pharmacologic considerations in the cardiac patient wayne e. ellis, ph.d., crna
TRANSCRIPT
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Pharmacologic Considerations in the
Cardiac Patient
Wayne E. Ellis, Ph.D., CRNA
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04/10/23
Treatment of Ischemia(primary)
• ASA 325 mg immediately
• Thrombolytics (Retevase) – > flow rate than TPA– 2 doses @ 30 min intervals– lyse clots through the activation of
plasminogen
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Primary Treatment
• Antiplatelet agents(abciximab, eptifibatide, tirofiban, integullin)
• GPIIb-IIIa antagonists
• inhibit platelet function by blocking the GPIIb-IIIa receptor, the final pathway of platelet aggregation
• thereby decreasing thrombi development and prevents arterial vessel occlusion
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Percutaneous Coronary Intervention
• Advantages include: higher recanulazation rates
• improved blood flow through the infarct-related vessel
• improved LV function
• lower in-hospital mortality rates
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Anesthetic Technique
Goals of Anesthesialoss of consciousness
amnesia
analgesia
suppression of reflexes (endocrine and autonomic)
muscle relaxation
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Preoperative Preparation
AnginaMedications to control it
Blood pressure controlledDiastolic < 95 torr
Congestive heart failure treatedDiuretics
Afterload reduction
Bed rest if indicated
Control diabetes
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Preoperative Medications
Sedation
Prevent tachycardia
Hypertension
Prepared for hypoxia
Supplemental oxygen
Calcium channel blockers not protective of perioperative ischemia
Antihypertensives continue on day of surgery
Stop Diuretics
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04/10/23
Low Molecular Weight Heparin
• Enoxaparin, Dalteparin
• Anticoagulant activity by binding to antithrombin III, which further binds and inactivates the coagulation factors IIa (thrombin) and Xa
• Advantages include dosed per body wt.
• Given q12 sub q.
• Less trombocytopenia and bleeding
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Opioids
• Advantage relates to the relative lack of myocardial depression – Exception Sufenta, Carfentanil, and high dose fentanyl
• They maintain stable hemodynamics and reduce heart rate
• A primary opioid technique may be of value in the patient with severe myocardial dysfunction
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Opioids
AdvantagesExcellent analgesia
Hemodynamic stability
Blunt reflexes
Can use 100% oxygen
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Opioids
DisadvantagesMay not block hemodynamic and hormonal
responses in patients with good LV function
Do not ensure amnesia
Chest wall rigidity
Respiratory depression
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Vasoconstrictors
• are useful in the prevention and treatment of ischemia r/t the ability to increase systemic BP
• Phenylephrine improves coronary perfusion pressure, at the expense of increasing afterload and Mv02
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Vasoconstrictors
• At the same time, phenylephrine causes venoconstriction, increasing venous return and left ventricular preload.
• The increase in CPP more than offsets the increase in wall tension
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Inhalation Agents
AdvantagesMyocardial oxygen balance altered favorably
by reductions in contractility and afterload
Easily titratable
Can be administered via CPB machine
Rapidly eliminated
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04/10/23
Inhalational Agents
• Disadvantages include myocardial depression
• systemic hypotension with possible tachycardia
• lack of postoperative analgesia
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Inhalation Agents
DisadvantagesSignificant hemodynamic variability
May cause tachycardia or alter sinus node function
Possibility of “coronary steal syndrome”
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Inhalation Agents
Potential for coronary steal
Alters coronary autoregulation
Alters regional blood flow
Little influence on outcome
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Coronary Steal
Arteriolar dilation of normal vessels diverts blood away from stenotic areas
Commonly associated with adenosine, dipyridamole, and SNP
Forane causes steal and new ST-T segment depression
May not be important since Forane reduces SVR, depresses the myocardium yet maintains CO
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04/10/23 WE Ellis 20
Antianginal medications
Beta-blockers
Calcium Channel Blockers
Nitrates
Nitropaste morning of surgery
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Nitrates
• Nitroglycerin = venodialator, reduces venous return, decreases wall tension(Mv02) also a coronary arterial dialator.
• Drug of choice for coronary vasospasm• Although primarily is a systemic
venodialator, at high doses causes arterial dilatation and systemic hypotension
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Cardioactive drugs
NitroglycerinLower LVEDP
Vasodilator
Poor ventricular function
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Beta Blockers
• Beta blockers reduce myocardial workload(Mv02), and oxygen consumption(V02) by reducing HR,BP, and contractility, and they increase the threshold for ventricular fibrillation.
• Indications for beta blockers include: sinus tachycardia, supraventricular dysrhythmias and hyperdynamic states
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Beta Blockers
Negative inotropic effects
Withdrawal following stoppage of beta blockerUnstable angina
Myocardial infarction
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04/10/23
Beta Blockers
• Propranolol (non-selective) t1/2 = 4-6 hours
• Metoprolol (B1 selective) t 1/2 = 4-6 hours
• Labatelol (1:7 ratio) t 1/2 = 2-4hours
• Esmolol (Beta1 selective) t1/2 = 9.5 minutes
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Esmolol
Control heart rate and blood pressure
Induction
Emergence
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Labetalol
Mixed alpha and beta
Control hypertension
Heart rate management
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Ca Channel Blockers
• Evidence for beneficial effects post mi is less compelling
• Nifedipine treatment is associated with a trend towards increased mortality and reinfarction
• Verapamil does not reduce mortality or reinfarction
• Verapamil - useful for slowing the ventricular response in atrial fibrillation/flutter
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Ca Channel Blockers
• Cardizem- in pt’s with non-Q wave infarction seems to reduce the reinfarction rate during the 1st 6 months after the infarction, but incidence of late infarction was similar to a placebo.
• Cardizem increases cardiac events in pt’s with LVEF<40% , but decreases their incidence in pt’s with preserved LV function
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Ca Channel Blockers
• All Ca blockers depress contractility, reduce coronary and systemic tone, decrease sino-atrial node firing, and impede atrioventricular conduction.
• The negative inatropic effect is greatest with verapamil
• Nifedipine + Cardizem are used in the prevention of coronary vasospasm
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Nifedipine
Controlling hypertension
Manage coronary artery spasm
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ACE Inhibitors
• Are effective in reducing ischemic effects after MI
• Treatment should be instituted within the 1st 24 hours of all pt’s with acute mi complicated by symptomatic or asymptomatic left ventricular dysfunction
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ACE Inhibitors
• Contraindicated in pt’s with hypotension, bilateral renal artery stenosis, history of a cough or angio-edema with ace inhibitors
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Aspirin
• ASA benefit well established as a secondary prevention
• Antiplatelet therapeutic dose (75-325mg/day)
• other antiplatelet agents such as dipyridamole are not supported in the literature except in pt’s with allergies to ASA who are poor candidates to oral anticoagulants
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Anticoagulants
• Studies of anticoagulant treatment after mi show reduction in death, recurrent MI, and thromboembolitic complications
• However, trials comparing warafin to ASA for secondary prevention show no difference in recurrent infarction or death
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Anticoagulants
• Are indicated for pt’s with ASA intolerance and for those at risk of embolisation from left ventricular or atrial clot(i.e. persistent atrial fib)
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Lipid Lowering Agents
• meta analysis of clinical trials show that lipid lowering agents produce a reduction in fatal and non-fatal MI’s and cardiovascular deaths
• Should be given to pt’s with LDL concentration >3.37 mmol/1
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Clonidine
Less hypertension
Decreased anesthesia requirements
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Anesthetic Management
Regional vs. general
Anesthetic management skills more important than technique
Safest technique is the one the practitioner does best
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Regional Anesthesia
Monitor patient more accurately
Control sympathetic responsesFluids
Esmolol
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General anesthesia
Avoids sympathectomy
Risks with intubationSympathetic stimulation
Hypoxia
Increased catecholamines
Loss of subjective monitorChest pain
Ischemia
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General Anesthesia required
NarcoticsEffective control of catecholamines
Respiratory depression
Prolonged ventilation
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Lidocaine
Blunt effects of intubation
1.5 mg/kg 4-6 minutes prior to intubation
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Nitrous Oxide
Rarely used due to:increased PVR
depression of myocardial contractility
mild increase in SVR
air expansion
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Induction Drugs
Barbiturates
Benzodiazepines
Ketamine
Etomidate
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Avoid Ketamine
Hypertension
Tachycardia
Use in trauma
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Etomidate
Painful to inject
More CV stability
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Barbiturate
Direct depressant
Extended duration of activity
Smaller doses1-2 mg/kg
Add benzodiazepines and narcotic
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Benzodiazepines
Quell anxiety
Hemodynamic stability
Extended duration of action
Potential for hypoxia
Lidocaine
Esmolol
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Muscle Relaxants
Used to:facilitate intubation
prevent shivering
attenuate skeletal muscle contraction during defibrillation
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Muscle Relaxants
Avoid pancuroniumTachycardia
ST segment changes consistent with ischemia
Doxacurium Duration similar to pancuronium
No cardiovascular effects
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Avoid Histamine releasing drugs
Curare
Atracurium
Mivacurium <15 mcg/kg
Hypotension
Tachycardia
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Nitrous Oxide
Constricts coronary arteries
Aggravates myocardial ischemia
High FiO2 recommendedMaintain saturation at 95-100%
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Intraoperative predictors
Choice of anesthetic
Site of surgery
Duration of Anesthesia
Emergency Surgery
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Intraoperative predictors
Choice of AnestheticNo difference in infarction rate GETA vs. Regional
No significant hypotension
No significant tachycardia
TURPRegional decreased risk post MI
Reinfarction rateSAB < 1%
GETA 2-8%
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Intraoperative predictors
Choice of AnestheticPatient with CHF will benefit from regional
techniqueSympathectomy
Decreased preload
Coronary StealPotent inhalation agents vs. narcotics
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Intraoperative predictors
Site of SurgeryThoracic and upper abdominal
2-3 X’s risk of extremity procedures
Duration of Anesthetic> 3 hours > risk of morbidity & mortality
Emergency Surgery2 - 5 X’s greater risk than nonemergent surgery
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Postoperative Management
Maintain analgesia
Balance supply and demand
Supplemental oxygen
Continue monitoring into postoperative period
Early transfusion