chronic kidney disease and anaesthesia - developinganaesthesia

Anaesthesia
&
Medical Disease
Seminar








Mongolia 2015

Table of Contents
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CARDIAC FAILURE 3
EBRAHIM BHAM


HYPERTENSIVE DISEASE 11
JAKE GEERTSEMA


ISCHAEMIC HEART DISEASE 19
JUN KEAT CHAN


ANAESTHESIA FOR PATIENTS WITH LIVER DISEASE 28
SIAN GRIFFITHS


CHRONIC KIDNEY DISEASE AND ANAESTHESIA 40
MICHELLE CHAN


THE ALCOHOLIC PATIENT 50
MICHELLE CHAN


CHRONIC OBSTRUCTIVE PULMONARY DISEASE 58
JAKE GEERTSEMA


SMOKING 64
MICHELLE CHAN


PATIENT WITH A RENAL TRANSPLANT 71
EBRAHIM BHAM


MYASTHENIA GRAVIS & MULTIPLE SCLEROSIS 75
SIAN GRIFFITHS


STROKE 85
AMANDA BARIC


SEPSIS 93
GWENDOLYN STEWART





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CARDIAC FAILURE

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DEFINITION OF HEART FAILURE

Heart Failure (HF) is a complex clinical syndrome that results from any
structural or functional impairment of ventricular filling or ejection of
blood.

The clinical syndrome of HF may result from disorders of the pericardium,
myocardium, endocardium, heart valves, or great vessels, or from certain
metabolic abnormalities. Most patients with HF have symptoms due to
impaired left ventricular (LV) myocardial function that impairs the ability
of the ventricle of the heart to fill with or eject blood (particularly
during physical activity).

STAGES OF HEART FAILURE

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Classification of Heart Failure (ACCF/AHA 2013)

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The ACCF/AHA stages of HF emphasize the development and progression of
disease, whereas the NYHA classes focus on exercise capacity and the
symptomatic status of the disease.



HEART FAILURE WITH REDUCED EJECTION FRACTION/ HFREF (SYSTOLIC HEART
FAILURE/IMPAIRED VENTRICULAR CONTRACTION)

Common causes:
. Coronary Heart Disease (CHD) and prior myocardial infarction (MI)
- Two-thirds of systolic heart failure cases. Ischemic heart disease
(IHD) is present in over 50% of new cases.
. Essential hypertension
- Contributes to heart failure via increased afterload and acceleration
of coronary heart disease. Hypertension is present in about two-thirds
of new cases.

Other causes:
. Valvular heart disease, especially mitral and aortic incompetence.
. Non-ischemic idiopathic dilated cardiomyopathy
- Younger patients, 30% of cases appear to be familial
- Idiopathic dilated cardiomyopathy is present in 5-10% of new cases.
. Dilated cardiomyopathy secondary to long-term alcohol abuse.
. Inflammatory cardiomyopathy or myocarditis
- Associated with viral infections, e.g. enteroviruses (especially
Coxsackie B virus).
. Peripartum cardiomyopathy
. HIV-related cardiomyopathy.
. Drug-induced cardiomyopathy
- Anthracyclines such as daunorubicin and doxorubicin, cyclophosphamide,
paclitaxel and mitoxantrone.
. Chronic arrhythmia.
. Thyroid dysfunction (hyper or hypothyroidism).


HEART FAILURE WITH PRESERVED EJECTION FRACTION / HFPEF (DIASTOLIC
DYSFUNCTION / IMPAIRED VENTRICULAR RELAXATION

Common causes:
. Hypertension (especially systolic hypertension)
- Patients tend to be female and elderly.
- Up to 50% of hospital admissions for congestive heart failure.
. Coronary Heart Disease - leading to impaired myocardial relaxation.
. Diabetes
- Men with diabetes are twice as likely to develop heart failure
- Women with diabetes are at a fivefold greater risk
- Myocardial ischemia is very common in diabetes
- Diabetes is associated with interstitial fibrosis, myocyte hypertrophy
and apoptosis, as well as both autonomic and endothelial dysfunction,
all of which may contribute to the diabetic cardiomyopathic state.

Other causes:
. Valvular disease, particularly aortic stenosis
. Hypertrophic cardiomyopathy
- Most cases are hereditary.
. Restrictive cardiomyopathy
- Either idiopathic or secondary to infiltrative disease, such as
amyloidosis.

DIAGNOSIS OF HEART FAILURE

There is no single diagnostic test for heart failure because it is largely
a clinical diagnosis based on a careful history and physical examination.
The main manifestations of heart failure are dyspnoea and fatigue, which
may limit exercise tolerance, and fluid retention, which may lead to
pulmonary and/or splanchnic congestion and/or peripheral oedema.
Orthopnoea, paroxysmal nocturnal dyspnoea and ankle oedema may appear at a
later stage. Physical signs are often normal in the early stages.

Examination should include assessment of vital signs, cardiac auscultation
(murmurs, S3 gallop) and checking for signs of fluid retention (e.g. raised
jugular venous pressure, peripheral oedema, and basal inspiratory
crepitations). Diagnosis is based on clinical features, chest X-ray and
objective measurement of ventricular function (e.g. echocardiography).

Step by step recommendation for Diagnosis:

1. All patients with suspected CHF should undergo an echocardiogram to
improve diagnostic accuracy and determine the mechanism of heart
failure.
2. Coronary angiography in patients with a history of exertional angina
or suspected ischemic left ventricular dysfunction
3. Plasma BNP or N-terminal pro-BNP measurement may be helpful in
patients presenting with recent-onset dyspnoea; it has a high negative
predictive value. Repeated measurement are done for monitoring and
adjustment of therapy in HF with systolic dysfunction
4. Cardiopulmonary exercise testing may be helpful in patients with
refractory HF, recurrent HFpSF (diastolic HF), or in whom the
diagnosis of HF is in doubt.
5. Endomyocardial biopsy may be indicated in patients with cardiomyopathy
with recent onset of symptoms, where CHD has been excluded by
angiography, or where an inflammatory or infiltrative process is
suspected.
6. Nuclear cardiology, stress echocardiography and PET scan can be used
to assess reversibility of ischemia and viability of myocardium in
patients with HF who have myocardial dysfunction and CHD.
7. Thyroid function tests should be considered, especially in older
patients without pre-existing CHD who develop atrial fibrillation, or
in whom no other cause of HF is evident.
8. MRI to assess and diagnose infiltrative disorders. However, MRI is not
widely available.

MANAGEMENT OF HEART FAILURE

Management involves prevention, early detection, slowing of disease
progression, relief of symptoms, minimisation of exacerbations, and
prolongation of survival.

Non-Pharmacological Management

. Regular physical activity with a specially designed program for all HF
patients is recommended except for those who have an acute
exacerbation, or are clinically unstable. They should undergo a period
of bed rest until their condition improves.
. Patient to follow up with a doctor or home visit by a nurse to prevent
clinical deterioration.
. Patients with coexisting sleep apnoea to consult with sleep physician
as they may benefit from nasal CPAP
. Fluid intake should generally be limited to 1.5 L /day with mild to
moderate symptoms, and 1 L /day in severe cases, especially if there
is coexistent hyponatraemia. Dietary sodium should be limited to below
2 g/day.
. Alcohol intake should preferably be nil, but should not exceed 10-20 g
a day (one to two standard drinks). Smoking should be strongly
discouraged.
. Patients should be advised to weigh themselves daily and to consult
their doctor if weight increases by more than 2 kg in a two-day
period, or if they experience dyspnoea, oedema or abdominal bloating.
. Patients should be vaccinated against influenza and pneumococcal
disease.
. High-altitude destinations should be avoided. Travel to very humid or
hot climates should be undertaken with caution, and fluid status
should be carefully monitored.
. Obese patients should be advised to lose weight.
. Pregnancy should be avoided in patients with moderate to severe HF.


Pharmacological Management

First Line Treatment

. Angiotensin Converting Enzyme Inhibitors (ACEIs)

Recommended for all patients with systolic heart failure (LVEF < 40%),
whether symptoms are mild, moderate or severe. (Unless not tolerated
or contraindicated)
. Angiotensin II receptor antagonists (ARB's)

Used as an alternative in patients who do not tolerate ACEIs due to
kinin-mediated adverse effects (e.g. cough). They should also be
considered for reducing morbidity and mortality in patients with
systolic CHF who remain symptomatic despite receiving ACEIs.
. Diuretics

Used to achieve euvolaemia in fluid-overloaded patients. In patients
with systolic LV dysfunction, diuretics should never be used as
monotherapy, but combined with an ACEI to maintain euvolaemia.
. Beta-blockers

Recommended for all patients with systolic CHF who remain mild to
moderately symptomatic despite appropriate doses of an ACEI. (Unless
not tolerated or contra-indicated).
Beta-blockers are also indica