Coronaries: Considerations

coronary (adj.)Look up coronary at Dictionary.com
c. 1600, “suitable for garlands,” from Latin coronarius “of a crown,” from corona “crown” (see crown (n.)). Anatomical use is 1670s for structure of blood vessels that surround the heart like a crown. Short for coronary thrombosis it dates from 1955. Coronary artery is recorded from 1741.

Anesthetic Considerations for Coronary Artery Disease patients, from Open Anesthesia

General:

  • avoid swings: keep normotensive (20% baseline) and baseline HR
  • Closely watch I/O EKG as 1mm ST change (+/-) for >60s = 10x cardiac event risk
  • 5 mins of hr >105 = 10x death risk p/o

Imaging/Studies

  • Assess echo, stress tests, viability studies, cath for LV fx, valve abnormalities, CAD
  • Quick Guide images: 
    Distribution of Coronary Arteries in relation to Echo Segments
    Distribution of Coronary Arteries in relation to Echo Segments

     

    echo sections
    Echo Segments and 3D View

 

Starting Off: Induce and Intubate

  • Etomidate or low dose propofol, Fentanyl + Midazolam
  • DL < 15s (be quick!)
  • if anticipate difficult intubation, consider spraying lidocaine, blocks, or iv lido prior to DL

Keep it going: Maintenance and Monitoring

  • Debate between Volatiles vs. N20 Opiate, conflicting data, use judgement
  • Volatiles depress but also provide preconditioning that is helpful
  • Short acting BB (Esmolol) not proven to help, but use judgement
  • Paralytics: Pancuronium increases BP and HR, Atracurium and miv can lower BP, Vec/Reoc/Cis neutral (though some concern about histamine with Cis, much lower than Atracurium)
  • Don’t reverse: glyco not well tolerated
  • Standard cardiac setup if high risk surgery (cardiac) or high risk pt (recent MI, CHF, unstable angina)
  • NTG good for ischemia

Finish up: Avoid hypothermia, adequate analgesia and sedation en route to ICU

 

 

 

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