The patient with ischaemic heart disease undergoing non cardiac surgery

Effect of gender on spect myocardial perfusion imaging results in Egypt

BACKGROUND

Globally, Ischemic heart disease (IHD) is considered a leading cause of mortality and morbidity affecting men than women. The more the population ages, the more the prevalence. There was a concern about improper referral of women to MPI testing. We aimed to study if there a gender effect on the results of MPI studies and if this could have an impact on future referral or investigation selection for diagnosis of IHD as a general or specially in women.

RESULTS

Female gender represented 266 (60%) while male represented in 177 (40%). Males demonstrated significantly higher age (55 ± 10 vs. 49 ± 9, P < .0001), weight (85 ± 11 vs. 83 ± 13, P = 0.006), height (166 ± 4 vs. 165 ± 4, P = 0.02), and smoking (35% vs. 0%, P < 0.001) than females. Male gender was associated with ten times increased risk of positive MPI (OR = 10, 95% CI = 5.348-18.868, P < 0.001). Diabetes was associated with an increased risk of positive MPI (OR = 1.82, 95% CI = 1.052-3.148, P = 0.032).

CONCLUSIONS

Positive MPI test are more common in males. Female patients with positive MPI were younger in age than male patients. Diabetes mellitus and age are traditional strong predictors for the presence of positive MPI test.

Anaesthetic Management of Right Inguinal Hernioplasty With Hemiorchidectomy in a High-Risk Dilated Cardiomyopathy Patient

This case report details the successful anaesthetic management of a 65-year-old male with severe dilated cardiomyopathy, coronary artery disease, and extensive cardiovascular risk factors scheduled for elective right inguinal hernioplasty with hemiorchidectomy. The anaesthetic approach, including regional nerve blocks (ilioinguinal, iliohypogastric, genital branch of genitofemoral) and transversus abdominis plane block, successfully minimised cardiac stress and maintained hemodynamic stability throughout the procedure.

Cervical Epidural Anesthesia in the Management of a Patient With Breast Cancer With Cardiac Dysfunction: A Case Report

As one of the most common cancers in the world, breast cancer management is fraught with difficulties. Modified radical mastectomy (MRM) is one of the surgical procedures that is essential to the treatment of breast cancer. Cardiovascular issues, especially a reduced ejection fraction (EF), make these procedures more complex. Due to their increased vulnerability to adverse cardiac events during surgery, it is imperative to preserve hemodynamic stability and reduce physiological stress responses in these patients. A promising option in this changing field of anesthetic techniques is cervical epidural anesthesia (CEA). It effectively reduces hemodynamic fluctuations frequently linked to general anesthesia while providing analgesia. We report the case of an elderly patient with decreased EF and breast cancer scheduled for an MRM. To ensure the best possible outcomes in complex cases, the case report covers preoperative assessment, anesthesia technique, intraoperative management, and postoperative outcomes. This highlights the critical significance of customizing anesthesia and surgical procedures, informed consent, and meticulous postoperative pain management, and ultimately advocates for the broader implementation of CEA in such settings.

Coronary Artery Occlusion with Sharp Blood Pressure Drop during General Anesthesia Induction: A Case Report

Most anesthetics reduce cardiac functions and lower blood pressure (BP), potentially causing excessive BP reduction in dehydrated patients or those with heart conditions, such as coronary artery disease (CAD). Considering the increased prevalence of cardiovascular disease with age, anesthesiologists must be cautious about BP reduction during general anesthesia in older adults. In the present case, a 76-year-old male patient with undiagnosed CAD in a hypovolemic state experienced a significant drop in systolic BP to the fifties during propofol and sevoflurane anesthesia. Despite the use of vasopressors, excessive hypotension persisted, leading to anesthesia suspension. Subsequent cardiac examinations, including computed tomography heart angio and calcium score, and coronary angiogram, revealed a near total occlusion of the proximal left anterior descending coronary artery (pLAD) and the formation of collateral circulation. After 5 days of hydration and anticoagulation medications and confirmation of normovolemic state, general anesthesia was attempted again and successfully induced; a normal BP was maintained throughout the surgery. Thus, it is important to conduct a thorough cardiac evaluation and maintain normovolemia for general anesthesia in older adults.

Patients with complicated gallstone disease in the emergency department: clinical impact and cost-effectiveness of emergency department disposition decision

Objective

The objective of this study was to assess the 1-year outcomes of emergency department (ED) patients with complicated gallstone disease, including surgery rates, initial admission rates, ED revisits, repeat hospitalizations, and cost.

Methods

Using 3 linked statewide databases from the Maryland Healthcare Cost and Utilization Project, we identified patients with a primary diagnosis of complicated gallstone disease treated in an ED between 2016 and 2018. We measured the healthcare use and direct costs in the ambulatory surgery, inpatient, and ED settings for 1 year after the initial ED visit. Finally, we performed a multivariate logistic regression analysis comparing initially admitted versus discharged patients.

Results

Of the 8751 patients analyzed, 86.8% were admitted to the hospital and 13.2% were discharged on their initial ED visit. Of the admitted patients, 78.7% received a cholecystectomy during the initial hospitalization plus 6.1% at a later date; of the discharged patients, 41.5% received a cholecystectomy. Admitted patients demonstrated lower recurrent gallbladder complications compared with those discharged (7.5% vs 44.5%), fewer ED revisits (4% vs 20.3%), and fewer repeat hospitalizations (4.5% vs 16.7%). Despite this, the 1-year cost in the admitted patients was higher ($9448 vs $2933). Obesity, age, and mood disorders but not race, ethnicity, or zip code were associated with admission at initial ED visit.

Conclusions

In our single-state analysis of ED patients with complications of gallstone disease, most patients are admitted on the initial visit and receive a cholecystectomy during that hospitalization. The discharged group had higher rates of 1-year complications, ED revisits, and repeat hospitalizations but lower cost.

Graded Epidural Anesthesia for Non-cardiac Surgery in the Prone Position in a Patient With Low Ejection Fraction

Ischemic heart disease (IHD), also known as coronary artery disease, occurs due to the blockage of coronary arteries which reduces the blood supply of the myocardium. The main goal of the anesthetic management of IHD patients undergoing non-cardiac surgery is to maintain the balance between myocardial oxygen supply and demand. Here, we report the anesthetic management of an IHD patient with a low ejection fraction who was posted for percutaneous nephrolithotomy in the prone position. We opted for graded epidural anesthesia with a low dose of a local anesthetic drug and opioid. Graded epidural anesthesia is a safe alternative over general anesthesia for patients with IHD and low ejection fraction as it reduces stress response to surgery, provides good postoperative analgesia, and avoids myocardial depressant drugs and coagulation responses.

Abstract No.: ABS0617: Anaesthesia management of high risk cardiac patients for lower limb vascular surgeries

Background and Aims:

Managing Cardiac patients for noncardiac surgery is a daunting task. Haemodynamic disturbances during neuraxial blocks or general anesthesia may worsen the cardiac pathology. Peripheral nerve blocks can prove to be a better alternative in lower limb vascular surgeries.

Methods:

We included 25 high risk cardiac patients posted for lower limb vascular surgeries. Both lumbar plexus and sacral plexus blocks were performed. Haemodynamic monitoring and perioperative new cardiac events were recorded. Any additional supplementation of drugs was also noted.

Results:

Out of 25 patients, 75 patients were male and rest 25 were females. Two patients required additional supplementation with total intravenous anaesthesia. No haemodynamic instability was recorded (table 1). One patient died due to ventricular tachycardia 4 hours after surgery.

Conclusion:

Combined lumbar and sacral plexus blocks resulted as an alternative to neuroaxial blocks or general anaestheisa in patients of high cardiac risk patients undergoing lower limb vascular surgeries.

Predictors of peri-operative cardiac events and development of a scoring tool for patients with chronic kidney disease undergoing non-cardiac surgeries: A prospective observational multicentre study

Background and Aims:

Cardiovascular diseases are the leading causes of morbidity and mortality in chronic kidney disease (CKD) patients. Our aim was to derive predictors of cardiac morbidity, mortality, cardiac complications and to develop/validate a scoring tool in patients with CKD undergoing non-cardiac surgery.

Methods:

A prospective observational multicentre study was done on 770 patients with CKD. The primary outcome (“Event”) was one or more than one of sudden cardiac death, pulmonary oedema, acute coronary syndrome, arrhythmia and 30-day mortality. Secondary outcome was hypertension and hypotension. Predictors of cardiac risk were identified. A scoring tool was developed on the 2018 dataset and was validated on the 2019 dataset.

Results:

The overall incidence of cardiac events was 290 (37.66%) whereas the incidence of major adverse cardiac and cerebrovascular events was 15.04%. Mortality due to cardiac cause was 13 (1.68%). On multivariate regression analysis, seven perioperative variables had significant association with increased risk of events: age > 65 years (P = 0.004), metabolic equivalents (METS) ≤4 (P≤0.032), emergency surgery (P =0.032), mean arterial pressure >119 (P = 0.001), echocardiographic scoring (P = 0.054), type of anaesthesia (P ≤ 0.0001) and type of surgery (P = 0.056). Using these variables, a risk stratification tool was developed. C statistics showed favourable predictive accuracy (0.714) and the model showed good calibration.

Conclusion:

This risk scoring tool based on preoperative variables will help to predict the risk of events in high-risk CKD patients undergoing non-cardiac surgery. This will help in better counselling and optimisation.

Comparative study of hemodynamic effects of intrathecal bupivacaine with butorphanol in cardiac and non-cardiac patients

Background and Aims:

The synergism between intrathecal opioids and low dose local anesthetics makes it possible to achieve reliable spinal anesthesia (SA) with minimal hypotension. The study objective was to compare the hemodynamic effects of reduced dose of 0.5% intrathecal bupivacaine (2mL) with 25 μg butorphanol in cardiac vs non-cardiac patients.

Material and Methods:

We included sixty patients aged 30-80 years, undergoing infraumbilical surgeries in the study and compared thirty cardiac patients with mild to moderate reduction in left ventricular ejection fraction (LVEF) on 2D echocardiography (Group C) with 30 non-cardiac patients (Group NC) for similar types of surgery. Both the groups received 0.5% bupivacaine 2.0 ml with 25 μg butorphanol.

Results:

The spinal block characteristics were similar in both groups (P > 0.05). The blood pressure of the patients in the two groups was comparable till 80 min P > 0.05 after which Group NC had significant increase in blood pressure compared to Group C upto 95 min (P < 0.05). Similarly, heart rate was comparable until 90 min (P > 0.05) after which Group NC had significant increase in heart rate versus Group C upto 100 min (P < 0.05). Eight patients in group C and five patients in group NC showed hypotension. Bradycardia was seen in 4 patients in group C in comparison to only one patient in group NC.

Conclusion:

We can safely consider spinal anesthesia with 10 mg bupivacaine and 25μg butorphanol in cardiac patients with mild to moderately reduced ejection fraction presenting for infraumbilical non-cardiac surgeries with the advantage of intraoperative hemodynamic stability and adequate postoperative analgesia.

Myocardial injury in elderly patients after abdominal surgery

BACKGROUND

The development of sensitive myocardial-specific cardiac biomarkers allows for detection of very small amounts of myocardial injury or necrosis. Myocardial injury (MI) as a prelude of the serious perioperative complication myocardial infarction, should be paid more attention, especially in elderly susceptible patients. Myocardial injury after abdominal surgery in elderly patients has not been described yet. The objectives of this study were to identify the incidence, predictors, characteristics and the impact of MI on outcome in elderly patients underwent abdominal surgery.

METHODS

Patients aged  ≥ 65 who underwent abdominal surgery longer than 2 h between January 2016 and March 2017 were reviewed. Patients with peak troponin I level of 0.04 ng/ml or greater (abnormal laboratory threshold) within once-administration-period and without non-ischemia troponin elevation proof (e.g., sepsis) were assessed for characteristics and prognosis. Risk factors of MI were determined by multivariable regression.

RESULTS

Among 285 patients with whole information, 36 patients (12.6%) suffered MI, only 2 patients (0.7%) fulfilled definition of myocardial infarction. With most of them occurred within first 7 days after surgery. Multivariable analysis showed that coronary artery disease (CAD) history [odds ratio (OR) 2.817, P = 0.015], non-laparoscopic surgery (OR 5.181, P = 0.030), blood loss ≥ 800 ml (OR 3.430, P = 0.008), non-venous maintain (OR 2.105, P = 0.047), and infection (OR 4.887, P = 0.008) as risk factors for MI. MI was associated with longer hospital stay (P = 0.006), more cardiac consultation (P = 0.011), higher infection(P = 0.016) and reoperation(P = 0.026) rate.

CONCLUSION

MI is common in elderly patients who underwent abdominal surgery, while myocardial infarction is infrequent. They are both associated with risk factors and worse prognosis. MI deserves more attention especially in elderly patients. Troponin I measurement is a useful test after massive surgery, which can help risk-stratifying patients, effective preventing, prompt managing and predicting outcomes. Routine monitoring of cardiac biomarkers especially within 7 days after abdominal surgery in elderly patients is recommended.