ILA 2: CV disease perioperative managment Flashcards
Mr Jones is a 65 year old gentleman who is admitted to your ward for an elective laparotomy and bowel resection for sigmoid diverticular disease.
He has a past medical history of hypertension, AF and ischaemic heart disease. He takes simvastatin, bendroflumethiazide, ramipril, atenolol and warfarin regularly and uses a GTN spray when needed.
- How are you going to assess the severity of his IHD?
CPET testing
Suggest some possible features of his baseline pre-operative ECG?
- May be NSR
- AF changes: irregularly irregular R-R interval, loss of P waves, fibrillations
- Ischaemic changes: ST depression
- Bradycardia/PR prolongation (secondary to atenolol)
Why is it important to check his UEs pre-operatively?
Baseline function, important for fluid balance
Should he have a preoperative echocardiogram?
If history, examination and/or CPET indicate possible heart failure / valve dysfunction
He takes simvastatin, bendroflumethiazide, ramipril, atenolol and warfarin regularly and PRN GTN spray.
a) Which medications will be stopped preoperatively?
b) How will you manage his anticoagulation in the perioperative period?
a) Omit ACEI/ARBs and diuretics 24h before surgery
b)
He has now returned to your ward from PACU following uneventful surgery. He had a general anaesthetic with morphine given intraoperatively and now has a PCA. He received 2L crystalloid fluids and 500ml colloid intraopertively. Estimated blood loss was 500ml.
His pre-operative Hb was 10 as he has had PR bleeding
secondary to diverticular disease.
a) When will you recheck his Hb?
b) At what Hb level would you transfuse this man?
a)
b)
Drugs to omit.
a) Cardiac/BP drugs
b) Diabetes drugs
c) Antiplatelets (aspirin, clopidogrel, dipyridamole)
d) Anticoagulants (warfarin, heparin, NOACs)
e) Other
a) Give all except: ACEI/ARBs and diuretics (omit 24h before surgery)
b) Adopt either VRIII or fast/check method for surgery
c)
d)
e) NSAIDs, lithium, non-essential medications in the short term
He is 3 hours post-op when you are called to see him. He is complaining of chest pain. His A-E is as follows…
A – Talking
B – Resp rate 35, sats 90% on air, bilateral crackles to mid zone
C – Heart rate 88 irregular, BP 160/100, cool, clammy, sweaty, CRT 4 secs, looks pale/grey
D – Agitated, complaining of central crushing chest pain radiating to left arm. Can’t get his breath
E – Abdomen is soft, slightly tender over the wound
a) What is the most likely diagnosis?
b) What are your immediate actions?
c) What investigations will guide your management?
a) ACS
b) High-flow oxygen, morphine, GTN spray/sublingual, aspirin?
c) ECG and troponins. Also: D-Dimer, CXR,
ECG shows marked ST depression and T inversion in lateral leads. CXR shows widespread alveolar shadowing, fluid in the horizontal fissure, bilateral effusions, sparing of upper lobes
- How would you manage him based on your clinical
findings and these results?
- Impression: NSTEMI/unstable angina, resulting in acute pulmonary oedema
- Plan: analgesia, oxygen, GTN, furosemide, antiplatelet
He is starting to improve slowly, chest pain has gone but he is still tachypnoeic. His arterial blood gases on 15L non rebreathing mask are as follows:
pH 7.15, pCO2 3.9, pO2 8.0, HCO3 19, BE -10, Lactate 5
a) Interpret these blood gases
b) What is the likely cause of the elevated lactate level?
c) What would you do? How does this help?
a) Lactic acidosis, T1RF
b) Hypoxaemia causing inadequate oxygenation of tissues and resultant anaerobic respiration
c) T1RF (possibly due to acute pulmonary oedema secondary to ACS) - treat with CPAP (PEEP helps to keep alveoli open at end of expiration to increase oxygen delivery to blood; increased intrathoracic pressure leads to decreased systemic venous return and so reduces preload)
