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MURMUR AND ANAESTHESIA

MURMUR AND ANAESTHESIA. DR BALAJI ASEGAONKAR CONSULTANT CARDIAC-ANAESTHESIOLOGIST , OZONE ANAESTHESIA GROUP, AURANGABAD . The Case. 22 yr M, suffered RT accident –suspected closed vascular injury No cardiac or pulmonary history No prior cardiac workup

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MURMUR AND ANAESTHESIA

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  1. MURMUR AND ANAESTHESIA DR BALAJI ASEGAONKAR CONSULTANT CARDIAC-ANAESTHESIOLOGIST, OZONE ANAESTHESIA GROUP, AURANGABAD.

  2. The Case • 22 yr M, suffered RT accident –suspected closedvascular injury • No cardiac or pulmonary history • No prior cardiac workup • EKG normal, labs normal • II/VI mid systolic crescendo- murmur • Pre op 2D Echo advised. • But…………….Not possible.

  3. Able to swim and walks for hours without dyspnoea or chest pain. • No thrill on murmur. • ECG and CxR normal

  4. AIM OF PRESENTATION • Do all murmurs requires further investigation? • On auscultation if someone finds murmur- What should be done? • Which murmurs are significant ? • Is the murmur is physiological or pathological?

  5. So what do you do? • Guess?…Argue?…Worry?…Refer everyone to cardiology? • Or do a thorough, focused exam. • …for evaluation, risk stratification, and management… • …and refer, delay, or cancel only when appropriate.

  6. What do you mean, thorough, focused Exam: • We are not cardiologists: We simply need to recognize when a cardiac condition affect the patient’s response to anaesthesia, and what to do about it. • Thorough enough to find all significant problems (sensitivity). • Focused enough to consider only significant problems (specificity).

  7. ....and StepwiseApproach? • Thorough, focused cardiac evaluation • Indicated cardiac testing and consultation. • Optimization of cardiovascular function in relation to the demands of the surgery and the anaesthesia.

  8. History • Dyspnoea on exertion • Orthopnea,PND. • Palpitations. • Easy fatigability • Syncope. • Chest pain. • Others.

  9. Clinical examination • Pulse • Blood pressure • Baseline saturation • Respiration • Anaemia • Signs of failure • Systemic examination

  10. Clinical examination • Inspection • Palpation – Thrill,2 nd HS • Auscultation

  11. How to listen • Do a good exam • left lateral decub • touch skin, listen • quiet • good ear fit • correct stethoscope placement • use maneuvers

  12. Maneuvers to Differentiate Murmurs • Valsalva: All murmurs decrease n intensity except HOCM & MVP – longer and louder • Respiration: Right sided sounds and murmurs get louder with inspiration • Prompt Squatting : increase VR and SVR -murmur of HOCM gets softer, The murmurs of MR& AR get louder.

  13. Classification of Murmurs • Timing • The relative position within the cardiac cycle and relation to S1/S2. • Intensity • Grade 1: Heard only with intense concentration • Grade 2: Faint, but heard immediately • Grade 3: Easily heard, of intermediate intensity • Grade 4: Easily heard and associated with a thrill • Grade 5: Very loud, with thrill and audible with only edge of stethoscope on chest wall • Grade 6: Audible with stethoscope off the chest wall

  14. Innocent murmur • Short systolic ejection murmur • Loudest at left sternal border • Grade 1-2/6 • Normal S2 • No other exam abnormalities • No evidence LVH or dilatation • No thrill • No increase with Valsalva

  15. Pathological murmurs • Diastolic { MS,AR} • Harsh murmurs • Associated with thrill. • Abnormal S1 or S2 • Louder than 3/6 • ECG & CxR changes. • Other clinical findings.

  16. Chest x ray

  17. Common Murmurs and Timing (click on murmur to play) Systolic Murmurs • Aortic stenosis • Mitral insufficiency • Mitral valve prolapse • Tricuspid insufficiency Diastolic Murmurs • Aortic insufficiency • Mitral stenosis S1 S2 S1

  18. Severe stenotic lesions • History- angina , syncope, CCF • Narrow pulse pressure. • ECG changes. • Chest X ray :Cardiomegaly ,post stenotic dilated aorta • Murmur with thrill

  19. Severe regurgitant lesions • Symptomatic patients • Wide pulse pressure. • Other signs of WPP. • Presence of ccf. • Cardiomegaly on X ray.

  20. If I miss murmur,what will happen ? • Nothing….. • Nonsymptomatic Pt + murmur =mild lesion • Symptomatic Pt + murmur = Dangerous

  21. APPROACH TO MURMUR

  22. For a link to sound files demonstrating examples of the heart sounds and murmurs in this presentation go to www.cardiologysite.com www.blaufuss.org

  23. How is a paradigm formed? synergysolutions08@yahoo.com

  24. A group of scientists placed 5 monkeys in a cage and in the middle, a ladder with bananas on the top. synergysolutions08@yahoo.com

  25. Every time a monkey went up the ladder, the scientists soaked the rest of the monkeys with cold water. synergysolutions08@yahoo.com

  26. After a while, every time a monkey went up the ladder, the others beat up the one on the ladder. synergysolutions08@yahoo.com

  27. After some time, no monkey dare to go up the ladder regardless of the temptation. synergysolutions08@yahoo.com

  28. Scientists then decided to substitute one of the monkeys. The 1st thing this new monkey did was to go up the ladder. Immediately the other monkeys beat him up. After several beatings, the new member learned not to climb the ladder even though never knew why. synergysolutions08@yahoo.com

  29. A 2nd monkey was substituted and the same occurred. The 1st monkey participated on the beating for the 2nd monkey. A 3rd monkey was changed and the same was repeated (beating). The 4th was substituted and the beating was repeated and finally the 5th monkey was replaced. synergysolutions08@yahoo.com

  30. What was left was a group of 5 monkeys that even though never received a cold shower, continued to beat up any monkey who attempted to climb the ladder. synergysolutions08@yahoo.com

  31. If it was possible to ask the monkeys why they would beat up all those who attempted to go up the ladder….. I bet you the answer would be…. “I don’t know – that’s how things are done around here” Does it sounds familiar? synergysolutions08@yahoo.com

  32. Don’t miss the opportunity to share this with others as they might be asking themselves why we continue to do what we are doing if there is a different way out there. synergysolutions08@yahoo.com

  33. Any Questions?

  34. THANKS

  35. Thanks!!!

  36. Aortic stenosis • Many studies tried to come up with grading systems. Valid factors (to one degree or another) included: • Decreased carotid volume • Delayed carotid upstroke • Decreased or absent S2 • Murmur loudest at RUSB • Valve calcification on CXR • Anesthesiologists also look for wide aorta on CXR from post-stenotic dilation

  37. Mutterings: • Look for: • effort syncope • angina • dyspnea • slow carotid rise • murmur peak in mid or late systole • decreased or absent S2 • pulse delay,

  38. Purr: • Trust the innocent murmur • Short systolic ejection murmur • Loudest at left sternal border • Grade 1-2/6 • Normal S2 • No other exam abnormalities • No evidence LVH or dilatation • No thrill • No increase with Valsalva

  39. Aortic stenosis • Significantly more likely if Pt has: • effort syncope • slow carotid rise • murmur peak in mid or late systole • decreased or absent S2 • pulse delay • Significantly less likely if Pt has: • No murmur • No radiation to carotid

  40. Pre op ECHO • Not an independent predictor • Only for standard indications • murmur/valvular disease • atrial fibrillation/flutter • dyspnea/CHF/cardiomyopathy • unstable angina

  41. "Only two things are infinite: The universe and human stupidity. And I am not so sure about the former." Albert Einstein synergysolutions08@yahoo.com

  42. The courage is knowledge of how to fear what ought to be feared & how not to fear what ought not to be feared

  43. Clues to order echo: • Prior CHF or MI • Evidence of valvular heart disease • Predictive utility only for Revised Cardiac Risk Index III and IV

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