Cindy E. BoomRS. Pusat JantungDan PembuluhDarah Harapan KitaJakarta

PREOPERATIVE

PREPARATION

PERSIAPAN PRA BEDAH

Semua pemeriksaan, persiapan, sistem skoring dll diperlukan untuk menentukan rencana tindakan bedah maupun anestesi, waktu pelaksanaan, jenis anestesi yang dipergunakan, persiapan obat-obatan, darah, cairan IV, penyulit anestesi, perawatan pascabedah (ICU/ rg. Rawat), biaya, inform consent dll

  GCS   PCS  

Eye opening

SpontaneousTo verbal stimuliTo painNone

4321

Ditto  

Verbal Oriented ConfusedInappropriate wordsNon specific soundsNone

54321

Oriented Words Vocal soundsCriesNone

54321

Motor Follows commandsLocalises painWithdraws in response to painFlexion in response to painExtension in response to painNone

654321

Ditto  

 

Trauma Score

16 13 10 7 4 1

% Survival

99 93 60 15 2 0

TRAUMA SCORE

0 1 2 3 4 5 6 7 8 9 10 Mild Moderate Severe

Pain threshold

Pain tolerance

Pain Rating Scales

CHOOSING PAIN KILLER AND ITS COMBINATIONS

10 Pain Intensity Scale

0 1 2 3 4 5 6 7 8 9 10 Mild Moderat

eSevere

Strong opioid ±

NSAID ±

adjuvant analgesic

paracetamolor/+

NSAIDNSAID ±

adjuvant analgesic

NSAIDNSAID ±

weak opioid ±

adjuvant analgesic

Pasien dengan kelainan jantung yang menjalani operasi non jantung meningkat

Komplikasi Perioperatif yang sering terjadi berhubungan dengan :Myocardial infarction (MI)ArrhythmiasPulmonary Insufficiency

PERSIAPAN PREOPERATIF PASIEN DGN KELAINAN JANTUNG UNTUK

OPERASI NON JANTUNG

Manifestasi dapat berupa:Infark miokardAngina tidak stabilGagal jantung (akut) kongestifDisritmiaKematian

MORBIDITAS JANTUNG PERIOPERATIF

① Akut/ recent MI 7-30 hari② Dekompensasi Kordis Akut/ Tidak Stabil :

lakukan terapi terlebih dahulu (optimalisasi)

③ Severe Aritmia.④ Penyakit Jantung Iskemik yang tidak stabil⑤ Total AV block transient pacemaker⑥ Penyakit katup jantung berat (severe valve

disease, misal AS severe) Yang lain adalah kontraindikasi RELATIF

KONTRAINDIKASI ABSOLUT UNTUK ANESTESIA

Perioperative Myocard Infarction (PMI) and Ischemia Priebe.Br J Anaesth 2005;95:3-19, Gombar S et al. IJA 2007;51(4):287-302

Major cause of short and long term morbidity and mortality associated with non-cardiac surgery.

More than one half of postoperative deaths are caused by cardiac events, most of which are ischemic in origin.

Incidence in patients with at risk of CAD, PMI was reported 20-63%.

Early mortality after PMI 3,5%-25% Postoperative MI: Preoperative MI: 3:1 Postoperative MI: Intraoperative MI: 5:1 Postoperative MI increased the odds for

long term cardiac events 20-fold.

Myocardial Ischemia

① CAD② Left Ventricular

Hyperthrophy (LVH)③ Reduced oxygen

supply④ Low flow ischemia

(coronary vasoconstriction, intracoronary thrombus/ plaque)

Myocardial Infarction

① Significant preexisting CAD

② Hypertensive③ Left Ventricle

Hyperthrophy④ Coronary plaque

disruption⑤ Subsequent

thrombosis

UNDERSTOOD THE PATHOPHYSIOLOGYGOMBAR S ET AL. IJA 2007;52(4):287-302, LANDESBERG G ET AL. CIRULATION 2009;119:2936-

2944

Landesberg G et al. Circulation 2009;119:2936-44

Kaul TK et al. IJA 2007;51(4):280-86

① Hemodynamic and Clinical Presentation

② ECG③ Functional (echocardiogram)④ Metabolic (coronary lactate

production)⑤ Biochemical (Troponin T, Troponin I,

Creatinekinase-MB)

MAKING A DIAGNOSISPRIEBE H.J BR J ANAESTH 2005;95:3-19,

Penyakit jantung yang membutuhkan terapi surgikal untuk penyakit jantungnya, pertimbangkan urgensinya.

Pembedahan Emergensi Pembedahan dengan resiko sedang atau tinggi

OPTIMALKAN kondisi jantung dan penderita:

- Tatalaksana Medikamentosa (diuretik, Inotropik, dll)- Tatalaksana Topangan Mekanik ( IABP,

pacemaker)

PRINSIP

PERCUTANEOUS CORONARY INTERVENTION (PCI) AND SURGERY

BARASH P, AKHTAR S. BR J ANAESTHESIA 2010; 105(S1):I3-I15

Percutaneous Coronary Intervention

Ballon Angioplasty

Bare MetalStent

Drug ElutingStent

Delay for elective /Non urgent

Proceed to OT+ Aspirin

Delay for elective /Non urgent

Proceed to OT+ Aspirin

< 14 d > 14 d > 30 – 45 d <30 – 45 d < 365 d > 365 d

Stepwise Approach to Preoperative Cardiac Assessment

Need for emergencynoncardiac

surgeryOperating room

Evaluate and treatper ACC/AHA

Guidelines

Vigilant perioperative and postoperative

management

Consider Operating Room

Low RiskSurgery

Active cardiac

conditions

No

Yes

Yes

No

Proceed withplanned surgery

Asymptomatic andgood functional

capacity

Yes

Proceed withplanned surgery

No

Yes

Manage based onclinical risk factors

No

Functional Capacity

1. Correlates with maximum oxygen uptake on treadmill testing

2. Demonstrated predictor of future cardiac events

3. Poor functional capacity may hide low threshold cardiac symptoms

ESTIMATED ENERGY REQUIREMENTS FOR VARIOUS ACTIVITIES

1 MET Can you take care of yourself ?

Eat, dress, or use the toilet ?

Walk indoors around the house ?

Walk a block or two on level ground at 2 to 3 mph or 3.2 to 4.8 km per h ?

4 METs Do light work around the house like dusting or washing dishes ?

Climb a flight of stairs or walk up a hill ?

Run a short distance ?

Do heavy work around the house like scrubbing floors or lifting or moving heavy furniture ?

Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football ?

Greater than 10 METs

Participate in strenuous sports like swimming, single tennis, football, basketball, or skiing?

THE RISKS PRIEBE HJ. BR J ANAESTH 2004;93:9-20, SAMBOLA A. CIRCULATION 2003;107:973-77

Clinical Predictors of Perioperative Cardiac Risks

Major Intermediate Minor

Acute or recent MI

Mild angina Advanced age

Unstable angina

Prior MI Abnormal ECG

Decompensated CHF

Compensated CHF

Rhythm other than sinus

Significant arrhythmias

DM History of stroke

Severe valvular disease

Renal insufficiency

Uncontrolled hypertension

Surgery Specific Cardiac Risks

High (5%)

Intermediate (<5%)

Low (1%)

Emergent surgery

Carotid endarterectomy

Endoscopic procedures

Aortic or major vascular surgery

Head and neck surgery

Superficial procedures

Peripheral vascular surgery

Intraperitoneal intrathorasic procedures

Cataract surgery

Large fluid shifts and blood loss

Orthopedic surgery

Breast surgery

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Attempts to Increase CARDIAC OUTPUT :

①Good oxygenation②Volume therapy③Drugs- vasoactive-

inotropic therapy④Correct metabolic

acidosis⑤Correct electrolyte

imbalance (hypokalemia)⑥Treat arrhythmias⑦Mechanical support

(Intraaortic baloon pum/IABP)

RESTORE THE CARDIAC OUTPUTHOWELL SJ, SEAR JW, FOEX P. BR J ANAESTHESIA 1004;92(4):57-83

① Avoiding extremes of hemodynamic disturbances (blood pressure (BP), tachycardia, hipercarbia, hypertermia, aritmia)

② Monitoring of cardiac ischemia (ECG, direct arterial pressure monitoring along with pulmonary artery (PA) catheter, TEE)

③ Hemodynamic control (anesthetic technique and pharmacological agents)

④ Beta blockers preventing perioperative cardiac morbidity

⑤ Adequate doses of analgesics (morphine 5-10 mg or sufentanyl or fentanyl 5-10 µg/kg)

⑥ Cardiac support ( inotrope or mechanical devices)

ANESTHETIC GOALS

INTRAOPERATIVE EVENTS THAT INFLUENCES THE OXYGEN BALANCE

STOELTING RK, DIERDORF SF. ANESTHESIA AND CO-EXISTING DISEASE 6TH EDITION, CHURCHIL LIVINGSTONE, PHIADELPHIA, 2012.

Decreased Oxygen DeliveryDecreased coronary blood flowTachycardiaDiastolic hypotensionHypocapnia ( coronary artery vasoconstriction)Coronary artery spasm

Decreased Oxygen ContentAnemiaArterial hypoxemiaShift of the oxyhemoglobin dissociation curve to the left

Increased Oxygen RequirementsIncreased preload (wall tension)Sympathetic nervous system stimulationTachycardiaSystemic hypertensionIncreased myocardial contractilityIncreased afterload

ANESTHETIC TECHNIQUEGOMBAR S ET.AL. IJA 2007;51(4):287-302, EAGLE KA ET ALL. ACC/AHA GUIDELINE2010 REV, HARRIS SH. ANESTHESIA AND PERIOPERATIVE COMPLICATIONS. MOSBY ST LOUIS, 2 ND ED;1999:293-307, FRABDORF J. HERTS SG. BR J ANAESTHESIA 2009;103(1):89-98

① Induction should be smooth, minimize pressor response to laryngoscopy and intubation.

② Various drugs can be use: lidocaine, nitroprusside, fentanyl, esmolol, nitrogycerine, captopril etc.

③ Maintain left Ventricular Function. N2O-Opioid with additional Sevoflurane, Isoflurane, Desflurane.

④ Severely impaired LV function: use narcotic base anesthesia ( Fentanyl 5-10 μg.kgBW.IV) in combination with IV sedation/

⑤ Neuroaxial anesthetic techniques. Result symphatetic blocade, decreases preload and afterload. Study found no difference in outcome in terms of cardiac morbidity.

⑥ Monitored anesthesia. Moderate-Severe anatomy and clinical-hemodynamic dysfunction, Intermediate-Major clinical cardiac risks and Intermediate-High risks surgery are recommended to use the invasive hemodynamic monitoring.

⑦ Perioperative Pain Management is mandatory during perioperative period.

⑧ Maintenance body temperature. Avoid hypothermia (air warming).

ANESTHESIA TECHNIQUE

① Which hypertensive patients have increasing perioperative risks?

② Will lowering preoperative blood pressure decrease the risks③ How long and how should blood pressure be controlled before

elective surgery?④ History of chronic hypertension with/without therapy⑤ Blood pressure ≥ 180/110 mmHg or 120/30 mmHg?⑥ Patients with cerebral, coronary or renovascular abnormalities⑦ Preoperative antihypertensive therapy for a few weeks/months

can reduce morbidity, especially in severe hypertension (3-4 weeks ideally)

⑧ Moderate hypertension: duration of therapy can be shorter⑨ Antihypertensive medication continued to the time of surgery,

except ACE-I⑩ Arterial blood pressure be kept within 10~20% of preoperative

level

HYPERTENSIVE

GULA DARAH, ALBUMIN, GOT/PT, UREUM, KREATININ, AKI, ARITMIA

Healthy vascular endothelium coated by endothelial glycocalyx – a layer of membrane-bound proteoglycans and glycoproteins.

Healthy vascular endothelium coated by endothelial glycocalyx – a layer of membrane-bound proteoglycans and glycoproteins.

THE ENDOTHELIAL GLYCOCALIXTHE ENDOTHELIAL GLYCOCALIX

Glycocalyx affect endothelial permeability.Prevent leukocyte and platelet adhesion.Decreases inflammation.Bounds plasma proteins and fluids.

700 ~ 1000 mL of “non-circulatory” plasma fixed within.

Maintains “oncotic gradient” despite intravascular and extravascular equilibration.

Glycocalyx affect endothelial permeability.Prevent leukocyte and platelet adhesion.Decreases inflammation.Bounds plasma proteins and fluids.

700 ~ 1000 mL of “non-circulatory” plasma fixed within.

Maintains “oncotic gradient” despite intravascular and extravascular equilibration.

Jacob M. et al: The endothelial glycocalix affords compatibility of starling’s principle and high cardiac interstitial albumin level.

Cardiovasc Res 2007; 73:575-86

Jacob M. et al: The endothelial glycocalix affords compatibility of starling’s principle and high cardiac interstitial albumin level.

Cardiovasc Res 2007; 73:575-86

THE ENDOTHELIAL GLYCOCALIXTHE ENDOTHELIAL GLYCOCALIX

hyperglycemiareperfusion injury

oxidized-LDL

Mechanical stress, Endotoxin exposure,Mediator SIRS, and

ANP (Atrial Natriuretic Peptide)Intact glicocalix Loss glicocalix

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