In this article, the author shares the experience of a patient with moderate mitral stenosis posted for total abdominal hysterectomy with bilateral salphingo oophorectomy.

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Anaesthetic management of a patient with ischemic heart disease(IHD) or coronary artery disease(CAD) is always a challenging task for an anaesthetist in terms of preoperative evaluation, intraoperative complications and postoperative outcome either in elective or emergency surgery.

Before discussing anaesthetic management the nature of the surgery is quite important because this gives a window period wherein effective pre optimisation will have a greater impact on the patient’s prognosis

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Examination

Clinical examination was normal and auscultation revealed a mid-diastolic murmur. Airway examination was normal ( MPG 2, TMJ - normal, TMD > 3.5 cm) Routine investigations - complete hemogram, blood sugar, S. electrolytes, TFT, LFT, coagulation profile were normal Specific investigations - ECG - NSR HR 70 bpm with non-specific ST-T changes, LVH + ECHO - EF 64%, Moderate MS (valve area 1.5 cm2) Mild MR/ Moderate AR, Mild PAH (PASP 42), Dilated LA Other investigations were done to rule out other causes of giddiness (CT brain and Carotid Doppler - No abnormality detected)

Medications

She was advised Tab Pantaprazole 40 mg, and Tab Alprazolam 0.5 mg the day before surgery. She was advised to continue Tab Penicillin, Tab Metoprolol 25 mg, Tab Aldactone 25 mg, Tab Digoxin 0.25 mg, and Tab Lasix 20 mg on the day of surgery. Preoperatively antibiotic Inj Amikacin 500mg iv was given 30 mins before surgery.

Surgery

1. The patient was shifted into the operating room, and a 20 G IV cannula was secured in the left hand. ASA standard monitors were connected and her preoperative vitals were. BP: 100/70mm/hg, PR 70 bpm, SpO2 was 98%.
2. Intraoperatively, she was premedicated with Inj MIDAZOLAM 1mg IV; Inj Fentanyl 150 mcg, Inj Loxicard 63.6mg IV.
3. An intra-arterial line was placed in the right hand with a 20 G cannula for continuous arterial BP monitoring.
4. Induced with Inj ETOMIDATE 20 mg.Intubated with Inj SUCCINYLCHOLINE 100 mg with 7 cuffed ETT fixed at 22 cm mark.
5. Maintained with O2 / air with 1-2% Sevoflurane. Intraoperatively, Inj Paracetamol 1g IV was given and a warmer was placed.
6. Vitals were maintained and monitored cautiously to HR( between 60-70 bpm) and IBP ( MAP between 65-75 mm/Hg). 410 mL of RL was given and blood loss of 430 mL with U/O 290 mL.
7. Surgical time was 2 hr 10 mins and the intraoperative period was uneventful.
8. After spontaneous attempts were attained the patient was reversed with Inj Myopyrollate 2.5 mg IV Inj Ondansetron 4 mg IV and Inj Loxicard 63.6 mg, and deep extubation was done with Inj Etomidate 10 mg IV.
9. The patient responded to oral commands and shifted to the SICU.

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Take home points

1. Proper history and clinical examination along with drug intake.
2. Choice of anaesthesia ( GA vs Regional ) Since the systolic blood pressure was around 100 mm/hg GA was preferred.
3. Reduction of pressor response during intubation by giving Inj Loxicard 3mL iv and monitoring using Intra arterial blood pressure monitoring.
4. Inducing with Etomidate due to its hemodynamic stability.
5. Intraoperatively providing adequate depth of anaesthesia by Sevoflurane, maintenance of heart rate by adequate administration of fluids and analgesics and warmer to prevent hypothermia.
6. Postoperative use of oxygen supplementation to prevent hypoxia and analgesics to prevent tachycardia and correction of haemoglobin post-surgery.

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Discussion

Patients with IHD undergoing non-cardiac surgery either elective or emergency are at an increased risk of perioperative complications such as:

• Myocardial ischemia/infarction
• Arrhythmias
• Cardiac failure
• Cardiac arrest

The Preoperative assessment of such patients should include the following:

• Patient’s history
• Clinical examination
• Specific investigations which would help us in the anaesthetic management

1. Risk factors such as cigarette smoking, hypertension, diabetes, family h/o congenital heart disease, prior h/o MI, obesity with BMI>30)
2. The severity of symptoms such as breathlessness on exertion, orthopnea, paroxysmal nocturnal dyspnea chest pain and effort tolerance in terms of metabolic equivalents - METS ( > 4 is always good)
3. Prior or recent drug intake ( beta blocker, ACE /ARB blockers / Anticoagulant/ Statins )
4. Specific investigations like ECG, 2D Echo, Cardia markers- Troponin T in evaluating recent MI and NT pro-BNP for cardiac failure patients if necessary apart from routine investigations.
5. Perioperative interventions such as CABG or Angioplasty/PCI before proceeding with the anaesthetic management.
6. Risk stratification by Lee’s revised Cardiac index ( which includes six factors)

• High-risk surgical procedures such as intrathoracic/intraperitoneal surgeries.
• History of IHD
• History of CCF
• History of stroke or TIA
• Preoperative insulin therapy
• Serum creatinine >2mg%)

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The goals in intraoperative management  

1. Avoid/treat/prevent myocardial ischemia.
2. Avoiding tachycardia ( by preventing pressor response during intubation / maintaining adequate plane of anaesthesia / preventing hypoxia / hypothermia / providing adequate analgesia)
3. Avoiding extremes of BP ( the latter two adversely affect the balance between oxygen supply and demand)
4. Maintain normothermia as hypothermia will lead to peripheral vasoconstriction contributing to increased afterload.

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The goals in postoperative management

1. All the above mentioned in the intraoperative period such as avoiding tachycardia, pain, and hypothermia.
2. Also, the use of supplemental oxygen is one of the simplest yet effective means of preventing myocardial ischemia.
3. In postoperative patients, it is recommended to maintain a haemoglobin level of greater than 8 mg/dl.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Vignesh N, MD (Anaesthesia & Critical Care)  is an Assistant Professor at Meenakshi Medical College and Research Institute in Kanchipuram.