PATIENTS Flashcards
ASTHMA PERIOP
recurrent paroxysmal dyspnoea with reversible airflow obstruction and increased bronchial hyper-responsiveness to a range of stimuli. ~5% population 10% children - may overlap with chronic airways disease Preop History -
Aortic Stenosis
Obstruction to LV systolic outflow across aortic valve
Cause: Age, bicuspid valve, RHD, Infective endocarditis
Hx - Angina, dyspnora, syncope - decreased ET - rheumatic fever - risk factors similar to IHD
Ex - pulse - slow rising carotid - hyperdynamic apex beat - mid systolic ejection murmur
Ix ECG - LVH + strain TTE - No leaflets. LVH, AVA, EF , transvalvular gradients
Severity Symptoms do not correlate well with severity
Treatment
No treatment will improve/halt progression
Avoid strenuous activty, treat heart failure, maintain sinus
Symptomatic need treatment as mortality is 50% at 2 years
Options - SAVR - severe AS , asymp severe AS EF <50%, or CABG and severe
TAVR if not suitiable or Perc balloon valvuloplasty
Anaesthesia Goals
Avoid Tachycardia, Maintain Sinus, Increase Preload, Increase SVR, Maintain PVR
GA Vs Regional vs local
CPR unlikely to help :(
Avoid sympathetic surges
Mitral Regurg
Retrograde flow into left atrium from incompetent mitral valve
Causes: primary - leflet, chordal or papillary muscle abnormalities (AMI, endocarditis, MVP)
secondary - LV dysfunction (variable aietology) pap muscle displacement, leaflet tehtering
Fraction of SV that regurgitates depends on:
Size of MV orifice, HR, Pressure gradient
Clinical Features:
Fatigue, weakness, dyspnoea
Acute MR = APO +/- shock
Exam
Pulse: Normal or sharp upstroke, AF
Ausc apical pan systolic murmur
Ix ECG , LVH, AF, left atrial enlargement
TTE - dilated LA, hyperdynamic LV, Regurgitant jet
Anaesthesia:
Maintain Sinus
High Normal HR ~80
Maintain preload
Maintain contractility
Decrease SVR (avoid increase)
- caution with opioids as can produce bradycardia
MITRAL STENOSIS
Narrowing of MV orifice that prevent opening during diastole and obsdtructs blood frlow from LA to LV
Causes - Rheumatic , RA, SLE, Carcinoid, LA myxoma, Post MV repair
Hx - Dyspnoea, PND, Hoarseness (LA compressing RLN)
Ex, mitral facies, Pulse AF, low pitched rumbling diastolic murmur
Ix - ECG LA enlargement, biphasic p waves, AF, RVH, RAD
TTE - quantify severity, estimate PASP
Severity
MVA, mean gradient, PASP
Treatment
Anticoagulation, B blockers ( avoid tachy arrthymias, treat CCF)
Surgery - valvotomy, MV replaement, perc balloon valvotomy
Anaesthesia Goals
Low Normal HR 60-80
Maintain sinus
Maintain preload
Increase SVR
Maintain PVR
Aortic Regurgitation
Retrograde Blood Flow into the Left Ventricle from the aorta as a result of an incompetent valve.
Causes - Leaflet abnormalities - IE, rheumatic fibrosis, trauma, congenital bicuspid, ankylosing spondylitis.
Aortic root abnormalities - Ehlers Danlos syndrome, Marfan’s syndrome, HTN, aoric dissection
Clinical Features
Hx - asymptomatic until severe. Dyspnoea on exertion , fatigue , palpitations , syncope
Ex bounding pulse, wide pulse pressure, decreased DBP
Auscultation - decrescendo high pitched early diastolic murmur along left sternal edge
Ix
ECH LVH
TTE - see image
Treatment -
acute : Afterload reduction, diuretics for APO, avoid bblockers
Chronic : vasodilators with ACE and nifedipine, diuretics
Surgery: acute severe AR and cardiogenic shock, severe AR undoing CABG, evidence of systolic dysfunction LVEF <50%
Anaesthesia
Maintain Sinus, High Normal HR 80, Maintain preload, maintain contractility, decrease afterload (dont increase SVR)
HEART FAILURE
Complex clinical syndrome resulting from structural or functional cardiac abnormality impairing ventricle to fill or eject blood as a result the heart fails to meet oxygen demand
HFREF - symptoms/clinical signs HF + LVEF <50%
HFPEF = symptoms/signs of HF and LVEF >50% + evidence of LV relaxation, filling diastolic dysfunction
NHYA 1 - ordinary activity no symptims, 2 with exertion , 3 less then ordnary exertion 4 = at rest
Treatment
Lifestyle
Medications - ACE/ATRB/BBlocker/Diuretic/Dig/Vasodilator
Surgical - Biventricular pacing, CRT, ICD, Transplant
Anaesthesia
degree of failure, cause and nature of cardiomyopathy, procedure
periop risk
ensure not decompensated
Intraop no evidence of GA vs Regional
