Preoperative Management: Anesthesia Consideration

Anesthesia Considerations
Preoperative Management
Contrera, Patterson, and Cushing (2014) discussed that the patients undergoing cardiac surgery should have a thorough preoperative assessment, including a history of medical conditions, and a complete physical examination. The preoperative evaluation should focus on the cardiovascular system, airway, pulmonary, neurologic, endocrine, renal, hepatic, and hematologic function (Contrera et al., 2014). Avoid tachycardia precludes episodes of LA and pulmonary hypertension with potential right ventricular dysfunction, as well as inadequate LV filling with concomitant systemic hypotension (Skubas, Lichtman, Sharma, & Thomas, 2009). Preoperative medications such as anxiolytics and beta-blockers used
to decrease anxiety-induced tachycardia, and potassium chloride for diuretic-induced hypokalemia (Hines & Marschall, 2013).
Prevented pulmonary hypertension and possible right-sided heart failure stemming from pulmonary vasoconstriction (Skubas et al., 2009). Avoid hypoxia, hypercarbia, and acidosis because they increase pulmonary vascular resistance (Skubas et al., 2009). Clinical research showed the benefit of perioperative beta-blocker therapy to enhance hemodynamic stability, decrease dysrhythmias, and reduce morbidity and mortality (Contrera et al., 2014). Anticoagulation should discontinue for a major surgery with anticipated consequential blood loss (Hines & Marschall, 2013).
Intraoperative Management
The anesthetic procedure based on a thorough understanding of the pathophysiology of MS and the cardiovascular effect of the anesthetic agents used (Elisha, 2014). During the intraoperative period avoided drugs that accelerate hypotension from histamine release, or that increase heart rate (Hines & Marschall, 2013). Maintained sinus rhythm at a normal heart rate and adequate cardiac output (CO) without increasing pulmonary congestion (Elisha, 2014). A nitrous-narcotic anesthetic with low concentrations of a volatile anesthetic used to decrease sustained changes in heart rate, systemic and pneumonic vascular resistance, and myocardial contractility (Hines & Marschall, 2013). Nitrous oxide may cause pulmonary vasoconstriction, especially if pulmonary hypertension is present (Hines & Marschall, 2013).
Avoid extreme decrease in myocardial contractility with careful monitoring to improve the hemodynamics, and reduction in both right and left ventricular afterload (Elisha, 2014).
Patients with severe MS need continued monitoring of intra-arterial pressure, pulmonary artery pressure, LA pressure, and transesophageal echocardiography (Hines & Marschall, 2013). The LA pressure of 25 mmHg required for maintaining an adequate resting CO (Elisha, 2014). Atrial tachyarrhythmia was causing hemodynamic instability treated with cardioversion (Elisha, 2014). A small dose of phenylephrine used for treat hypertension (Elisha, 2014).
Postoperative Management
During the postoperative period, patients remain at a high risk of pulmonary edema, and right side heart failure (Hines & Marschall, 2013). Increased heart rate and pulmonary vascular resistance due to pain and hypoventilation, and should adequately treat (Hines & Marschall, 2013). After thoracic or abdominal surgery, the patient must continued on mechanical ventilation (Hines & Marschall, 2013). Anticoagulation should resume as quickly as possible (Hines & Marschall, 2013). The patient monitoring should continue for the postoperative period with the same vigilance (Hines & Marschall, 2013).
Summary
Rheumatic heart disease is common worldwide and seen with increasing frequency in developing countries. A better knowledge of the physiological and the pathological impact of MS and proper diagnosis, management, and follow-up of patients are imperative to reduce long-term morbidity and mortality. To develop an anesthetic plan for the patient, cardiovascular history, a thorough patient interview, and an accurate examination and assessment are very essential. Appropriate monitoring required by the anesthesia provider, in maintaining the patient's compensatory mechanisms during the preoperative, intraoperative and postoperative stages of surgery.