ICU NOTES BY Dr Fahad Rafiq Butt

Cardiac Anesthesia
 1- Anticoagulants:
Indirect Thrombin Inhibitors:

Unfractionated Heparin

Factor Xa Inhibitors:

Rivaroxaban

Fondaperinaux

Rivaroxaban has to be stopped between 24-72 hours before surgery

Unfractionated Heparin dose is 80U/kg Bid S/C for thromboprophylaxis…

Last dose before surgery it should be stopped before 4 hours.

After surgery/Edpidural done or removed… 2 hour later we can start heparin.

Indirect thrombin plus Factor Xa Inhibitors:

Enoxaparin/Deltaparin/Clexane

Prophylactic dose to prevent venous thromboembolism: 0.5mg/kg x OD

Therapeutic Dose: 1mg/kg x Bid

Prophylactic dose should be stopped 12 hours before surgery. And it can be restarted 4 hours after procedure.

There are 2 surgeries after which enoxaparin is not to be restarted even 24 hours after surgery.. i.e., Neurosurgery and Vascular surgery.. after
these surgeries it is on discretion of surgeon to start the dose or not.

Therapeutic dose has to be stopped 24 hours before any surgery/procedure.

After procedure.. therapeutic dose cannot be started with epidural catheter in situ..

Epidural catheter should be removed atleast 4 hours before starting again therapeutic dose.

Direct Thrombin Inhibitors:

Liperudin, Argatroban, Bivalrudin…

Used only in HIT (Heparin induced Thrombocytopenia)

Vitamin K Antagonist:

Warfarin…

Has to be stopped 5 days before surgery.. and warfarin can be restarted 12 – 24 hours after surgery usually at time of discharge.

2- Antiplatelet:
Arachidonic Acid Pathway Inhibitors:

Aspirin… No recommendation to stop before surgery.

Not contraindicated for any neuraxial block.

ADP receptor Blockers:

Clopidogrel, Ticlopidine

Clopidogrel to be stopped 5 days before surgery

Ticlopidine to be stopped 14 days before surgery

Phosphodiesterase inhibitors:

Dipiridamole:
duration of action is 3 hours.

Adenosine dose should be reduced if given with Dipiridamole because it potentiates its effect.

Dipiridamole risk of bleeding is very low, so not needed to be stopped before surgery.

GPIIbIIIa Inhibitors:

Tirofiban, Ebtifibatide, Abcsiximab

Half lives are 6 - 8 hours. So these should be stopped 6 – 8 hours before surgery.

3- Bridging Therapy:
The gold standard of bridging therapy is to bridge the antiplatelets with anti platelets, and bridge anticoagulants with anticoagulants.

As in our country only antiplatelets available are aspirin and clopidogrel…

If a patient is taking clopidogrel.. stop clopidogrel 5 days before surgery.. shift to Tirofiban on TDS dose.. and morning of surgery skip the dose of
tirofiban 8 hours before surgery.

If this is not option available in answers and as Tirofiban is not available in our country; then we can shift to anticoagulants to bridge from
antiplatelets..

Clopidogrel stopped 5 days before and shift patient to therapeutic Enoxaparin 1mg/kg dose and then 24 hours before surgery stop Enoxaparin too.

Warfarin is also stopped 5 days before and shift patient to therapeutic Enoxaparin 1mg/kg dose and then 24 hours before surgery stop Enoxaparin
too.

If a patient was taking Clopidogrel and undergoes a fracture.. to see if there is risk for bleeding.. test to be done is Bleeding time.. But Gold
Standard test is Throboelastogram (TEG)…

What products should be available to reverse effect of clopidogrel?… Platelets…

A patient has taken warfarin.. Emergency reversal of warfarin effect?

Prothrombin Complex Concentrates

If this is not option then second choice is FFPs.. because FFPs need to be given in large quantity.

If a patient has one day before undergoing surgery.. the Vit K should be administered one day before and PCCs shoud be available intraoperative.

Antidote for Therapeutic Enoxaparin?

FFPs
 4- Cardiac interventions:
Balloon Angioplasty, Bare metal stenting, Drung Eluting stenting

Bare metal stenting: Clopidogrel to be used minimum 6 weeks

Balloon Angioplasty: Clopidogrel minimum 3 weeks

Drug Eluting stenting: Two generations… 1st generation 12 months, 2nd Generation.. 6 months use of clopidogrel before discontinuing.

Door to needle time: entering hospital till Thrombolytics therapy: <60min

Door to balloon time: entering hospital till PCI/balloon inflation: <90 min

Cardiac pt:

Acute Coronary Syndrome: Chest pain along with ECG changes along with raised cardiac enzymes is called Acute Coronary Syndrome.

Types of angina:

1. Stable: Pain with exertion

Rx: MONA Morphine, Oxygen, Nitrate, Aspirin

2. Unstable: Change in character / nature/ duration of stable angina

Rx: MONA

3. Prinzmetal: Spasmodic contractions of coronary vessels

Rx: Calcium channel blockers (nifedipine)

Pt with heart problem, which meds to stop and which to continue

1. B blockers: Continue

If not on it, don’t start acutely. At least 1 week on B blockers before surgery (otherwise worst outcomes)

2. Nitrates/ Calcium channel blockers/ Statins: Continue

3. ARBs/ ACEIs:

a) High fluid shift expected, stop them 48hrs pre-op. Can cause intra op refractory hypotension (which means a hypotension that is not responsive
to Vasopressors)

b) Generally, in hypertensive pt, should be stopped. If ventricular dysfunction then can be continued if hypotension not expected

Anxiolytics (alprazolam 0.5mg PO night before surgery) to avoid tachycardia

Cardiac pt, Intubation not mandatory, better put LMA.

Methods to Blunt Laryngoscopic Response:

1st best is Esmolol 0.5mg/kg/min infusion or stat 30sec before intubation

2. Remifentanyl: 0.5mic/kg/min infusion

3. Lidocaine: 1.5mg/kg stat 30 sec before intubation

4. Propofol 0.5mg/kg stat 30 sec before

5. Alfentanyl: 20-30 mic/kg stat 60 sec

Most important factor to be controlled intra op for IHD pt:

Avoiding tachycardia

Other factors:

Good analgesia

Hb more than 9

Esmolol during Intubation and extubation

Shift to HDU/ICU post-op

Prone to have an MI: On 3rd post op day

Cardiac perfusion:

Supply:

1. LV gets blood during diastole only. In tachycardia diastole gets shorter so less blood in LV.

Increase diastolic time (avoid tachy) to inc perfusion

2. Hb>9. To increase oxygen delivery to tissues

(To increase oxygen delivery to peripheral tissues, transfuse PRBCs)

(Hb x SaO2 x 1.34) + PaO2 x 0.003

3. Coronary Perfusion Pressure = Aortic Diastolic Pressure - LVEDP (Left Ventricular end diastolic pressure)

4. Artery diameter:

Demand:

1. Heart Rate: Demand is increased in Tachycardia

2. SVR/ Afterload: If SVR inc.. demand increased

3. Dec Preload [(Venous Return) starling law] to reduce demand

4. Dec myocardial contractility to reduce demand

How to manage demand & supply if there is Intra-op M.I.?

1. Inc FiO2 to 100%

2. Reduce pain (sypathetic outflow leads to tachy, inc contractility, inc SVR)

3. Nitrates: GTN/ nitroprusside (capacitance vessels venous dilatation … venous pooling) dec preload

GTN: increases capacitance (pooling in veins, dec preload) also arterial in high doses. More recommended

Nitroprusside: Arterial Dilatation

4. Anti platelets: Clopidogrel etc

5. B blockers: dec sympathetic outflow

6. Diuretics (Ferusemide)/ CPAP in cardiac failure pt

Trop T most sens & specifc

Recent MI: Trop T; becomes detectable within 4-12 hrs , 12-24hrs peak, upto 7 days detectable

CKMB: For re-MI as its detectable for 24-48 hrs

ST elevation is seen in:

Acute MI

Prinzemetal

Brugada synd

Pericarditis
 5- Hypertension:
JNC 7 Classification of Hypertension

Table 3: Classification of blood pressure for adults

Blood Pressure SBP DBP

Classification mmHg mmHg

Normal <120 and <80

Prehypertensio 120–139 or 80–89

n

Stage 1 140–159 or 90–99

Hypertension

Stage 2 ≥160 or ≥100

Hypertension

Most common presentation of Hyertension: Primary Hypertension/Essesntial Hypertension.

Secondary HTN: Pheochromocytoma, Hyperaldosteronism, Cushings

Stage 3 >180/110

Postpone surgery on >180/110 0R if there is any end organ damage

Urgent surgery: which extra monitoring?

Urine output (autoregulation curve of chronic hypertensive pt remains towards the right) so MAP of perfusion becomes higher

Known hypertensive, how much MAP to avoid end organ damage? : 20% above or below of baseline MAP

ASA 1 pt, hypotensive anesthesia, allowable MAP: 55-60mmHg

 6- Valvular Heart Disease:
Aortic Stenosis:

Patient Presents with (SAD) Syncope, Angina, Dyspnoea

Signs:

Slow rising pulse

Murmur of Aortic stenosis is systolic (ejection systolic murmur) radiating to neck

Investigations findings:

ECG changes… ST-T wave changes, T-inversions, ST depressions or elevations

Echo: To determine valvular area in mild, moderate, severe and critical stenosis.

Normal aortic valve area is 2.5-3.5cm2

Mild 1.6-2.5cm2

Moderate 1-1.5cm2

Severe less than 1cm2

Critical less than 0.7cm2

Valvular gradient: LV pressure – Aortic pressure

If its less than 20mmHg mild

Moderate 20-50mmHg

More than 50mmHg severe

Perioperative care: If at any point of time patient has SAD elective surgery should be postponed till valves replaced. Means symptomatic patient
should undergo valve replacement before elective surgery.

Asymptomatic patient but valve gradient more than 50mmHg and major risk surgery - - valve should be replaced before Operation
Can continue with intermediate or minor surgery.

Haemodynamic goals:

• (Low) normal HR.

• Maintain sinus rhythm.
• Adequate volume loading.
• High normal systemic vascular resistance (SVR).

Patients with severe AS have a fixed cardiac output. They cannot compensate for a reduction in the SVR which results in severe hypotension,
myocardial ischaemia, and a downward spiral of reduced contractility, causing further falls in BP and coronary perfusion.

Aortic Regurgitation:

Most common cause: Rheumatic Heart Disease

Seondary cause: Connective tissue diseases like Marfan syndrome and tertiary syphilis

History: palpitations and dyspnoea.

Examination: Pulse: water hammer pulse, widened pulse pressure

3 signs:

1. Corrigan’s sign: visible neck pulsations

2. Demusset’s sign: Constant head nodding involuntary
3. Quincke’s sign: There is visible capillary pulsations in the nail bed

Murmur: Diastolic Decrescendo Murmur

CXR: Boot shaped heart

Haemodynamic goals

• High normal HR—around 90 bpm.

• Adequate volume loading.
• Low SVR.
• Maintain contractility.

Mitral Stenosis:

Commonest Cause: Rheumatic Heart Disease (rheumatic fever)

Valve area Normal: 4-6 cm2

Mild, Moderate, Severe

ECG Finding: P mitrale, Atrial Fibrillation (in all mitral valve problems)

History: Dyspnoea, hemoptysis, recurrent bronchitis

Examination: Right heart failure signs… raised JVP, hepatomegally, Acites

CXR: Straightening of left heart border due to enlarged atria

Echo: see valve area only.

Haemodynamic goals

• Low normal HR 50–70bpm. Treat tachycardia aggressively with

β-blockers.
• Maintain sinus rhythm, if possible. Immediate cardioversion if AF occurs
perioperatively.
• Adequate preload.
• High normal SVR.
• Avoid hypercapnia, acidosis, and hypoxia, which may exacerbate
pulmonary hypertension.

Mitral Regurgitation:

There is Supramaximal left ventricular ejection fraction in mitral regurgitation

Formula for regurgitant fraction: Amount of blood regurgitated in left atrium / stroke volume

Examination:

Murmur: PanSystolic murmur

Haemodynamic goals
• High normal HR.
• Adequate preload.
• Low SVR.
• Low pulmonary vascular resistance (PVR).

Neuraxial blockade is now not an absolute contraindication in stenotic valvular diseases

Aortic stenosis, mitral regurg.. systolic murmur

Aortic regurg, mitral stenosis.. diastolic murmur

Mitral stenosis and mitral regurg… atrial fibrillation

Mitral regurg, aortic regurg.. patient with hypotension… drug of choice… epinephrine or ephedrine (fast and loose.. high normal heart rate, low
SVR)

Stenotic lesions.. Slow and tight.. low normal heart rate, high normal SVR

Means for hypotension.. drug of choice.. phenylephrine

Normovolemia, nomoxia, norocarbia, avoid acidosis.

Slow and tight is needed in Tetrology of Fallot (TOF), Hypertrophic Obstructive Cardiomyopathy (HOCM), aortic/mitral stenosis… because these are
fixed cardiac out put lesions… so drug of choice will be phenylephrine.
 7- Arrhythmias:
Most common arrhythmia intra-op is Sinus Tachycardia

Tachycardia with HTN intra-op reasons  Light anesthesia, pain, thyrotoxicosis, malignant hyperthermia, pheochromocytoma, adrenaline,
ephedrine, ketamine.

Tachycardia with hypotension: reason  Hypovolemia due to blood loss, sepsis.

Sinus Bradycardia: <60/min.

Atropine first in algorithm.

Causes:

Reflexes: Vasovagal, Laparoscopic insufflations, Oculo cardiac reflex, Trigemino cardia reflex, Valsalva maneuvour.

Patient: Hypothyroidism, Hypothermia, Raised ICP, Myocardial ischemia,Sick sinus syndrome.

Drugs: B Blockers, Digoxin, Halothane (junctional bradycardia), Suxamethonium (direct Muscarinic effect on heart) Suxa causes tachycardia by
blocking autonomic ganglia in the CNS.

Management:

If some reflex is cause.. stop the stimulus.

2nd step: Atropine 0.6mg and go till 3mg maximum dose.

If not responding to Atropine.. see if taking Beta blockers or not..

If no B Blocker.. then drug of choice is Dopamine and Adrenaline.

If B Blocked.. then Glucagon, Isoprenaline, and Transcutaneous pacing.

SVT:
Narrow complex tachycardia.

If origin in atrium.. narrow complex

If origin from ventricle and not passing through AV node.. then broad complex.

If patient is having hyperlipidemia or taking Statins.. then No carotid massage or Valsalva.

Adenosine 6mg (with 20ml flush ideally via central line)  12mg  12mg

Adenosine side effect: Bronchospasm, and Transient Asystole…

If no effect from Adenosine.. then B Blocker..Metoprolol.. second choice Esmolol

Drug of choice for SVT treatment in Asthmatic patients is … Verpamil

Atrial Fibrillation:
Irregularly irregular heart rate

Causes: Mitral valve disease, Previous MI, Pericarditis, Sepsis, Thyrotoxicosis, Alcoholics.

Management: Immediate action?

If A. Fib started within 48 hours (stable patient)  DC Cardioversion.

If more than 48 hours (stable patient)  Echo first to rule out Left Atrial Clot  then decide what to do.

If patient unstable  DC cardioversion

Rate control: B Blockers (Metaprolol)

Rhythm control: Amiodarone

Beta Blockers from A to M.. other than Lahore College (Labetalol & Cavidalol) all are Cardioselective Beta Blockers.

M to Z Beta Blockers are Non selective.

Labetalol & Carvidalol are Alpha and Beta Blockers.

Amiodarone side Effects: QT prolongation, Effect on thyroid function, Pulmonary Fibrosis.

If a patient on Amiodarone comes for surgery… Pulmonary Function tests should be done in pre-op.

Broad Complex Tachycardia:

Ventricular Tachycardia

Stable: VT with pulse: Lidocaine 1.5mg/kg i.v stat second choice Amiodarone 300mg stat over 20 min, then 900 mg over next 24 hours.

Unstable: with pulse: DC Cardioversion

Unstable pulseless VT: Defibrillate.

V. Fib  Defibrillate

Difference between DC Cardioversion and Defibrillation: When R wave is at its peak, that time synchronized will deliver shock.

The purpose is that when ventricles are depolarizing (contracting) the whole ventricle will benefit from shock. During R wave the heart is more
prone to electrical activity. After R wave ventricles go to refractory phase, and there stimulation will have no effect.

SVT  50 – 100 Joules start

Unstable A. Fib and Unstable V. Tach  start with 200 J

Defibrillation is a unsynchronized random administration of shock during a cardiac cycle.

Monopolar and Bipolar.

Monopolar is single pole, it needs an exit pad as well. Chances of pacemaker disruption are more. Chances of shock are more.

Bipolar, there are two poles. Current enters through one and goes out from other. So chances of shock are less..

Monopolar causes heart muscle damage.

 Heart Blocks:
First Degree: Prolonged PR interval. More than 0.2 second

Second Degree:

Mobitz Type 1:

Progressive lengethening of PR until an atrial beat is missed.

Mobitz Type 2:

Patterned.. beat missed after few beats.

There is intermittent atrial P wave without a QRS complex.

Third Degree:

Complete dissociation of P and R wave.

Indications of Permanent Pacemaker:

3rd Degree AV Block, Bradycardia with symptoms, Post operative AV Block not expected to resolve, infranodal AV nodal block with LBBB,
symptomatic second and third degree blocks.
 8- Cardiomyopathies:
Types of Cardiomyopathies:

HOCM (Hypetrophic Obstructive Cardiomyopathy)

Restrictive Cardiomyopathy

Dilated Cardiomyopathy

Peripartum Cardiomyopathy

HOCM (Hypetrophic Obstructive Cardiomyopathy):

There is a pressure overloaded hypertrophy of left ventricle  due to which there is septal hypertrophy and dynamic outflow obstruction during
systole.

Hemodynamic Goals: We have to deal it same like a stenotic lesion or TOF patient… slow and tight…

Low normal HR, inc SVR, Normovolemia, low contractility.

Restrictive cardiomyopathy:

Can’t give anesthesia to this patient. Because heart size is decreased. Very restricted heart.

Can’t give positive pressure ventilation and no anesthesia.

Only thing that can be given is Ketamine.

Dilated Cardiomyopathy:

Avoid Anesthesia in this too.

Inotropic support of choice: Dobutamine.

Peripartum Cardiomyopathy:

A heart failure in the third trimester of pregnancy without any other cause.

Diagnostic features: its although a diagnosis of exclusion but four criteria need to be filled:

1. Heart failure developing in 3rd trimester (at end of pregnancy), or five months postpartum.
2. Absence of other causes of cardiac failure.
3. Absence of cardiac symptoms prior to pregnancy
4. Left ventricular dysfunction with EF < 45%.

Differential Diagnosis:

 Pulmonary embolism
 Amniotic Fluid embolism
 Sepsis
 MI
 DCM (Dilated Cardiomyopathy)
 Arrhythmias
 PIH (Pregnancy Induced Hypertension)
 Pre Eclampsia

Mortality Percentage: Upto 50%

Investigations:

Rule out all differentials.

Management:

Early intervention with a multi disciplinary approach which should include Cardiologist, Obstetrician, Anesthetist and Neonatologist.

Pharmacological Therapy:

If patient develops cardiomyopathy after pregnancy (within 5 months postpartum), drug of choice is ACE inhibitors.

If cardiomyopathy developed during pregnancy.. then Hydralazine, Nitrates, B bLockers.

These patients have high risk of VTE.. so prophylactic dose of LMWH is to be given.

Non Pharmacological:

Non invasive ventilation… Intubation might be required.

To support heart… IABP (Intra Aortic Balloon Pump), Left ventricle assisting devices, Heart Transplant.

The mainstay treatment is preconception counseling.

If had a peripartum cardiomyopathy in previous pregnancy and survived, Counsel the mother to avoid pregnancy as risk of peripartum
cardiomyopathy is very high in next pregnancy.

Anesthesia Managament:

Standard Obstetric Protocols.. 2 working i.v lines, standard monitoring, 2 pressors/2 depressors

Awake central line, and awake arterial line.

Aortocaval compression to be avoided at all cost.

Earliest epidural is advised to block sympathetic response.

Hemodynamic Goals:

Keep slow and loose… normal low HR, dec SVR, maintain normal contractility.

Avoid following drugs:

Oxytocin (causes tachycardia), Ergometrine (causes HTN).

Medicine to be always in hand:

Esmolol (for tachycardia), Fentanyl (for pain), Dobutamine (for reduced contractility), Milrinone (for pulmonary HTN).

To achieve uterus contraction use following instead of Oxytocin:

Carboprost, Mifipristone

Pathophysiology:

There is decreased ventricular systolic function that causes dec contractility and dec LVEF.

The compensation occurs through enlargement of left ventricle  increasing the end diastolic volume and stroke volume.

In the late part of pregnancy when the compensation fails  cardiac failure occurs.
 9- Pace Makers:
5 symbols on a pacemaker

1. Which chamber is paced: VAD (ventricle, atrium, dual) it cannot be zero.

2. Which chamber is sensed: VAD (ventricle, atrium, dual) can also be zero or none.
3. Response of pacemaker: Inhibit, Tachycardia, Dual, zero or none (TIDO)
4. Rate modulation
5. Multi site pacing

Pace make VVI

Pacing ventricle, sensing ventricle, inhibiting function

DDI

Dual pacing, dual sensing, inhibiting

Patient with sick sinus syndrome (SA node not working)

Use AOO.. (Only pace Atria…)

In pre-op of a patient with pace maker:

When

Where

Why

How

What type

Last Battery checked when?

1. Is patient pacemaker dependant… to see do ECG… see pacing spikes.. if spikes before each beat it means pt is pacemaker dependant.
2. CXR to see position of pacemaker.
3. Response has to be turned off.. i.e., inhibiting or tachycardia function.

Intra operative see:

Site of surgery

Donot use monopolar.. use Bipolar only.

Diathermy pad should be as close to surgery site as possible.

Ask surgeon to keep short bout and small currents..

Isoprenline and TPM should be available.

After surgery need to check the pacemaker.

Magnet not recommended anymore. It doesn’t work on new pacemaker.

If pacing spikes disappear during bag mask ventilation… it happens due to hypocarbia