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

2. 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.

3. 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.

4. 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?

5. 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?

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

7. 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

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

9. Panel discussion

10. 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

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

12. 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.

13. GOLDMAN’s Risk Index
Third heart sound (S3)    Elevated jugulovenous pressure    Myocardial infarction in past 6 months    ECG: premature arterial contractions or any rhythm other than sinus 7    ECG shows >5 premature ventricular contractions per minute 7    Age >70 years    Emergency procedure    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

14. 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

15. Rate of cardiac death, nonfatal myocardial infarction, and nonfatal cardiac arrest according to the number of predictors
No risk factors percent (95% CI percent)
One risk factor percent (95% CI percent)
Two risk factors percent (95% CI percent)
Three or more risk factors 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 to 1.0 percent versus <1 percent with beta blockers
One to two risk factors 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

16. Detsky and Goldman calculators

17. ACC/ AHA Guidelines 2007

18. 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

19. 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

20. Functional Capacity

21. 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

22. 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