Transcript Focusing on the Surgical Patients with Cardiac Problems

Focusing
on the Surgical Patient with
Cardiac Problems
By Kate J. Morse, RN, ACNP-BC, CCRN
Nursing2009, March 2009
2.1 ANCC contact hours
Online: www.nursingcenter.com
© 2009 Lippincott Williams & Wilkins. All world rights reserved.
Significance
 Baby boomers born 1946-1964 will be
increasingly greater consumers of healthcare in
the coming decades
 39% of these patients will have cardiovascular
disease
 American College of Cardiology/American Heart
Association (ACC/AHA) have established
guidelines for perioperative cardiovascular
evaluation
Preoperative evaluation
 Determines cardiovascular risk
 Additional testing may be done
 Surgeon and anesthesiologist will examine
patient
 Nurse can perform health history and physical
assessment
Questions to ask patient
 Do you experience chest pain?
 Do you take nitroglycerin?
 Do you need to rest between taking a shower




and dressing?
Can you walk up a flight of stairs?
Have you stopped an activity due to symptoms?
Do you have swelling or pain in your feet, legs?
Does anyone in your family have heart trouble?
Physical assessment
 Take BP in both arms, checking for artery
stenosis
 Assess carotid pulses for bruits
 Auscultate lungs and heart sounds
 Examine extremities for edema and signs of
peripheral vascular disease
Conditions to treat
Active cardiac conditions, which should be treated
before noncardiac surgery, include:
 acute coronary syndromes
 decompensated heart failure
 significant dysrhythmias (high-grade
atrioventricular blocks and symptomatic
ventricular dysrhythmias), supraventricular
dysrhythmias (poorly controlled atrial fibrillation,
symptomatic bradycardia, ventricular tachycardia)
 severe valvular heart diseases (severe aortic
stenosis or symptomatic mitral stenosis)
Guidelines
 Make a distinction between:
- history of myocardial infarction (MI)
- abnormal Q waves on a 12-lead ECG
- an acute MI
 Irreversible myocardial necrosis (history of MI or
abnormal Q waves) is considered a clinical risk
factor
Guidelines
 Active cardiac condition is defined as:
- an acute MI 7 days or less before the exam
- a recent MI occurring more than 7 days ago
but less than or equal to a month ago with
evidence of ischemic risk by clinical symptoms
or noninvasive study
Low cardiac risk
 Patient with recent MI but no further risk with
stress test
 Elective surgery may still be postponed 4 to 6
weeks after the MI
Body systems linked to
increased cardiac risk
 Pulmonary: lung disease increases patient risk
of complications
 Evaluate risk with:
- accurate smoking history
- pulmonary function tests (PFTs)
- arterial blood gas analysis
- chest X-ray
Diabetes
 Most common metabolic disease
 Can complicate surgery
 These patients often have undiagnosed
coronary artery disease (CAD)
 Tight glycemic control is key - glucose below
200 is target
Kidney disease
 Can be associated with cardiac disease
 Preoperatively patient’s renal function will be
assessed with lab tests:
- blood urea nitrogen
- creatinine clearance
- glomerular filtration rate
 Fluid and electrolyte levels will be monitored and
balanced in someone who’s renally impaired
Hematologic disorders
 Anemia places stress on cardiovascular system
 If complete blood cell count reveals anemia,
blood transfusion risk will be assessed by
surgeon
 Hypercoagulability conditions (polycythemia,
thrombocytopenia) put patient at risk for clotting
and should be addressed preoperatively
Step-by-step approach for
surgical risk
 Determine urgency of surgery
- emergent surgery, cardiologist will make
recommendations
- if elective, may be delayed or postponed
 Evaluate patient for active cardiac conditions
Step-by-step approach for
surgical risk
 Evaluate surgical risk - is the procedure low,
intermediate, or high risk?
 Evaluate patient’s functional capacity
- done subjectively by asking patient questions
regarding activities of daily living
- stress test
Step-by-step approach for
surgical risk
 Evaluate clinical risk factors
- patient has symptoms
- unknown functional capacity
 Clinical risk factors include
- history ischemic heart disease
- history heart failure
- history cerebral vascular disease
- diabetes
- renal disease
Recommendations
 If no clinical risk factors, surgery can proceed
 If one or two clinical risk factors, surgery can
proceed with beta-blocker therapy; additional
testing should be considered
 If three or more clinical risk factors, consider
cardiac risk; additional testing shouldn’t be done
if it won’t change plan of care
Cardiac risks in noncardiac
surgery
The guidelines stratify surgical risk according to
three levels:
 Vascular
(cardiac risk greater than 5%)
- Major vascular procedures such as aortic
repair
- Peripheral vascular surgery
Cardiac risks in noncardiac
surgery
 Intermediate risk
(1% to 5%)
- Intraperitoneal and intrathoracic surgery
- Head and neck surgery
- Carotid endarterectomy
- Orthopedic surgery
- Prostate surgery
Cardiac risks in noncardiac
surgery
 Low risk
(less than 1%)
- Endoscopic procedures
- Superficial procedures
- Cataract surgery
- Breast surgery
- Ambulatory surgery
Diagnostic tests
 Exercise stress test is first choice unless
contraindicated
 Pharmacologic stress test if unable to walk or
exercise
 Coronary arteriograph - invasive test evaluates
coronary anatomy
Cardiac revascularization
 May be done prior to elective noncardiac
surgery
 For severe multivessel disease or significant left
main CAD
 Two options - coronary artery bypass graft or
percutaneous coronary intervention (PCI) with
bare-metal or drug-eluting stents
Surgery post PCI
 Elective surgery should be delayed 4 to 6 weeks
after PCI with bare-metal stents
 Delay 12 months after drug-eluting stents
 Medications post PCI (aspirin, Plavix) put patient
at risk for bleeding
 If patient underwent balloon angioplasty, elective
noncardiac surgery isn’t recommended for 4
weeks
Medications and surgery
 Aspirin and Plavix therapy increase risk of
bleeding
 Beta-blockers should be continued
 If patient has one or more clinical risk factors,
beta-blockers should be started preoperatively if
not taking already
Medications and surgery
 A patient having vascular surgery should be
started on a statin
 Statins may also be considered in patients in
patients with one clinical risk factor having an
intermediate risk procedure
 Uncontrolled hypertension or CAD patients may
need a alpha-agonist
Other presurgical
considerations
 Patients with implanted pacemakers or
cardioverters should alert anesthesiologist/
surgeon so appropriate safety precautions are
taken