Perioperative Care—Recent MI

Perioperative Care—Recent MI

Concept

Many patients will have elevated operative risk given car- diac history. Risk factors include HTN, DM, angina, vas- cular disease, + family history.

Way Question May be Asked?

Any common general surgery issue, with the patient hav- ing had a recent MI.

“56 y/o male, heavy smoker, with recent MI, now pres- ents with signs and symptoms c/w acute cholecystitis.” The examiners may actually throw the scenario at you where the patient has multiple problems, like obstructing or bleeding rectal cancer, and will have had a recent MI.

How to Answer?

Goldman criteria

aortic stenosis, MI within 6 months, emergency surgery, nonsinus rhythm, age > 70 years, JVD, poor medical condition (PO2 less than 60, CR > 3.0, chronic liver dx

Emergency operations performed without cardiac prepa- ration have an up to 5% perioperative risk of MI No type of anesthesia (local, epidural, or general) is

better than any other when administered by good anesthesiologist

Preoperative work-up as best as possible to determine cardiac status (EKG, CXR, ECHO—ejection frac- tion)

If find reversible defect on stress thallium → cardiac cath

If find a lesion, have bypass performed

Pre-op SGC and NTG gtt and maximize hemodynamics with invasive monitoring

Pt with conduction system disease may require tempo- rary pacemaker support during surgery

~10% perioperative mortality with:

(a) recent MI (risk, ~30% if less than 30 days, 6% if less than 3 months, 2 % if 3–6 months)

(b) decompensated heart failure (c) unstable angina

(d) severe valvular disease (less than 0.9 cm

for aor- tic valve and 1.5 cm

for mitral valve)

Common Curveballs

Intraoperative ischemia Intraoperative arrhythmias Post-op ischemia

Post-op arrhythmias (a. fib particularly popular as a complication in any scenario whether recent MI or not—don’t forget your ACLS!)

Post-op pulmonary edema How will you manage pt pre-op

Clean Kills

Not knowing any of Goldman criteria (don’t need to know all of them)

Not adequately working up pt pre-op Forgetting about intra-op monitoring

Believing one type of anesthesia superior to another—

risk itself is just anesthesia so do the surgery you need to do

Not appropriately dealing with post-op complications

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