• Consider where the patient will go post-op

CCrISP® Australasia Edition 4

 Scenario 3
Paged to see a 74-year-old obese woman, 36 hours
following open left nephrectomy for renal cell carcinoma.
Nurse notes the patient is somewhat breathless; intern
informs you patient has ‘heart failure’.

What are you going to do?

CCrISP® Australasia Edition 4

 Immediate management
ABCDE

Full patient assessment

Chart review
History & systematic examination
Available results

Decide & plan

Stable Unstable/Unsure

Daily management plan Diagnosis required

Specific investigations

Definitive treatment
Medical
Surgical
Radiological

CCrISP® Australasia Edition 4

 To confirm heart failure
Immediate management Full patient assessment
• Dyspnoea • Documented history of
failure
• Widespread crackles
• Proven on ECHO
• Tachycardia, gallop
rhythm • Large excess of fluid
• Raised JVP • Enlarged heart on CXR
• New dysrhythmia • Pulmonary oedema on
CXR
Remember – the commonest cause of dyspnoea
and crackles is atelectasis
CCrISP® Australasia Edition 4
 Venous pressure
• “Normal” right atrial pressure
– 0–7 mmHg
– 0–10 cm H2O
– describes population distribution, not the “correct” pressure
in an individual
• The neck is just a “window” on the column of fluid
(i.e. blood)
• The right atrium is ~ 5 cm below the sternal angle
(always state your reference point)

CCrISP® Australasia Edition 4

 JVP at 45°

Sternal angle

5 cm

Right atrium

Note: If the venous pressure is low or normal, you may not see anything.
Assessing at 45°is good for raised venous pressures.

CCrISP® Australasia Edition 4

 Scenario 3

What does the patient’s CXR show?

CCrISP® Australasia Edition 4

 Scenario 3
Given frusemide and placed on CPAP. Urine output 460 ml
over 2 hours, but becomes hypotensive and urine output
dwindles to almost nothing for 2 hours.

Have you done the right thing?

CCrISP® Australasia Edition 4

 Cardiac failure and after-load
The vicious circle

Reduced Increased
cardiac demand
performance

Increased LV wall tension Inadequate

( O2 debt) cardiac output

Changes in Increased SVR Sympathetic

regional (after-load) response
perfusion  catecholamines

CCrISP® Australasia Edition 4

 Scenario 4
You are paged to see a 57-year-old man, day 2 after a
large musculocutaneous gluteal pedicle flap for trochanteric
pressure ulcer, known Type II DM, rather low BP despite
plenty of fluids, nurse is concerned, ‘a bit pale and sweaty’
and having ventricular ectopics

How would you sort this out?

CCrISP® Australasia Edition 4

 Immediate management
ABCDE

Full patient assessment

Chart review
History & systematic examination
Available results

Decide & plan

Stable Unstable/Unsure

Daily management plan Diagnosis required

Specific investigations

Definitive treatment
Medical
Surgical
Radiological

CCrISP® Australasia Edition 4

 O2

HR

BP

RR
CCrISP® Australasia Edition 4
 In = 2400 ml Out = 425 ml

CCrISP® Australasia Edition 4

CCrISP® Australasia Edition 4
 Diagnosing peri-operative
myocardial ischaemia
• Serial troponins
• ECG
• Echocardiography

CCrISP® Australasia Edition 4

 Treatment of peri-operative
myocardial ischaemia
• Oxygen
• Analgesia
• Aspirin
• Cardiology review
– Heparin (?) (thrombolysis usually precluded)
– Percutaneous coronary intervention (PCI)
– CABG (?)

CCrISP® Australasia Edition 4

 What are your questions?

CCrISP® Australasia Edition 4

 Key messages
• Many surgical patients carry risk factors for acute peri-
operative coronary events
• Some treatments for heart disease increase the risk of
peri-operative bleeding
• Acute coronary syndromes are not uncommon in
post-operative patients
– Urgent multidisciplinary consultation is required

• Heart failure needs to be diagnosed and treated

optimally

CCrISP® Australasia Edition 4