so your patient has a cardiac history.ppt - weebly leeper mn, rn, cns m‐s, ccrn, faha ... •svr...

9/7/2010

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So Your Patient Has A Cardiac History

Barbara Leeper MN, RN, CNS M‐S, CCRN, FAHA

Baylor University Medical Center

Dallas, Texas

Objectives

• Discuss the clinical implications of the following cardiovascular problems during the post‐operative periodHypertension

Coronary artery disease

Heart Failure

• Outline key aspects of the nursing plan of care for these patients during the immediate post‐operative period

Prevalence of Cardiovascular Disease

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The Numbers

• Cardiovascular disease (CVD) continues to be an epidemic in this country

• Although mortality rates have declined the burden of CVD remains high

2006: 1 of every 2.9 deaths was attributable to CVD.

Lloyd-Jones D, et al. Heart Disease and Stroke Statistics 2010 Update: A Report from the American Heart Association. Circ 2009;109.

The Numbers – Risk Factors

• 33.6% of adults ≥ 20 years of age have hypertension

74,500,000 adults

Nearly equal in both gendersNearly equal in both genders

• 35,700,000 adults ≥ 20 years of age have total serum cholesterol levels 240 mg/dL16.2% of the population



• 17,200,000 have diagnosed diabetes 7.7% of the adult population

• 6,100,000 have undiagnosed gdiabetes

• Estimated 29% have pre-diabeteswith abnormal fasting glucose levels


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• 2008, among Americans 18 years of age: 23.1% of men and 18.3% of women

continued to be cigarette smokers g

• In grades 9 through 12:21.3% of male students and 18.7% of

female students reported current tobacco use



• The percentage of the nonsmoking population with detectable serum nicotine (indicating exposure to secondhand smoke) was 46 4% in 1999–2004smoke) was 46.4% in 1999 2004Those 4 to 11 years of age = 60.5%

Those 12 to 19 years of age = 55.4%


Why is this important for us to know?

Because these are the patients we care for regardless of what their primary procedure

or diagnosis may be.

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Cardiovascular Disease

Hypertension

Coronary Artery Disease

Rhythm Disturbances

Heart Failure

Hypertension ‐ Definitions

Category SBP mmHg DBP mmHg

Normal < 120 < 80

Prehypertension 120 – 139 80 – 89

Stage 1 –Hypertension

140 - 159 90 – 99

Stage 2 Hypertension

≥ 160 ≥ 100

Chobanian et al. JNC 7 Guidelines. JAMA, 2003

Hypertension

• Considered to be the most common pre‐operative morbidity and, therefore, post‐operative morbidity

• Issues• Issues

Poorly treated hypertensive patients have increased intra‐operative BP lability which can lead to post‐op complications

• Myocardial ischemia / MI

• Stroke

• Vascular issues

Duke J. Anesthesia Secrets, ed 3. St Louis: CV Mosby, 2006

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Vasodilators

• Nicardipine

Calcium channel blocker

Easy to titrate – do

• Sodium Nitroprusside

Direct vasodilator: more arterial thanEasy to titrate do

not see extreme BP fluctuations with titration

more arterial than venous

Can cause coronary steal syndrome

Indicated for hypertensive crises

Vasodilators

• Nitroglycerine:

Direct vasodilator: balanced effects on arterial and venous bed

Some cardioprotective effects

• Nifedipine (Procardia) – sublingual

FDA Block Box Warning r/t giving this for acute lowering of blood pressure

•Associated with AMI, stroke, death

Hypotension • Consider etiologies

Hypovolemia

Functional hypovolemia

Drugsugs

Medical and surgical diseases

•DKA

•Diabetes insipidus

•High output renal failure

•Bowel disease

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Coronary Artery Disease

Spectrum of CAD

Clinical Implications

• CAD is often present in younger individuals especially if diabetic

• CAD is not always associated with symptoms

f l G i i i i l ki• Careful ECG monitoring is important looking for signs of ischemia and onset of rhythm disturbances

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ST‐Segment Monitoring

ST Segment Monitoring

• Purpose:

To identify episodes of ischemia

• Many patients have silent ischemia:

Myocardial ischemia not associated with s&s

EKG ChangesST Segment

Look at ST segment 0.06‐0.08 sec. after J point

Normal ST Segment (isoelectric)

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ST‐Segment Elevation vs DepressionDepression

ST Segment Elevation

RR

TT

PP

QQ

SS

Isoelectric LineIsoelectric LineSTST

SegmentSegmentPRPR

IntervalInterval

ST Segment Depression

PP

RR

TTPP TT

QQSS

Isoelectric LineIsoelectric Line

STSTSegmentSegment

PRPRIntervalInterval

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Rhythm Strip at 0730 1/20

3 hours later

Rhythm Disturbances

Atrial Fibrillation / Flutter

Ventricular Ectopy

AV Blocks

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Ventricular Ectopy

• Identify the cause and treat

• Consider if due to:

Ischemia

Electrolyte abnormalities

AV Blocks• Commonly associated with myocardial ischemia, especially if inferior MI.

RCA provides blood supply to inferior wall of LV and to the AV node in large number of patients.

• Assess hemodynamic impact. Remember, you can not always reply of the BP. It is late indicator of hemodynamic compromise.

• Treatment: Increase the ventricular rate

Atropine

Pacemaker


• Can occur as a consequence of hypothermia

• Common with thoracic and cardiac surgical procedures

li i l i i h i di• Clinical issues assoc with impact on cardiac output:

Loss of atrial kick

Rapid ventricular response

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• Management:

Priority is to slow conduction through the AV node thereby slowing ventricular response

•Calcium channel blockers are effective•Calcium channel blockers are effective

Secondary priority it to restore sinus rhythm

•Antiarrhythmics:

– Amiodarone commonly used

– Also consider use of procainamide

Devices

Pacemakers

Implanted Defibrillators

Pacemakers

Coding System for PacemakersI Chamber Paced II. Chamber

SensedIII.Mode of Response to a Sensed Event

O = none O = none O = none

A = atriaV = ventricleD = dual

A = atriaV = ventricleD = dual

T = triggeredI = inhibitedD = dual

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Pacemakers: Nursing Implications

• Temporary or Permanent?

• What mode of pacing is being used?

I h i k d d i• Is the patient pacemaker dependent, i.e., is there an underlying rhythm?

ICDs / PCDs

• In most cases should be inactivated (turned off) prior to the patient going to surgery

• If left on….

Fentanyl reduces defibrillation thresholdsFentanyl reduces defibrillation thresholds

Pentobarbitol and enflurane increase defibrillation thresholds

• Magnets will deactivate or reprogram

• Generally, if patient develops VT or VF, stand back and allow the device to “do its thing”

Heart Failure

Spectrum of HF

Clinical Implications

Nursing Management

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Spectrum of Heart Failure

• Definition

Complex clinical syndrome

Characterized by

• Classifications

Left sided vs right sided

Backward vs forward Characterized by

• Dysfunction of RV, LV or both

• Neurohormonal changes

Backward vs forward

Acute vs chronic

Systolic vs diastolic

Compensated vs decompensated

Frank Starling Principle

• Preload = volume administration

• Stroke Volume = contractility

Neurohormonal Responses • Decreased CO leads to:

Increased sympathetic stimulation

Activation of renin‐angiotensin‐aldoesterone system

• Increased HR

•Peripheral vasoconstriction

• Increased levels of aldosterone

– Increased reabsorption of Na+ and water

• Therefore, beta blockers and ACEIs are cornerstones of therapy

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Causes of HF

• Coronary artery disease (US)

• Hypertension

• Nonischemic dilated cardiomyopathy

• Valvular heart disease

NYHA Classification

Classification Description

I Asymptomatic with normal physical activity

II Symptomatic with normal physical activity (dyspnea)

III Less than normal physical activity causes symptoms

IV Symptomatic at rest. LV EF ≤ 25%. Annual mortality rate 40%

Taking a pt with HF to surgery

• Decompensated HF are not candidates for elective procedures. However, if emergent, a PAC and arterial line may be inserted.

These are used to monitor hemodynamicThese are used to monitor hemodynamic responses to fluid therapy, anesthetic agents as well as pharmacological interventions (inotropes and vasodilators)

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Post‐op Management in HF

• Nursing plan of care should include addressing issues related to preload, afterload and contractility

Preload: volume administrationPreload: volume administration

Afterload: vasodilator therapy

Contractility: inotropic therapy

• Our responsibility is to assess the patient’s response(s) to volume and drug titration

Hemodynamic Monitoring

• Preload – Frank Starling Principle

• Afterload

Monitor with

SV LV f l d• SVR – LV afterload

•PVR – RV afterload

The higher the afterload, the harder the heart has to work

Increases myocardial oxygen demands

May result in reduced myocardial contractility

Post‐op Fluid Management In Patients With HF

• Why give volume? To optimize the preload status of the ventricle

• Traditionally monitor “filling pressures”

RAP/CVP f RV l dRAP/CVP for RV preload

PAD/PAWP for LV preload

• However, current evidence does not support the reliability of these parameters indicating the preload status of the patient, regardless of the clinical situation.

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Post‐op Fluid Management

• How to monitor preload responsiveness

Use of SVV – stroke volume variation

• If < 13% ‐ Patient is not fluid responsive

• If > 13% patient is likely to be fluid responsive• If > 13% ‐ patient is likely to be fluid responsive

• The real issue in this group of patients is to monitor the rate of infusions, particularly those who use standard orders, i.e., 1000 mL D5/RL, infuse at 125 mL/hour

Other Considerations in HF• HF patients are more sensitive to the myocardial depressant effects of many of the anesthetic agents, especially

Propofol

Barbituates

Etomidate – has fewer effects

Ketamine may increase the HR and BP due to sympathetic effects although in patients with high SNS activity already, this drug can depress myocardial contracility

Duke J. Anesthesia Secrets, ed 3, St Louis: CV Mosby, 2006

Beta Blockers

Reduction of Perioperative CardiacReduction of Perioperative Cardiac Events

Fleischmann KE, et al. 2009 ACCF/AHA focused update on perioperative beta blockade. A report of the American College of Cardiology Foundation / American Heart Association Task Force on Practice Guidelines. Circulation 2009;109.

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Beta Blockers

• Evidence for reduction of perioperative ischemia

• May reduce risk of MI and cardiovascular death in high risk patients

.

Beta Blockers:Clinical Risk Factors

• History of:

Ischemic heart disease

C t d i h t f ilCompensated or prior heart failure

Cerebrovscaular disease

Diabetes mellitus

Renal insufficiency (pre‐op se creatinine >2mg/dL)

Fleishmann KE, et al. Circ, 2009;109

Which Patients / Procedures

• Patients who are having surgery and are receiving beta blockers for angina, symptomatic arrhythmias or hypertension

• Patients undergoing vascular surgery who arePatients undergoing vascular surgery who are at high risk determined by presence of ischemia on pre‐op testing

• Several RCTs demonstrate significant reductions in peri‐operative cardiac death associated with the administration of beta blockers Fleishmann KE, et al. Circ, 2009;109

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Risks and Caveats• Low heart rates (may drop to the 40’s)

• Hypotension (BP < 90mmHg)

• Heart failure

• “Initiation well before a planned procedure with careful titration perioperatively to achieve HR control while avoiding frank bradycardia and hypotension is recommended.”

• “Routine administration of peri‐operative beta blockers in higher fixed dose regimens is not recommended.

Fleishmann KE, et al. Circ, 2009;109

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