Anestesi Pada Pasien Dengan Anestesi Pada Pasien Dengan Penyakit Sistem Kardiovaskular Penyakit Sistem Kardiovaskular

Departemen Anestesiologi dan Terapi Intensif Departemen Anestesiologi dan Terapi Intensif Fakultas Kedokteran Fakultas Kedokteran

Universitas Sumatera UtaraUniversitas Sumatera UtaraMedanMedan20122012

Clinical Predictors of Increased Clinical Predictors of Increased Perioperative Cardiovascular RiskPerioperative Cardiovascular Risk (myocardial infarction, heart failure, death)(myocardial infarction, heart failure, death)

MajorMajor Unstable coronary syndromesUnstable coronary syndromes - Acute of recent MI with evidence of important ischemic - Acute of recent MI with evidence of important ischemic by clinical symptoms or noninvasive study by clinical symptoms or noninvasive study - Unstable of severe angina (Canadian class III and IV)- Unstable of severe angina (Canadian class III and IV) Decompensated heart failureDecompensated heart failure Significant arrythmiasSignificant arrythmias - High-grade atrioventricular block- High-grade atrioventricular block - Symptomatic ventricular arrythmias is the presence of - Symptomatic ventricular arrythmias is the presence of underlying heart diseaseunderlying heart disease - Supraventricular arrythmias with uncontrolled ventricular rate- Supraventricular arrythmias with uncontrolled ventricular rate Severe valvular diseaseSevere valvular disease

Clinical Predictors of Increased Clinical Predictors of Increased Perioperative Cardiovascular RiskPerioperative Cardiovascular Risk (myocardial infarction, heart failure, death)(myocardial infarction, heart failure, death)

IntermediateIntermediate Mild angina pectoris (Canadian class I or II)Mild angina pectoris (Canadian class I or II) Previous MI by history of pathological Q wavesPrevious MI by history of pathological Q waves Compensated or prior heart failureCompensated or prior heart failure Diabetes mellitus (particularly insulin dependent)Diabetes mellitus (particularly insulin dependent) Renal insufficiencyRenal insufficiency

Clinical Predictors of Increased Clinical Predictors of Increased Perioperative Cardiovascular RiskPerioperative Cardiovascular Risk (myocardial infarction, heart failure, (myocardial infarction, heart failure, death)death) MinorMinor Advanced ageAdvanced age Abnormal ECG (left ventricular hypertrophy, left Abnormal ECG (left ventricular hypertrophy, left

bundle branch block, ST-T bundle branch block, ST-T abnormalities)abnormalities) Rhythm other than sinus (eg, atrial fibrillation)Rhythm other than sinus (eg, atrial fibrillation) Low Functional capacity (eg, inability to climb one Low Functional capacity (eg, inability to climb one

flight of stairs with a bag of flight of stairs with a bag of groceries)groceries) History of strokeHistory of stroke Uncontrolled systemic hypertensionUncontrolled systemic hypertension

Shortcut to noninvasive testing Shortcut to noninvasive testing in preoperative patients in preoperative patients if any two factors are presentif any two factors are present

1.1. Intermediate clinical predictors are present Intermediate clinical predictors are present (Canadian class I or II angina, prior MI based (Canadian class I or II angina, prior MI based on history of pathological Q waves, on history of pathological Q waves, compensated or prior heart failure, or compensated or prior heart failure, or diabetes)diabetes)

2.2. Poor functional capacity (less than 4 METs)Poor functional capacity (less than 4 METs)3.3. High surgical risk procedure (emergency High surgical risk procedure (emergency

major operations, aortic repair or peripheral major operations, aortic repair or peripheral vascular surgery, prolonged surgical vascular surgery, prolonged surgical procedures with large fluid shifts of blood procedures with large fluid shifts of blood lossloss))

Cardiac risk stratifaction for Cardiac risk stratifaction for noncardiac surgical proceduresnoncardiac surgical proceduresHighHigh (reported cardiac risk often greater than 5%) (reported cardiac risk often greater than 5%)

- Emergent major operations, particularly in the elderly- Emergent major operations, particularly in the elderly - Peripheral vascular surgery- Peripheral vascular surgery - Anticipated prolonged surgical procedures associated - Anticipated prolonged surgical procedures associated with large fluid shift and/or blood losswith large fluid shift and/or blood lossIntermediate Intermediate (reported cardiac risk generally les than 5%)(reported cardiac risk generally les than 5%) - Carotid endarterectomy- Carotid endarterectomy - Head and neck surgery- Head and neck surgery - Prostate surgery- Prostate surgeryLow Low (reported cardiac risk generally less than 1%)(reported cardiac risk generally less than 1%) - Endoscopic procedures- Endoscopic procedures - Superficial procedure- Superficial procedure - Cataract surgery- Cataract surgery - Breast surgery - Breast surgery

25 – 50% kematian setelah pembedahan 25 – 50% kematian setelah pembedahan non jantung disebabkan komplikasi non jantung disebabkan komplikasi kardiovaskuler. Perioperatif Infark Miokard kardiovaskuler. Perioperatif Infark Miokard (IM), Edema Pulmonal, Gagal Jantung (IM), Edema Pulmonal, Gagal Jantung Kongestif (GJK), Aritmia dan Tromboemboli Kongestif (GJK), Aritmia dan Tromboemboli adalah yang paling sering tampak pada adalah yang paling sering tampak pada pasien dengan dengan penyakit pasien dengan dengan penyakit kardiovaskuler sebelumnya.kardiovaskuler sebelumnya.

Insiden kardiogenik pulmonari edema post Insiden kardiogenik pulmonari edema post operative sekitar 2% pada pasien-pasien operative sekitar 2% pada pasien-pasien dengan usia diatas 40 tahun, 6% pada dengan usia diatas 40 tahun, 6% pada pasien-pasien dengan riwayat gagal pasien-pasien dengan riwayat gagal jantung dan 16% pada pasien dengan jantung dan 16% pada pasien dengan poorly compensated heart failure.poorly compensated heart failure.

PRE OPERATIVE PRE OPERATIVE MANAGEMENTMANAGEMENT

- Riwayat penyakit, pemeriksaan fisik dan EKG harus Riwayat penyakit, pemeriksaan fisik dan EKG harus difokuskan untuk mengidentifikasi potensi terjadinya difokuskan untuk mengidentifikasi potensi terjadinya kardiovaskuler yang serius (CAD, CHF, Aritmia)kardiovaskuler yang serius (CAD, CHF, Aritmia)

- Bila ditemukan penyakit kardiovaskuler maka perlu Bila ditemukan penyakit kardiovaskuler maka perlu ditentukan resiko kardiak adalah evaluasi dasar yang meliputi ditentukan resiko kardiak adalah evaluasi dasar yang meliputi keadaan umum, usia, kelas fungsional, fakta resiko kardiak, keadaan umum, usia, kelas fungsional, fakta resiko kardiak, kormodibitas penyakit lain (diabetes mellitus, gangguan kormodibitas penyakit lain (diabetes mellitus, gangguan fungsi ginjal, penyakit vaskular perifer dan penyakit paru fungsi ginjal, penyakit vaskular perifer dan penyakit paru kronik) dan jenis operasi kronik) dan jenis operasi

- Bila perlu dapat dilakukan pemeriksaan transthoracic Bila perlu dapat dilakukan pemeriksaan transthoracic echocardiography (TTE) yang dapat membantu evaluasi echocardiography (TTE) yang dapat membantu evaluasi resiko perioperative komplikasi kardiak yang berat resiko perioperative komplikasi kardiak yang berat

Oxygen delivery = Cardiac output x Arterial oxygen contentOxygen delivery = Cardiac output x Arterial oxygen content

Stroke volume x Heart rateStroke volume x Heart rate Hemoglobin x Arterial Hemoglobin x Arterial oxygen oxygen saturationsaturation

PreloadPreload AfterloadAfterload ContractilityContractility

INTRAOPERATIVE MANAGEMENTIntraoperative Predictors for PCM Intraoperative Predictors for PCM (Perioperative Cardiac Morbidity)(Perioperative Cardiac Morbidity)

- - Diantara predictor intraoperative klasik, pembedahan Diantara predictor intraoperative klasik, pembedahan emergensi, pembedahan vaskular besar dan operasi lebih emergensi, pembedahan vaskular besar dan operasi lebih dari 3 jam pada pembedahan abdominal atas atau torakdari 3 jam pada pembedahan abdominal atas atau torak

- Diantara prediktor dinamik, hipotensi dan takhikardi Diantara prediktor dinamik, hipotensi dan takhikardi memprediksi PCMmemprediksi PCM

- Sedanngkan hipertensi masih merupakan prediktor yang Sedanngkan hipertensi masih merupakan prediktor yang kontroversialkontroversial

- Myocardial iskemia diduga sebagai prediktorMyocardial iskemia diduga sebagai prediktor- LV end-diastolic pressure adalah pengukur yang sensitif LV end-diastolic pressure adalah pengukur yang sensitif

pada iskemiapada iskemia

Mangano DT. Perioperative cardiac morbidity. Mangano DT. Perioperative cardiac morbidity. Anesthesiology 1990;72:153-184Anesthesiology 1990;72:153-184

Monitor the PatientMonitor the Patient

- EKG: simultaneous leads VEKG: simultaneous leads V55 and II, multiple-lead ST-segment and II, multiple-lead ST-segment analysis if availableanalysis if available

- Blood pressure: noninvasive automatic Doppler Blood pressure: noninvasive automatic Doppler sphygmomanometric techniquesphygmomanometric technique

- Pulse oximeter for arterial oxygenation Pulse oximeter for arterial oxygenation - Temperature: esophagealTemperature: esophageal- Swan-Ganz catheter: PCWP, pulmonary artery diastolic pressure Swan-Ganz catheter: PCWP, pulmonary artery diastolic pressure

(PADP), hemodynamic study only for patients with ventricular (PADP), hemodynamic study only for patients with ventricular dysfunctiondysfunction

- Central venous pressure (CVP) line: if the patient has good LV Central venous pressure (CVP) line: if the patient has good LV functionfunction

- Foley catheter: urine outputFoley catheter: urine output- Oxygen analyzer for inspired gas mixtureOxygen analyzer for inspired gas mixture- End-tidal COEnd-tidal CO2 2 analyzeranalyzer

INTRAOPERATIVE MANAGEMENTINTRAOPERATIVE MANAGEMENT

Hemodynamic Hemodynamic MonitoringMonitoring

Hemo = Blood (Darah)Hemo = Blood (Darah) Dynamic = Flow (Aliran)Dynamic = Flow (Aliran) Parameter Utama:Parameter Utama:

– Invasive Blood Pressure (IBP) – tekanan darah yang Invasive Blood Pressure (IBP) – tekanan darah yang diukur diukur

– Cardiac Output – jumlah darah yang dipompa per Cardiac Output – jumlah darah yang dipompa per menitmenit

– Contractility – kecepatan dan kekuatan kontraksi Contractility – kecepatan dan kekuatan kontraksi – Vascular Resistance – hambatan aliran darahVascular Resistance – hambatan aliran darah– Fluid Level – jumlah cairan dalam tubuh/pembuluh Fluid Level – jumlah cairan dalam tubuh/pembuluh

darahdarah

OVERVIEW OF FACTORS AFFECTING TISSUE PERFUSSIONOVERVIEW OF FACTORS AFFECTING TISSUE PERFUSSION

MYOCARDIAL CONTRACTILITYMYOCARDIAL CONTRACTILITY

PRE-LOADPRE-LOAD AFTER-LOADAFTER-LOAD

STROKE VOLUMESTROKE VOLUME HEART RATEHEART RATE

CARDIAC OUTPUTCARDIAC OUTPUT PERIPHERAL RESISTANCEPERIPHERAL RESISTANCE

BLOOD PRESSUREBLOOD PRESSURE

TISSUE PERFUSSIONTISSUE PERFUSSION

VOLUME

DIAMETER

VISCOSITAS

PRINSIP UMUMPRINSIP UMUM Sensor harus mendeteksi signal secara Sensor harus mendeteksi signal secara

akuratakurat Monitoring tidak pernah sebagai Monitoring tidak pernah sebagai

terapeutikterapeutik Evaluasi resiko – keuntungan Evaluasi resiko – keuntungan

menggunakan monitormenggunakan monitor Monitoring adalah suatu tim prosesMonitoring adalah suatu tim proses

Artery LineArtery Line

Pengukuran langsung tekanan darahPengukuran langsung tekanan darah Teknik lebih akuratTeknik lebih akurat Informasi hemodinamik kontinyuInformasi hemodinamik kontinyu Pengambilan multipel sampel arteriPengambilan multipel sampel arteri

Pada Kondisi apa perlu Pada Kondisi apa perlu pengukuran invasive pengukuran invasive arterial pressure ?arterial pressure ?

Akut hipertensi atau perdarahanAkut hipertensi atau perdarahan Cirulatory or cardiac arrestCirulatory or cardiac arrest Hipertensi krisisHipertensi krisis SepsisSepsis Neurologik injuriNeurologik injuri Komplikasi post operasiKomplikasi post operasi Pasien dengan vasoactive drugsPasien dengan vasoactive drugs Pasien membutuhkan pemeriksaan analisa Pasien membutuhkan pemeriksaan analisa

gas darah yang seringgas darah yang sering

Haemodynamic MonitoringHaemodynamic Monitoring

INVASIVENON INVASIVE

Non InvasiveNon Invasive PalpationPalpation Doppler ProbeDoppler Probe AuscultationAuscultation OscillometryOscillometry Arterial tonometryArterial tonometry

20 cm

115

110

100

Aneroid gauge

Brachial artery

Radial artery

Doppler probe

Doppler

Air chamber

PressureElement of pressure sensor

Artery Wall

Sensor

InvasiveInvasive Arterial CatheterArterial Catheter Central Venous CatheterCentral Venous Catheter for pressure monitoring, volume for pressure monitoring, volume

replacement, or central drug infusionreplacement, or central drug infusion Pulmonary Artery (Swan-Ganz) Pulmonary Artery (Swan-Ganz)

CatheterCatheter

PemakaianPemakaianHemodynamic MonitoringHemodynamic Monitoring

Banyak dibutuhkan di Critical Care dan Banyak dibutuhkan di Critical Care dan SurgerySurgery

Fungsi:Fungsi:– Memantau kondisi jantung pasienMemantau kondisi jantung pasien– Menentukan perawatan yang akan diambilMenentukan perawatan yang akan diambil

Dilakukan oleh dokter AnesthesiDilakukan oleh dokter Anesthesi Menggunakan Swan-GanzMenggunakan Swan-Ganz Parameter yang dibaca: PAW & TD COParameter yang dibaca: PAW & TD CO

Tujuan Monitoring Tujuan Monitoring Hemodinamik InvasifHemodinamik Invasif

Memberi informasi kuantitatifMemberi informasi kuantitatif Homeostasis fisiologis ada atau tidakHomeostasis fisiologis ada atau tidak Mendapatkan peringatan “dini” Mendapatkan peringatan “dini”

perubahan status pasienperubahan status pasien Intervensi terapeutik adekuat/ tidak Intervensi terapeutik adekuat/ tidak

dan benar/ kelirudan benar/ keliru

Penggunaan Pulmonary Artery Penggunaan Pulmonary Artery Catheter (PAC)Catheter (PAC)

- Diperkirakan terjadi peningkatan fluid shiftsDiperkirakan terjadi peningkatan fluid shifts- CHF akibat komplikasi MICHF akibat komplikasi MI- Pada CAD yang signifikan yang menjalani prosedur Pada CAD yang signifikan yang menjalani prosedur

yang berhubungan dengan stress hemodinamik yang berhubungan dengan stress hemodinamik yang signifikan ; dan pada sistolik dan diastolik LV yang signifikan ; dan pada sistolik dan diastolik LV disfunction, cardiomiopaty dan valvular disease disfunction, cardiomiopaty dan valvular disease yang menjalani operasi dengan resiko tinggi yang menjalani operasi dengan resiko tinggi

INTRAOPERATIVE INTRAOPERATIVE MANAGEMENTMANAGEMENT

Eagle KA, Berger PB, Calkins H, Anesth Analg 2002;94:1052-1064Eagle KA, Berger PB, Calkins H, Anesth Analg 2002;94:1052-1064

Alat yang selama ini Alat yang selama ini dipakaidipakai Pulmonary Artery Pulmonary Artery

Catheter:Catheter:– Swan Ganz / Right Swan Ganz / Right

Heart CatheterHeart Catheter– Sudah sejak >25 Sudah sejak >25

tahuntahun– Parameter:Parameter:

PA PressurePA Pressure PA Wedging (PAOP)PA Wedging (PAOP) CO/CICO/CI

Lumen pada Swan-Lumen pada Swan-GanzGanz

Suntikan untuk membuka balon

Kabel ThermistorBalon

Lumen:1. Distal: mengukur pressure2. Proximal: Injeksi cairan3. Middle: pemberian obat

Lokasi Thermistor

Lubang Proximal

Lubang Distal

Cara pemasanganCara pemasangan Masuk dari vena leher Masuk dari vena leher

(Jugular) atau (Jugular) atau selangkangan (femoral)selangkangan (femoral)

Dorong Catheter di Dorong Catheter di jantung kananjantung kanan

Keluar dari RV ke Keluar dari RV ke pembuluh utama pembuluh utama sebelum paru-paru sebelum paru-paru (Pulmonary Artery)(Pulmonary Artery)

Injeksi cairan (dingin), Injeksi cairan (dingin), thermistor mengukur thermistor mengukur perubahan suhu darah perubahan suhu darah terhadap waktu terhadap waktu (Thermodilution)(Thermodilution)

Pemasangan Swan-Ganz Pemasangan Swan-Ganz ke Monitorke Monitor

Tampilan di MonitorTampilan di MonitorMONITORED: CO 6.9

HR 70

MAP 86

CVP 10

PAM 18

PAW 12

WEIGHT 75.0

HEIGHT 168.0

CALCULATED:

BSA 1.85

CI 3.7

SV 98.6

SVR 88.0

SVRI 1626

PVR 69

PVRI 128

LVSWI 53.7

RVSWI 5.8

Tetapi tidak semua monitor bisa menghitung seperti ini!Tetapi tidak semua monitor bisa menghitung seperti ini!

Keunggulan Swan Keunggulan Swan GanzGanz Sudah populerSudah populer Bisa mengukur Pressure PA Bisa mengukur Pressure PA

Wedging (PAW/PAOP)Wedging (PAW/PAOP) Pemberian obat langsung ke Pemberian obat langsung ke

jantung (melalui Middle Lumen ke jantung (melalui Middle Lumen ke jantung kanan)jantung kanan)

Paling AkuratPaling Akurat

Kelemahan Swan GanzKelemahan Swan Ganz Pemasangan sulit, Pemasangan sulit,

tergantung skilltergantung skill Data yang di baca tidak Data yang di baca tidak

continuous (hanya continuous (hanya pada saat injeksi pada saat injeksi cairan)cairan)

Posisi di dalam jantung Posisi di dalam jantung (RA & RV)(RA & RV)

Parameter: CO/CI, PA Parameter: CO/CI, PA pressure, PAW pressurepressure, PAW pressure

Tidak semua orang Tidak semua orang bisa memasangbisa memasang

Terlambat memberikan Terlambat memberikan perawatan tepat perawatan tepat karena kurang data karena kurang data dan tidak updatedan tidak update

Jika terlalu lama bisa Jika terlalu lama bisa menyebabkan aritmiamenyebabkan aritmia

Kebutuhan sekarang Kebutuhan sekarang lebih banyak lebih banyak parameterparameter

LOW LOW PRELOADPRELOAD

HypoperfusionHypoperfusion

RAP or CVP < 6 mmHgRAP or CVP < 6 mmHgPAW or LA pressure < 8 mmHg in patient without PAW or LA pressure < 8 mmHg in patient without cardiac dysfunction, or < 18 mmHg in patient with cardiac dysfunction, or < 18 mmHg in patient with cardiac dysfunctioncardiac dysfunction

Administration of fluid in attempt to increased Administration of fluid in attempt to increased circulating volume circulating volume IV fluid challenges of 100 to IV fluid challenges of 100 to 250 ml crystalloid solution should be administrered 250 ml crystalloid solution should be administrered over 10 minute until evidence of improved perfusion over 10 minute until evidence of improved perfusion occurs.occurs.

HIGH HIGH PRELOADPRELOAD

Left-side filling pressure ↑ Left-side filling pressure ↑ pulmonary venous pressure pulmonary venous pressure becomes higher than colloid osmotic pressure surrounding the becomes higher than colloid osmotic pressure surrounding the vasculature vasculature causes fluid to be driven from the vasculature causes fluid to be driven from the vasculature and into surrounding interstitial or interalveolar spaces and into surrounding interstitial or interalveolar spaces

dyspneadyspnea PAW > 20 -22 mmHg PAW > 20 -22 mmHg hypoperfusionhypoperfusion PAW > 30 mmHg PAW > 30 mmHg

Cardiogenic pulmonary edemaCardiogenic pulmonary edema

Oxygen uptake ↓ Oxygen uptake ↓ hypoxemia with increased oxygen delivery hypoxemia with increased oxygen deliveryHigh ventricular end diastolic pressure (measured by PAWP) High ventricular end diastolic pressure (measured by PAWP)

decreased coronary collateral blood flowdecreased coronary collateral blood flow

Therapy Therapy Diuretics and Ventilator Diuretics and Ventilator

Low

car

diac

Out

put

sym

ptom

s

Car

diac

out

put (

L/m

in/m

2)

normal

Heart failure

Nitropruside and dopamine

NitroprusidePhentolamineDigitalis

Diuretics nitrates

Pulmonary congestion

Left ventricular end diastolic pressure (mmHg)

Ventricular function curves depicting effects of various agents used for treating heart failure. Diuretics and nitrates lower filling pressure along the same curve and have little action on forward cardiac output. Positive inotropic agents and arterial vasodilators shift the ventricular function curve upward and to the left, increasing cardiac output for any left ventricular end-diastolic pressure. The combination of an arterial vasodilator and a positive inotropic agents (e.g, nitropruside and dopamine or amrinone) can augment cardiac output and lower filling pressure to a greater extent.

AFTERLOAAFTERLOADD

Left ventricle Left ventricle SVR SVR vasoconstrictionvasoconstriction

Right ventricleRight ventricle PVR PVR vasodilatationvasodilatation

Myocardial Vein oxygen Myocardial Vein oxygen consumption (MVoconsumption (MVo22))

Relation ship between stroke volume and wall tension (i.e., afterload) for the intact left ventricle. At constant preload, increase in wall tension result in a decline in stroke volume. Increased preload or increased contractility shifts the curve upward and to right, resulting in a greater stroke volume for any given afterload.

Wall tension

Sto

ke

volu

me

LOW LOW AFTERLOADAFTERLOAD

Pressure = Flow x ResistancePressure = Flow x ResistanceSVR ↓ SVR ↓ severe hypotension severe hypotension

inadequate coronary artery perfusioninadequate coronary artery perfusionVasopressor Vasopressor vasoconstriction secondary to vasoconstriction secondary to stimulation of stimulation of alpha receptors in alpha receptors in vascular smooth musclevascular smooth muscle

Phenylephrine, Phenylephrine, metaraminol, metaraminol, norepinephrine, norepinephrine, ββ1-stimulating properties1-stimulating propertiesephedrine, ephedrine, dopamine (> 10 to 20 dopamine (> 10 to 20 µµg/kg/min)g/kg/min)

HIGH HIGH AFTERLOADAFTERLOAD

CO ↓CO ↓ Symphatetic stimulation cause arterial Symphatetic stimulation cause arterial BP ↓ BP ↓ vasoconstriction to maintain blood pressurevasoconstriction to maintain blood pressure

Stroke volume ↑Stroke volume ↑MV0MV02 2 ↓↓

Arteriovasodilators Arteriovasodilators smooth muscle relaxant smooth muscle relaxant activate activate ββ2 adrenergic 2 adrenergic receptor in the smooth muscle of the arterioles receptor in the smooth muscle of the arterioles (hydralazine, nitroprusside, nitroglycerine)(hydralazine, nitroprusside, nitroglycerine) Calcium channel blockersCalcium channel blockers Alpha blockersAlpha blockers Angiotensin converting enzyme (ACE) inhibitorsAngiotensin converting enzyme (ACE) inhibitors CounterpulsationCounterpulsation

CONTRACTILITCONTRACTILITYY

Decreased contractility associated with reduced Decreased contractility associated with reduced ejection can occur with :ejection can occur with :- Hypovolemia- Hypovolemia- Myocardial ischemia- Myocardial ischemia- Infraction- Infraction- Certain pharmacologic and anesthetic agents- Certain pharmacologic and anesthetic agents

Increases in inotropism may be necessary to Increases in inotropism may be necessary to maintain adequate stroke volume and oxygen maintain adequate stroke volume and oxygen deliverydelivery

In patient with ischemic heart disease In patient with ischemic heart disease increase increase in MVoin MVo22 that accompanies increased contractilitythat accompanies increased contractility

DECREASED DECREASED CONTRACTILITYCONTRACTILITY

Studies by Shoemaker et.al. have shown that Studies by Shoemaker et.al. have shown that maintenance of a stroke work index of the left ventricle maintenance of a stroke work index of the left ventricle > 55 g-m/beat is associated with improved survival in > 55 g-m/beat is associated with improved survival in the shock patients.the shock patients.

Improvement in myocardial contractility can be Improvement in myocardial contractility can be obtained with the use of :obtained with the use of : - Inotropic agents catecholamins - Inotropic agents catecholamins (dopamine, dobutamine, isoproterenol, epinephrine)(dopamine, dobutamine, isoproterenol, epinephrine) increased adenosine 3increased adenosine 3’’:5:5’’-cyclic phosphate (cyclic -cyclic phosphate (cyclic AMP)AMP) - Phosphodiesterase inhibitors (amrinone and - Phosphodiesterase inhibitors (amrinone and milrinone)milrinone) inhibits the breakdown of cyclic AMP into its inactive inhibits the breakdown of cyclic AMP into its inactive form form

INCREASED INCREASED CONTRACTILITYCONTRACTILITY

Increase in oxygen demandIncrease in oxygen demand

Beta blockers Beta blockers inhibits inhibits stimulation of stimulation of ββ1 adrenergic 1 adrenergic receptors in the myocardium receptors in the myocardium (cardioselective) and (cardioselective) and ββ2 2 adrenergic receptors in the smooth adrenergic receptors in the smooth muscle in the arterioles of the lung muscle in the arterioles of the lung (nonselective)(nonselective)

HEART HEART RATERATE

CO = Stroke volume (SV) x Heart rate (HR)CO = Stroke volume (SV) x Heart rate (HR)

HR > 120 bpm may associated with decreased HR > 120 bpm may associated with decreased in SV and CO because of decreased diastolic in SV and CO because of decreased diastolic filling time of the left ventriclefilling time of the left ventricle

HR with shortened diastolic duration also HR with shortened diastolic duration also decrease left ventricle coronary perfuasion decrease left ventricle coronary perfuasion time and increased MVotime and increased MVo2 2 causing imbalance causing imbalance between myocardial oxygen supply and between myocardial oxygen supply and demanddemand

HEART HEART RATERATE

Beta blocker Beta blocker reduce chronotropism reduce chronotropism and calcium channel blockers to and calcium channel blockers to decrease conductiondecrease conduction

Bradycardia with the heart rate of < Bradycardia with the heart rate of < 50 bpm 50 bpm CO ↓ and tissue perfusion CO ↓ and tissue perfusion ↓↓

Therapy Therapy Atropine Atropine Pace makerPace maker

HEMOGLOBINHEMOGLOBIN Abnormal reduction of hemoglobin can Abnormal reduction of hemoglobin can

improve a significans threat to tissue improve a significans threat to tissue oxygenation has much as aproximatelly oxygenation has much as aproximatelly 98 % of the oxygen is carried by the 98 % of the oxygen is carried by the hemoglobin molecules.hemoglobin molecules.

Abnormally high hemoglobin Abnormally high hemoglobin concentration can increase cardiac out concentration can increase cardiac out put secondary to increased viscosityput secondary to increased viscosity

Arterial Oxygen Arterial Oxygen Saturation Saturation SaOSaO2 2 can be maintaine at norma can be maintaine at norma

levellevel ( >97 % ) with :( >97 % ) with :

IncreasedIncreasedPEEPPEEPCPAPCPAPACMOACMO

(Afterload)SVR/PVR

(Preload)PAW/LA/RA

(Contractility)LVWSI/RVWSI

Heart rate

Arterial oxygen saturation

Hemoglobin

Too High

Too High

Too High

Too High

Too High

Too High

Too Low

Too Low

Too Low

Too Low

Too Low

Too Low

Calcium antagonistsArterial vasodilatos

IABPAlpha blockersACE inhibitors

DiureticsVenous vasodilators

Beta blockersIABP

Calcium antagonist

Beta blockersCalcium antagonist

Vasopressors

Vasopressors

Positive inotropicsVentricular

ossist devices

Pacemaker Atropine

↑ FiO2PEEP/CPAP

Hyperbaric oxygenationECMO

Blood productHb solution

Hemodynamic effects of commonly used cardiovascular Hemodynamic effects of commonly used cardiovascular drugsdrugs

DrugsDrugs HRHR AfterloaAfterloadd

ContractiliContractilityty

PreloaPreloadd

ComentsComents

INOTROPIC INOTROPIC AGENTSAGENTSDigoxinDigoxinDopamineDopamine

DobutamineDobutamineIsoproterenolIsoproterenolNorepinephriNorepinephrineneEpinephrineEpinephrineMethoxamineMethoxamineAmrinone/ Amrinone/ milrinonemilrinone

- or ↓or ↓± or ± or

↑↑

- or ↑- or ↑↑↑↑↑↑ ↑ or or

↓↓↑ ↑↑ ↑

--- or ↑- or ↑

±±- or ↑- or ↑

±±↓ ↓↓ ↓↑ ↑↑ ↑

↑ ↑ or ↓or ↓↑↑↑↑↓ ↓

↑↑↑↑↑↑

↑↑↑↑↑ ↑↑ ↑↑↑

↑↑↑↑--↑↑

-- ↑ ↑ or or

↓↓

↓↓↓↓↑↑↑ ↑ ↑ ↑ ↓↓

↓ ↓ Ventricular rate in AFVentricular rate in AFEffect on SVR is dose Effect on SVR is dose dependent; ↑ renal dependent; ↑ renal blood flowblood flow

Can cause dysrythmiasCan cause dysrythmiasCan cause dysrythmiasCan cause dysrythmiasCan cause dysrythmiasCan cause dysrythmias

Hemodynamic effects of commonly used cardiovascular Hemodynamic effects of commonly used cardiovascular drugsdrugs

DrugsDrugs HRHR AfterloaAfterloadd

ContractiliContractilityty

PreloadPreload ComentsComents

ANALGESIC ANALGESIC AGENTSAGENTSMorphineMorphine

DIURETICSDIURETICS(furosemide,(furosemide,ethacrynic acid, ethacrynic acid, bumetanide)bumetanide)

ANTIDYSRHYTHMIANTIDYSRHYTHMIC AGENTSC AGENTSLidocaineLidocaineProcainamideProcainamideQuinidineQuinidineAtropineAtropine

-

--

------↑↑

↓↓

↓↓

--------

--

--

± ↓± ↓± ↓± ↓± ↓± ↓

--

↓↓

↓↓

-- ----

- or ↓- or ↓

May ↓ cardiac May ↓ cardiac output if diuresis output if diuresis excessiveexcessive

Regional VS General Anestesia pada Pasien Regional VS General Anestesia pada Pasien dengan Penyakit Jantungdengan Penyakit Jantung

- Pasien dengan penyakit jantung telah dibandingkan efek-efek Pasien dengan penyakit jantung telah dibandingkan efek-efek regional vs general anestesi pada insidensi infarc perioperative, regional vs general anestesi pada insidensi infarc perioperative, disritmia dan CHF. Pada kebanyakan penelitian telah disritmia dan CHF. Pada kebanyakan penelitian telah menunjukkan tidak ada perbedaan pada infarction rate selama menunjukkan tidak ada perbedaan pada infarction rate selama general dan regional (spinal, epidural, nerve block, lokal general dan regional (spinal, epidural, nerve block, lokal anestesia)anestesia)

- Regional anestesi dapat menguntungkan pada pasien-pasien Regional anestesi dapat menguntungkan pada pasien-pasien dengan sebelumnya MI yang menjalani transurethral dengan sebelumnya MI yang menjalani transurethral prostatectomy; reinfarction rate pada anestesi spinal kurang prostatectomy; reinfarction rate pada anestesi spinal kurang dari 1% vs 2-8% pada anestesi generaldari 1% vs 2-8% pada anestesi general

- Pemilihan anestesia yang paling baik adalah sesuai dengan Pemilihan anestesia yang paling baik adalah sesuai dengan kebijakan tim perawatan anestesia, yang mana akan kebijakan tim perawatan anestesia, yang mana akan mempertimbangkan kebutuhan ventilasi posoperative; efek mempertimbangkan kebutuhan ventilasi posoperative; efek kardiovaskular, depresi miokardial; blokade simpatiskardiovaskular, depresi miokardial; blokade simpatis

INTRAOPERATIVE INTRAOPERATIVE MANAGEMENTMANAGEMENT

- Bode RH Jr, Lewis KP, Zarich SW, et al. comparison of general and regional anesthesia. - Bode RH Jr, Lewis KP, Zarich SW, et al. comparison of general and regional anesthesia. AnesthesiologyAnesthesiology 1996;84:3-131996;84:3-13- Mangano DT. Perioperative cardiac morbidity. - Mangano DT. Perioperative cardiac morbidity. Anesthesiology Anesthesiology 1990;72:153-1841990;72:153-184- Norris EJ, Beattie C, Perler BA, et al. - Norris EJ, Beattie C, Perler BA, et al. Anesthesiology Anesthesiology 2001;95:1054-10672001;95:1054-1067

INDUKSI ANESTESIINDUKSI ANESTESI

- Induksi yang baik adalah penting untuk Induksi yang baik adalah penting untuk mencegah hipotensi, hipertensi dan mencegah hipotensi, hipertensi dan takhikardi, yang mana dapat menyebabkan takhikardi, yang mana dapat menyebabkan iskemi miokardialiskemi miokardial

- Semua obat-obat anesthesi dapat digunakan Semua obat-obat anesthesi dapat digunakan pada pasien penyakit jantung, kecuali pada pasien penyakit jantung, kecuali ketamin karena dapat menyebabkan ketamin karena dapat menyebabkan hipertensi dan takhikardihipertensi dan takhikardi

Martin DE, Rosenberg H, Aukburg SJ, et al. Lowe-dose fentanyl blunts circulatory responses to tracheal Martin DE, Rosenberg H, Aukburg SJ, et al. Lowe-dose fentanyl blunts circulatory responses to tracheal intubation. intubation. Anest Analg Anest Analg 1982;61:6801982;61:680

INTRAOPERATIVE MANAGEMENTINTRAOPERATIVE MANAGEMENT

Penggunaan Obat AnestesiaPenggunaan Obat Anestesia

- Pada akhir pembedahan, diharapkan dapat dilakukan Pada akhir pembedahan, diharapkan dapat dilakukan ekstubasi. Digunakan Nekstubasi. Digunakan N22O dan kombinasi Isoflurane O dan kombinasi Isoflurane dosis rendah dan Fentanil untuk mempertahankan dosis rendah dan Fentanil untuk mempertahankan anestesiaanestesia

- Narkotik dosis tinggi sebaiknya dicegah bila ventilasi Narkotik dosis tinggi sebaiknya dicegah bila ventilasi postoperative tidak direncanakanpostoperative tidak direncanakan

- Pemakaian intermediate-acting neuromoscular Pemakaian intermediate-acting neuromoscular blocking agent seperti vecuronium, atracurium dan blocking agent seperti vecuronium, atracurium dan rocuronium dapat digunakan secara aman karena rocuronium dapat digunakan secara aman karena tidak menyebabkan perubahan kardiovaskular tidak menyebabkan perubahan kardiovaskular

INTRAOPERATIVE INTRAOPERATIVE MANAGEMENTMANAGEMENT

-Fleming N.Con: the chice of muscle relaxants is not important in cardiac surgery. Fleming N.Con: the chice of muscle relaxants is not important in cardiac surgery. J Cardiothorac Vas Anesth : J Cardiothorac Vas Anesth : 1995;9:772-7741995;9:772-774Hudson RJ, Thomson IR. Pro: the choice of muscle relaxants is important in cardiac surgery.Hudson RJ, Thomson IR. Pro: the choice of muscle relaxants is important in cardiac surgery. J Cardiothorac Vas J Cardiothorac Vas Anesth Anesth 1995;9:768-7711995;9:768-771

Remember : BP = CO x SVR BP = (SV x HR) x SVR

1. Low SVR : • sympathetic blockade• vasodilators• spinal shock• anaphylaxis• blood transfusion • septic shock

2. Low HR ( see bradycardia )3. Low Stroke Volume4. Medicine :

• SVR lowering : nipride• preload lowering : NTG• contractility lowering : beta blockers

5. Surgeons disturbing baroreceptors carotid artery surgery

HYPOTENSIONHYPOTENSION

HYPERTENSION1. Pain / Light anesthesia2. Hypermetabolic state (fever / sepsis, thyroid storm, MH crisis)3. Catecholamine (hypoxia, hypercarbia, acidosis, awareness during surgery)4. Medicine (eg, epinephrine injection )5. Endocrine (pheochromacytoma, MH, thyroid crisis)6. Renal (parenchymal, renovascular)7. Cushing’s reflex8. Coarctation9. Full bladder

TACHYCARDIA1. Light anesthesia / pain2. Hypovolemic Shock3. Hypermetabolic State :

• shivering• fever• MH• thyroid• alcohol “withdrawal”

4. Catecholamine :• hypoxia, hypercarbia• acidosis• pheochromacytoma

5. Sepsis6. Medicine :

• atropin, gallamine• pancuronium, ketamin

7. Arrhytmia :• Atrial : SVT, Atrial fibrillation , Atrial flutter, pre-excitation• Ventricular : VT (remember epi + halothane )

BRADYCARDIA1. HYPOXEMIA !!2. Athletic heart3. Deep anesthesia4. Vagal Causes :

• occulocardiac• maxillary traction• peritoneal traction• cervical dilatation• laryngoscopy

5. Cushing’s reflex6. Medicine :

• neostigmine, edrophonium, pyridostigmine• beta blocker

7. Arrhytmias

OBAT INTRAVENA :OBAT INTRAVENA :BARBITURAT * METHOHEXITONE * THIOPENTONE

BP ok : * CAPACITANCE VENODILATATION PRELOAD

* SVR

* MYOCARDIAL CONTRACTILITY

BENZODIAZEPIN : * DIAZEPAM * MIDAZOLAM

BP PENGARUHNYA TIDAK KENTARA

CARDIAC INDEX PERUBAHAN SVR MINIMAL

K E T A M I N :

HEART RATE CONTRACTILITY BP SVR O2 Consumption Risk MCI

CONTRA INDICATION : Hypertension ( + ) Hyperthyroid History of MCI Intra Cranial Pressure

MORPHINE HIPOTENSI ( + ) , ok : - VASOMOTOR TONE - CAPACITANCE VESSEL - HISTAMIN RELEASE

PETIDINE HEART RATE - ANTICHOLENERGIC ACTION (PARASYMPHATOLITIC, ATROPIN LIKE ACTION) BLOOD PRESSURE - CONTRACTILITY - SVR

O P I A T

INHALASIINHALASIN2O circulation effect minimal

SVR, PVR

HALOTHANE contractility

ENFLURANE cardiac output

SVR

HALOTHANE provocator : “catecholamine induced dysrhytmias”

HALOTHANE + ADRENALINE EMERGENCY

BP

ETHER

ISOFLURANE SYMPHATIC STIMULATION

CYCLOPROPAN

BP N @

RESPON KARDIOVASKULAR RESPON KARDIOVASKULAR TERHADAP PEMBEDAHAN DAN TERHADAP PEMBEDAHAN DAN ANESTESIANESTESI

TEKNIK PREANESTETIK & MONITORINGTEKNIK PREANESTETIK & MONITORING LARINGOSKOPI & INTUBASILARINGOSKOPI & INTUBASI PERUBAHAN FUNGSI VENTILASIPERUBAHAN FUNGSI VENTILASI POSISI TUBUHPOSISI TUBUH PERDARAHANPERDARAHAN STIMULASI DARI PEMBEDAHANSTIMULASI DARI PEMBEDAHAN KEDALAMAN ANESTESIKEDALAMAN ANESTESI

Depressi Segment STDepressi Segment ST- Menunjukkan iskemia miokard disebabkan Menunjukkan iskemia miokard disebabkan

peningkatan myocardial oksigen demand atau peningkatan myocardial oksigen demand atau penurunan oksigen supply. Peningkatan oksigen penurunan oksigen supply. Peningkatan oksigen supply koreksi hipotensi, hipoksemia dan anemi supply koreksi hipotensi, hipoksemia dan anemi berat. Penurunan oksigen demand koreksi berat. Penurunan oksigen demand koreksi hipertensi dan takhikardi dengan memperdalam hipertensi dan takhikardi dengan memperdalam level anestesia atau gunakan vasodilator, beta level anestesia atau gunakan vasodilator, beta blockers dan kalsium channel blockers. blockers dan kalsium channel blockers.

- Bila tidak ada perubahan haemodinamik - Bila tidak ada perubahan haemodinamik nitrogliserin drip, intravenous nicardipine dapat nitrogliserin drip, intravenous nicardipine dapat digunakan untuk mengurangi spasme koronerdigunakan untuk mengurangi spasme koroner

INTRAOPERATIVE INTRAOPERATIVE MANAGEMENTMANAGEMENT

- Ishibashi Y, Shimada T, Yoshitomi H, et al. Ishibashi Y, Shimada T, Yoshitomi H, et al. Clin Exp Pharmacol Physiol Clin Exp Pharmacol Physiol 1999;26:404-4101999;26:404-410 Mangano DT. Perioperative cardiac morbidity. Mangano DT. Perioperative cardiac morbidity. Anesthesiology Anesthesiology 1990;71:153-1841990;71:153-184

EkstubasiEkstubasi

- Ketika pasien bangun, nafas adekuat dan Ketika pasien bangun, nafas adekuat dan efek blokade neuromuscular telah hilangefek blokade neuromuscular telah hilang

- Untuk mencegah takhikardi yang Untuk mencegah takhikardi yang berhubungan dengan ekstubasi dan berhubungan dengan ekstubasi dan emergensi, dapat diberikan dosis preventif emergensi, dapat diberikan dosis preventif seperti 1 mg/kg lidokain atau esmolol atau seperti 1 mg/kg lidokain atau esmolol atau 0,1 mg/kg labetalol, diltiazem, atau 0,1 mg/kg labetalol, diltiazem, atau verapamil 2 menit sebelum ekstubasi verapamil 2 menit sebelum ekstubasi

INTRAOPERATIVE INTRAOPERATIVE MANAGEMENTMANAGEMENT

- Helfman SM, Gold MI, Delissen EA, et al. Helfman SM, Gold MI, Delissen EA, et al. Anesth Analg Anesth Analg 1991;72:482-4861991;72:482-486 Mikawa K, Nishina K, Maekawa N, et al. Mikawa K, Nishina K, Maekawa N, et al. Anesth Analg Anesth Analg 1996;82:1205-12101996;82:1205-1210