How to manage a patient of low EF for non cardiac surgery under GA ?

Management of GA in a patient with low EF for non cardiac surgery 

 GA considerations- 

 Pre-anaestheticcheck up involves checking for investigations like

Routine: 

Hemogram- Anaemia is a hyperdynamiccirculation causing tachycardia.Tachycardia increases oxygen demand, decreases diastolic filling of coronary vessels and thus makes myocardium susceptible for ischaemia.

LFT/KFT - may be deranged

Specific Investigations:

 Chest X-ray: signs of LV failure,pulmonary oedema

 Echocardiography: EF, associated diastolic dysfunction, ischaemia mitral regurgitation 

 Angiography:see for Coronary artery disease

•    Continuation of cardiac drugs like beta blockers and statins (please refer to highlights section for details)

•    Monitoring with Central venous cannulation, Pulmonary artery catheter, Transoesophagealechocardiography, Invasive arterial pressure monitoring is necessary other than temperature,urine output monitoring        which are important cardiac wise

 Management Goals- According to Cardiac Grid:

1.  Heart rate – has to be maintained.Tachycardia is hazardous 


2.  Rhythm- Sinus rhythm is very important for maintaining adequate stroke volume 


3.  Contractility- depressed contractility will decrease stroke volume hence maintaining contractility is important 


4.  Preload- adequate for LV filling 


5.  Afterload- maintained, if increased - LV has to pump against resistance and it may fail

•    Induction: Inj Etomidate is the drug of choice for induction 0.2-0.3 mg/kg

•    Inotropes: should be started if required 

          Inj Dopamine 2-5microgms/kg/min

          Inj Adrenaline 0.01-0.05microgms/kg/min

          Inj Nor-adrenaline 0.01-0.05microgms/kg/min

•    Fluid management to be optimised by CVP at least if PAC or TEE is not available 

•    Vigilance and timely use of anti arrhythmic drugs like Amiodarone, Xylocard etc.

     Complications that can occur :

o    Pulmonary oedema 

o    LV failure

o    Intractable hypotension 

o    Arrhythmias 

o    Sudden Cardiac Arrest