ANESTHESIA FOR A GERIATRIC PATIENT WITH HEART DISEASE DR.BALAVENKAT,DR.KALYANASUNDARAM, DR.SUDARSHAN,DR.VENKATACHELLAM,DR.MAHESH

A 83-year-old, 65 kg man fell down in his yard and was diagnosed as left femoral neck fracture. The patient’s medical history includes coronary artery disease, for which he had undergone 4-vessel coronary artery bypass grafting nine years prior to this admission; hypertension, a history of stroke one year earlier; insulin-dependent diabetes and benign prostatic hypertrophy. His medications at home included Nitroglycerin 0.4 mg daily, Metoprolol 25 mg twice daily, Lisinopril 20 mg daily, Aspirin with Clopidogrel daily, Insulin injection 20 units daily, Metformin 400 mg twice daily, Finasteride 5 mg daily.

His ECG has ST depression in Lead I and aVL His ECG has ST depression in Lead I and aVL. He has Q waves in II, III and aVF. He has occasional ventricular ectopics. His chest X-ray showed cardiomegaly and pulmonary plethora. A transthoracic echocardiogram showed a decrease in ejection fraction . EF is 25-30% as compared to his baseline EF of 40-45%. His S.Creatinine is 1.8mg/dl. His random Bld sugar is 225mg/dl. His coagulation is normal. He is posted for early fracture repair and arthroplasty.

Dr.Sudarshan/Dr.Venkatachellam 1.What is the risk involved in this case? High or moderate ? 2.How do we stratify the risk in old age? Do they have an increased risk than their younger counterparts with same risk factors?

Dr.Kalyanasundaram/Dr.Balavenkat 3.Should we have to optimize him before taking him up for surgery? 4.What more information is needed? What should be done for optimization of his risk?

Dr.Sudarshan/Dr.Venkatachellam 5.How do we manage his medications? 6.What are the anesthetic concerns in this case?

Dr.Balavenkat/Dr.Venkatachellam 7.What kind of anesthetic is preferred? Regional or General? Does the type of anesthesia influence the outcomes? 8.Does the degree of monitoring influence the outcomes in this patient

Dr.Sudarshan/Dr.Kalyanasundaram 9.What postop complications can be expected in this patient? 10.How should we manage postop pain in this patient?

Panel discussion

A 83-year-old, 65 kg man fell down in his yard and was diagnosed as left femoral neck fracture. The patient’s medical history includes coronary artery disease, for which he had undergone 4-vessel coronary artery bypass grafting nine years prior to this admission; hypertension, a history of stroke one year earlier; insulin-dependent diabetes and benign prostatic hypertrophy. His medications at home included Nitroglycerin 0.4 mg daily, Metoprolol 25 mg twice daily, Lisinopril 20 mg daily, Aspirin with Clopidogrel daily, Insulin injection 20 units daily, Metformin 400 mg twice daily, Finasteride 5 mg daily. His ECG has ST depression in Lead I and aVL. He has Q waves in II, III and aVF. He has occasional ventricular ectopics. His chest X-ray showed cardiomegaly and pulmonary plethora. A transthoracic echocardiogram showed a decrease in ejection fraction (EF) of 25-30% as compared to his baseline EF of 40-45%. His S.Creatinine is 1.8mg/dl. His random Bld sugar  is 225mg/dl. His coagulation is normal. He is posted for early fracture repair and arthroplasty

ASA Grading ACC/ AHA Guidelines 2007 Goldman Risk index Lee’s modification

ASA GRADING Grade I A normal healthy patient Grade II A patient with mild systemic illness Grade III A patient with severe systemic disease, that limits function, but is not incapacitating. Grade IV A patient with severe systemic disease that is a constant threat to life. Grade V A moribund patient who is not expected to survive without the operation. Grade VI A declared brain dead patient whose organs are being removed for donor purposes.

GOLDMAN’s Risk Index Third heart sound (S3) 11    Elevated jugulovenous pressure 11    Myocardial infarction in past 6 months 10    ECG: premature arterial contractions or any rhythm other than sinus 7    ECG shows >5 premature ventricular contractions per minute 7    Age >70 years 5    Emergency procedure 4    Intra-thoracic, intra-abdominal or aortic surgery 3 Poor general status, metabolic or bedridden 3 >25 – 56% Death,22% severe complications <26 – 4% Death, 17% severe complications <6 – 0.2% Death, 0.7% severe complications

Lee’s Revised Goldman cardiac risk index Six independent predictors of major cardiac complications High risk type of surgery H/o. IHD History of HF History of cerebrovascular disease Diabetes mellitus requiring treatment with insulin Preoperative serum creatinine >2.0 mg/dL

Rate of cardiac death, nonfatal myocardial infarction, and nonfatal cardiac arrest according to the number of predictors No risk factors - 0.4 percent (95% CI 0.1-0.8 percent) One risk factor - 1.0 percent (95% CI 0.5-1.4 percent) Two risk factors - 2.4 percent (95% CI 1.3-3.5 percent) Three or more risk factors - 5.4 percent Rate of cardiac death & nonfatal MI, cardiac arrest or ventricular fibrillation, pulmonary edema, and/or complete heart block according to the No.of predictors and use nonuse or of beta blockers No risk factors - 0.4 to 1.0 percent versus <1 percent with beta blockers One to two risk factors - 2.2 to 6.6 percent versus 0.8 to 1.6 percent with beta blockers Three or more risk factors - >9 percent versus >3 percent with beta blockers

Detsky and Goldman calculators http://www.vasgbi.com/riskdetsky.htm

ACC/ AHA Guidelines 2007

INTERMEDIATE Predictors “Cardiac Predictors” MAJOR Predictors Unstable coronary syndromes Decompensated CHF Significant Arrhythmias Severe valvular disease MINOR Predictors Age Abnormal ECG Systemic hypertension Stroke INTERMEDIATE Predictors Mild angina Prior MI Compensated or prior CHF Diabetes Mellitus Renal disease

INTERMEDIATE Risk < 5% TYPE OF SURGERY Low risk < 1% Endoscopic procedures Superficial procedure Cataract Breast HIGH RISK > 5 % Emergeny major operations, especially in elderly Aortic and other major vascular procedures Peripheral vascular procedures Anticipated prolonged procedure with large fluid shift/blood loss INTERMEDIATE Risk < 5% Carotid endarterectomy Head and neck Intraperitoneal & intrathoracic Orthopedic Prostate

Functional Capacity

Step I Step 2 Step 3 Step 4 Step 5 Consider OT OT NO NO NO Perioperative surveillance & post op risk stratification and management Need for emergency non cardiac surgery Yes OT NO Step 2 Evaluate and treat as per AHA guidelines Active Cardiac condition Yes Consider OT NO Step 3 Proceed with planned surgery Low risk surgery Yes NO Step 4 Active Cardiac condition Proceed with planned surgery 1.Unstable coronary syndromes 2. Decompensated HF (NYHA functional class IV; 3. Significant arrhythmias 4. Severe valvular disease Functional capacity > or = 4 MET’s without symptoms Yes NO or Unknown Step 5

History of CAD, or CVA Pulmonary Diabetes mellitus Renal impairment Hematologic disorders STEP 5 3 or more risk factors 1 or 2 risk factors No risk factors Vascular Intermediate risk Intermediate risk Vascular Proceed with the planned surgery Consider testing if it will change management Proceed with planned surgery with HR Control or consider non invasive testing if it will change the management