Cardiac Procedures

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Chapter 28:  Adult Cardiac Procedures:  Anesthesia Considerations

 

Adult Cardiac Procedures:  Anesthesia Considerations

 

Hemodynamic Classification
Clinical Condition (hemodynamic) Cardiac Index (liters/minute/meter2) Pulmonary Capillary Wedge Pressure (PCWP) Therapeutic Intervention
Normal/hyperdynamic > 3 < 12 -adrenoceptor blocker
Hypovolemia (reduced perfusion) < 2.7 < 9 increased intravascular volume and then reassess
Left ventricular failure (mild) < 2.5 18-22 diuretics (e.g. chlorothiazide (Diuril)); nitrates
Left ventricular failure (severe) {adequate blood pressure} < 1.8 > 22 BP dependent-possibly nitrates; vasodilators
Left ventricular failure (severe);hypotension < 1.8 > 22 Dependent on extent of hypotension: balloon pump, dopamine (Intropin), dobutamine (Dobutrex) {positive inotropic agents}; nitrates

{Adapted from Pasternak, Braunwald and Sobel: Acute myocardial infarction: In Braunwald, editor: Hard Disease,ed 4, Philadelphia, WB Saunders, 1992,  p 1250 {also, Table 68-2 from Ross, AF, Gomez, MN. and Tinker, JH Anesthesia for Adult Cardiac Procedures in  Principles and Practice of Anesthesiology (Longnecker, D.E., Tinker, J.H. Morgan, Jr., G. E., eds)  Mosby, St. Louis, Mo., pp. 201-218, 1998.

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Analysis of Cardiovascular Function

 

Primary Reference: Shanewise, JS and Hug, Jr., CC, Anesthesia for Adult Cardiac Surgery, in Anesthesia, 5th edition,vol 2, (Miller, R.D, editor; consulting editors, Cucchiara, RF, Miller, Jr.,ED, Reves, JG, Roizen, MF and Savarese, JJ) Churchill Livingston, a Division of Harcourt Brace & Company, Philadelphia, pp. 1753-1799, 2000.

  1. Overall ventricular function +/-stress challenge {dobutamine (Dobutrex) challenge}: ejection fraction

  2. Ventricular wall motion anomalies

  3. Mitral valve regurgitation, secondary to left ventricular dilatation or papillary muscle rupture/dysfunction

Thallium  Scanning

  • "Top two panels of short axes slices shows severe stress perfusion defects involving the septum and inferior walls
  • Bottom left panel of vertical long axis slices shows severe stress perfusion defect involving the apex and interior walls
  • Bottom right panel of horizontal   long axis shows a severe stress perfusion defect involving the septum.  The lateral wall in all views appear normal
  • The inferior and septal walls redistribute completely in the rest 4 hour views indicating ischemia.
  • This represents a small area of infarction" 
  • Background-Thallium scans

Diagnostic Testing, Andrew F. McLaughlin, Nuclear Medicine Physician, Sydney (Aust Prescr 1994; 17; 3; 57-60); http://www.australianprescriber.com/magazines/vol17no3/thallium_scanning.htm  

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