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خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده: مورد

Key points for anesthetic and hemodynamic management for patients with mitral stenosis

Key points for anesthetic and hemodynamic management for patients with mitral stenosis
Hemodynamic goals Avoid Monitor Intervention
Sinus rhythm Avoid atrial fibrillation or other SVT 5-lead ECG Manage new-onset atrial fibrillation or other SVT:
  • HR control
  • Cardioversion for SVT with hemodynamic instability (if no evidence of LA thrombus*)
Slow to normal HR (50 to 70 bpm)

Avoid tachycardia

Avoid severe bradycardia <50 bpm

5-lead ECG

Pulse oximetry with visible waveform

Prevent pain-induced tachycardia by ensuring adequate anesthetic depth and effective analgesia

Manage tachycardia related to hypotension with phenylephrine (or norepinephrine)

Decrease HR with beta blockers if necessary
Maintain afterload

Avoid hypotension

Avoid sympathectomy (eg, spinal anesthesia)

 Intra-arterial BP for major surgical procedures Administer a vasoconstrictor (eg, phenylephrine, norepinephrine) to manage hypotension
Adequate preload Avoid hypervolemia

Clinical course and oxygenation

Development of flash pulmonary edema (may present as acute coughing and hypoxemia in an awake patient)

Management of pulmonary edema
(with rate control, cardioversion if indicated*, and diuresis if indicated)

Treat hypoxemia related to pulmonary edema immediately with 100% oxygen, PEEP, and, if necessary, intubation and controlled ventilation
Avoid hypovolemia Assess clinical response to fluid boluses (hemodynamics, including TEE parameters, CVP, and PAP, cardiac output, and mixed venous oxygenation in cardiac surgical or selected high-risk noncardiac surgical procedures)

Maintain intravascular volume status

Resuscitation for hemorrhage, maintain caution during rapid volume repletion due to potential for flash pulmonary edema and RV strain
Maintain RV contractility Avoid doses of drugs that cause significant myocardial depression

Hemodynamics

TEE for cardiac surgical or selected high-risk noncardiac surgical procedures

 If inotropic support is needed, milrinone or dobutamine may be used if SVR and systemic BP are maintained; low-dose epinephrine may be necessary in hypotensive patients
Minimize PVR (optimize oxygenation and ventilation)

Avoid hypoxemia

Avoid hypercarbia

Pulse oximetry with visible waveform

Capnometry (end-tidal CO2)

ABG analysis if an intra-arterial catheter is in place

PA catheter for cardiac surgical or selected high-risk noncardiac surgical procedures

 Minimize risk of hypoxemia and hypercarbia by:
  • Administering supplemental oxygen
  • Ensuring adequate ventilation

ABG: arterial blood gas; BP: blood pressure; bpm: beats per minute; CO2: carbon dioxide; CVP: central venous pressure; ECG: electrocardiogram; HR: heart rate; LA: left atrial; MS: mitral stenosis; PA: pulmonary arterial; PAP: pulmonary artery pressure; PEEP: positive end-expiratory pressure; PVR: pulmonary vascular resistance; RV: right ventricular; SVR: systemic vascular resistance; SVT: supraventricular tachyarrhythmia; TEE: transesophageal echocardiography.

* Since there is increased risk of thromboembolism following cardioversion (even when there is no visible LA thrombus), particularly in patients with higher CHA2DS2-VASc scores, recent cardioversion is a factor is considering whether/when anticoagulation is started postoperatively.

Graphic 148584 Version 2.0

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