Echocardiography to detect left ventricular ejection fraction (LVEF) is the single most important determinant.
If patient is on aspirin it should be stopped 1 week before.
ECG other than routine investigation is employed. Lead V5is the best to diagnose left ventricle infarctions.
Pulmonary artery catheterization should be considered if large intravascular fluid shifts are expected.
Transesophageal echocardiography (TEE) is useful method for continuous assessment of intraoperative left ventricular function.
Type of anaesthesia
General anaesthesia is preferred over spinal. Hypotension associated with spinal may not be tolerated. If spinal or epidural is to be given (epidural preferred) maintenance of blood pressure is very important.
Premedication: Benzodiazepines should be given night before and on the day of surgery. The patient should be calm.
Induction: Cardiovascular response to laryngoscopy and intubation should be blunted by lignocaine, esmolol, opioids. Tachycardia is not acceptable at any cost.
Induction is done with thiopentone/propofol (agent of choice is etomidate but is not available readily).
Maintenance: Anaesthesia is maintained by O2 + N2O (Nitrous oxide) + opioids.
Inhalational agents depress the cardiac output which can be detrimental in cardiac patients. Isoflurane can cause coronary steal.
Vecuronium is the muscle relaxant of choice (it is cardiac stable).
Hypocapnia should be avoided as it can cause coronary vasoconstriction.
Reversal: Glycopyrrolate is given (no atropine) along with neostigmine.
Postoperative Period: Postoperative period is very crucial, chances of infarction are still high in postoperative period.
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