Non cardiac surgery in a patient with transplanted heart

1. Non cardiac surgery in a patient with transplanted heart Presenters – Dr. Praveen Talawar Dr. Rakesh Garg Moderator – Dr. Bhalla www.anaesthesia.co.inanaesthesia.co.in@gmail.com

2. Anesthetic management

3. Subsequent Surgical intervention…… Disease acquired as a consequence of immunosuppression such as • malignancy, • infection, and • steroid induced osteoporosis or Unrelated problems pertaining to • ENT, • Urologic, • Ophthalmic, • Orthopaedic, • Dental procedures etc

4. Surgery:1985 • Steed et al – • Greater incidence of general surgical complications in post-transplant patients • These complications are associated with a greater than expected mortality rate

5. Preoperative assessment • Function of the transplanted organ • Function of other organs (those compromised due to immunosuppression ) • The presence of an infection?

6. Investigations …… ACNA:1994 • Review of patient’s record book (biopsy reports) • Complete blood count (including DLC) • Serum electrolytes (Na+, K+, Cl-, HCO3- ) • Urea, Creatinine • Glucose • LFT, • CXR, ECG • Assessment of indwelling pacemaker if present • PT, aPTT • Echocardiogram

7. Anesthetic management • There are no prescribed recommendations for non cardiac surgery in post cardiac transplant patients

8. Anesthetic management • All preoperative drug therapy should be continued during the perioperatve period • Prophylactic antibiotics • IE- prophylaxis : as needed • If pacemaker is in place , its proper function should be confirmed & temporary pacemaker should be kept standby • “Stress dose” of steroids – if patient on steroids (as a part of immunosuppressive regime)

9. Emergency medications • Inotropes - Epinephrine • Chronotropes – Epinephrine Isoproterenol Dobutamine Pacing- external pads / internal wires • Vasoconstrictors- Phenylephrine & Vasopressin

10. Anesthetic management Anesthetic techniques • Patients should be premedicated with usual premedication of choice • Transplanted heart patients have  Increased systemic vascular resistance  Dependent upon venous return for cardiac output Any technique that may suddenly reduce either venous return/ SVR must be carefully monitored

11. The intraoperative anesthetic strategy  Dictated by underlying surgical diagnosis & any other complicating factors that may be present • Modifications may be necessary to address concomitant conditions such as  Reflux, full stomach, increased intracranial pressure, or the diagnosis of coronary vasculopathy, graft failure or rejection

12. Monitoring • The choice of monitoring is as determined by the type of surgical procedure, anesthesia planned, ( ECG, NIBP, SpO2, EtCO2) • ECG – monitored for both ischemia & arrhythmias, the presence of two P waves is expected

13. Monitoring • Perioperative invasive monitoring requires fully aseptic techniques to minimize the risk of infection & should be discussed in terms of benefit-risk ratio • When CVP monitoring is necessary , the catheter -via the anticubital fossa or the left IJV, • as routine cardiac biopsies are performed usually via the Right IJV • Where available, TEE may be preferable to invasive central monitoring

14. Medically stable patients undergoing noncardiac, non thoracic surgery after cardiac transplantation undergo  the same induction techniques including thiopentol, inhalational agents • An IV induction followed by tracheal intubation & ventilation using a neuromuscular blocking agent, an opioid & an inhalational agent seem to be the popular

15. Oral endotracheal intubation is preferred over nasal intubation because of potential infection caused by nasal flora • The use of LMA is acceptable • Normal sympathetic response to laryngoscopy & intubation are absent • Tachycardia in response to light anesthesia or hypovolemia  absent or delayed

16. Reversal of muscle relaxation can be performed safely without the use of muscarinic antagonists • Bradycardia after neostigmine use has been reported • Routine use of muscarinic antagonists would mostly beneficial to block the muscarinic side effects of anticholinesterases

17. Interaction of anesthetic drugs & immunosuppressive drugs • In one study after heart transplant, all patients receiving cyclosporine A demonstrated chronic nephrotoxicity within 2 years of transplantation • Drugs excreted by the kidney may not be readily cleared Anesth-Analg 1987

18. Potentiation of effects of barbiturates, fentanyl & muscle relaxants particularly atracurium & vecuronium by cyclosporine has been described in animal studies • No clinically significant potentiation seen in human transplant patients J Cardiothorac Vasc Anesth 1991 • Azathioprine – antagonize NDMR, larger doses may be required

19. Kanter et al:Anesthesiology:1977 • Review of 29-charts of patients underwent anesthesia following cardiac transplantation • 15 surgeries- first 3 months ( surgical procedure for the saving life/limb) • 14 surgeries, 10-68 months following transplantation

20. Kanter et al… • Prior to the elective surgical procedures, -CVS evaluation • Angiography • ECG • Endomyocardial biopsy to evaluate status of -  the coronary arteries ,  the hemodynamic status, &  the presence or absence of rejection

21. Kanter et al… Anesthetic management • Monitoring-MAP, CVP in all major cases • Induction/maintenance of anesthesia – were tailored to the patient needs, • Induction agents-thiopental, diazepam, ketamine & droperidol with or without  narcotics-morphine, fentanyl,

22. Kanter et al… • inhalational agents –N2O, methoxyflurine, halothane & enflurane, • muscle relaxation-succinylcholine, d-tubocurarine, dimethylcurine or pancuronium • The most popular method N2O/Narcotic/relaxant/low dose inhaled volatile anesthetic

23. Kanter et al… • Cardiovascular drugs used are- Atropine, isopreterenol, ephedrine, norepinephrine, dopamine, sodium nitroprusside Except for atropine & pancuronium – there was no unusual response to any of above agents

24. Kanter et al… • Excluding retransplantation there was no episodes of intraoperative hypotension or arrhythmias that could not be explained on the basis of acute blood loss or sepsis

25. Cheng et al:CJA:1993 • 18 of 86 recipients who returned for 32 NCS procedures at Toranto Hospital between 1985-1990

26. Cheng et al:CJA:1993 • Induction- thiopentone (2-4mg/kg) , fentanyl (1-7µg/kg) - succinylcholine (1-1.5mg/kg) • Maintainance- O2/N2O/Iso/Enflurane • Muscle relaxation- vecuronium/pancuronium No delayed awakening/ unplanned postoperative ventilation

27. Cheng et al:CJA:1993 • SAB (75mg Lidocaine)-2/27 elective  No important hemodynamic changes were observed in any anesthetic groups  No anesthesia related morbidity or mortality

28. Cheng et al- suggested – “General, neurolept- and spinal anesthesia do not affect hemodynamic function or postoperative outcome in heart transplanted patients undergoing subsequent noncardiac surgery”

29. Joshi et al: Anesthesiology 1996 • Cardiac transplant patients tolerated pneumoperitoneum for laparoscopic Cholecystectomy without adverse effects • Cardiac index & Hemodynamics were unaltered by establishment of a pneumoperitoneum & all patients recovered without adverse events

30. Ceroni et al :Eur Spine J:2001 • Reported successful correction of idiopathic scoliosis after heart transplantation under GA in 15 year old child , taking due care of physiology and pharmacological reactions of the denervated heart

31. B/L core decompression in a patient with transplanted heartProf:Chandralekha( AIIMS): 2006 • 28 year /female : • H/O cardiac transplantation in 2001 (ind-DCM) • Underwent B/L core decompression under GA • Premedication- diazepam, ranitidine • Induction –fentanyl(60µg), thiopentone(200mg) & vecuronium(5mg) • Maintainace-O2, N2O, Isoflurane • No episodes of hypotension / bradycardia • Total blood loss- 200ml • Patient’s residual NMB-reversed, extubated , observed for 1 day in AB8 ICU, & discharged to the ward next day

32. Regional anesthesia • The rapid changes in preload & SVR that accompany spinal or epidural anesthesia  significant threat of hypotension with a heart devoid of sympathetic reflex compensation

33. Regional anesthesia can be administered safely, provided • Sufficient augmentation of circulating volume • A block with more gradual, controllable onset • Prompt recognition & treatment of hemodynamic disturbances with direct acting sympathomimetic agents

34. Allard et al:CJA:2004 Decreased HR & BP in recent cardiac transplant patient after SAB. • Cardiac transplant patients may tolerate neuraxial anesthesia admirably • Change in HR- mediated by mechanisms intrinsic to the transplanted heart and /or by reduced catecholamine secretion from adrenal medulla

35. Day-care surgery • In the absence of any complicated medical issues, same day surgery is safe • Routine monitoring & preparation ( antibiotic prophylaxis) - sufficient

36. The pregnant patient with a transplanted heart, Bordignon et al Arq Bras Cardiol 2000 • Approx - 30% of cardiac transplantation are performed in women • Many of them are - childbearing age • Lowenstein et al (1998) - reported the first pregnancy after cardiac transplantation

37. Pregnancy after cardiac transplantation has been contraindicated because of the risk to mother & conceptus • Hemodynamic alterations • Immunosuppressive therapy

38. The pregnant patient with a transplanted heart…, Morini et al: Human Reprod-1998 • Morini et al - reviewed the outcome of 23 pregnancies in a women with a transplanted heart • MC-indication- viral cardiomyopathy • Maternal immunosuppressive therapy does not appear to have an adverse effect on fetal & neonatal outcome

39. Patients receiving cyclosporine&prednisone often develop HTN • Require antihypertensive therapy • The physiologic changes of normal pregnancy (BV, RBF) may require a change in the dose of cyclosporine

40. Complications related to pregnancy (preeclampsia, PROM, infections)  more common in women with a transplanted heart • “stress” dose of corticosteroids during or after delivery if steroids are part of their immunosuppressive regime

41. Epidural anesthesia- preferred anesthetic technique for LSCS with the slow induction of epidural anesthesia  compensatory mechanisms • SAB – has been administered successfully for cesarean delivery in women undergone heart-lung transplantation

42. Pediatric heart transplant recipients for NCS. Kostopanagiotou et al:Paeds anesth:2003 • Local , regional, or general anesthesia can be safely delivered to pediatric heart transplant recipients

43. Postoperative concerns • Early extubation – is desirable to minimize the risk of pulmonary infection from prolonged mechanical ventilation • The function of other organs compromised by immunosuppressive drugs or chronic heart failure such as liver or kidneys should be closely monitored by laboratory testing • ECG- Because these patients are at risk of silent ischemia

44. Postoperative concerns • Immunotherapy should be resumed at preoperative doses • Fluid balance - carefully monitored, hypo/ hypervolemia – undesirable • Evidence of infection should be sought & promptly investigated & treated

45. Thank you www.anaesthesia.co.inanaesthesia.co.in@gmail.com