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Getting to the HEART of the matter - considerations for anaesthetising the cardiac patient.

Anaesthesia and Cardiac Disease Patients

Patients with a degree of cardiac insufficiency present a unique anaesthetic challenge. Changes not only in the cardiovascular system, but also in hepatic, thermoregulatory, and neurological systems mean that careful consideration of drugs, protocols, and procedures must be observed to ensure the best anaesthetic outcome.

Alfaxan® has been demonstrated to have minimal effect on the cardiovascular system when used within the registered dose range in dogs and cats1,2. It has also been shown to be a clinically acceptable induction agent in dogs with severe systemic disease3 and a high anaesthetic risk.

Pathophysiology/Physiology

The most common forms of acquired cardiac disease in the dog are chronic atrioventricular valve disease (mitral (L) > tricuspid (R)), and dilated cardiomyopathy, whilst hypertrophic cardiomyopathy is most common in the cat4. Even when appropriate treatment is sought, progression of cardiac disease can result in congestive heart failure, as over extended periods of time the compensatory mechanisms utilised to maintain cardiac output start to have detrimental effect on the patient’s normal physiological function.

Whilst there are many other forms of cardiac disease, the anaesthetic management detailed here will focus predominately on these more common conditions. Ultimately, the basic principles outlined here will apply to all cardiac cases.

Patient assessment

All patients with a known history of cardiac disease should be carefully managed under anaesthesia and it is also important to consider that many patients with cardiac disease may remain subclinical for much of their life. Asymptomatic patients with audible cardiac murmurs should be managed with the same consideration as those with overt cardiac disease.  It is recognised in human medicine that patients with stable, well managed cardiac disease are much less likely to develop complications during anaesthesia5. It is therefore important, on the day of anaesthesia, to determine whether a currently medicated cardiac patient is showing any signs of progression of disease and if so, this should be addressed wherever possible, prior to proceeding with the planned anaesthetic procedure.

Key Points

  • Maintain cardiac output
  • Avoid large fluctuations in heart rate (both increase and decrease)
  • Avoid hypotension and hypertension
  • Maintain good ventilation and oxygenation
  • Maintain adequate fluid balance

Anaesthetic Considerations 

A thorough pre-anaesthetic evaluation of patients with a heart murmur should be made to determine severity of disease. Clinicians should aim to stabilise the patients prior to elective procedures and use drugs which have minimal impact on the cardiovascular system.

PREPARATION: Patients should be fasted for anaesthesia the night before, however water should not be withheld until premedication. As cardiac disease increases some of the risks associated with anaesthesia, it is important to place an intravenous catheter prior to administration of any drugs if this can be done without stressing the patient. Have emergency cardiovascular (inotropic, vasoconstrictive, anti-arrhythmogenic) agents on hand. Patients should be assessed for hydration status the morning of anaesthesia, and appropriate fluid therapy initiated if required. Identify the availability of accurate and working monitoring equipment to ensure the best possible outcomes from anaesthesia. Pre-anaesthetic blood work and electrolyte monitoring is recommended, particularly in patients receiving furosemide, as hypokalaemia may predispose a patient to dysrhythmias.  (Also visit: Food for Thought: Pre-anaesthetic Fasting).

It is generally recommended that patients continue to receive their cardiac medication on the day of anaesthesia. Administration of ACE inhibitors on the day of anaesthesia is controversial, due to the potential for development of significant intraoperative hypotension and needs to be considered on a case-by-case basis. If ACE inhibitors are to be continued on the day of anaesthesia, it is important to monitor blood pressure closely and have inotropic and vasoconstrictor agents available for management of intraoperative hypotension under anaesthesia. In these instances, try to avoid the use of other vasodilatory agents such as acepromazine in your anaesthetic plan5,6,7.

PREMEDICATION: Balanced anaesthesia should be the aim with any anaesthetic protocol. Some cardiac disease patients may not require much sedation, and often administration of an opioid is enough. If additional sedation is required, benzodiazepines are a good choice to be used in combination with an appropriate opioid in cardiac patients. Acepromazine is vasodilatory and will compound hypotensive issues under anaesthesia, particularly if the patient is being treated with an ACE inhibitor. Alpha-2 agonists have significant impact on the cardiovascular system, including a decrease in cardiac output and an increase in the likelihood of second-degree AV block, and as a result should be used judiciously and after careful consideration in patients with cardiovascular disease. (Also visit: Perspectives on Premeds series - Phenothiazines; Opioids; Alpha-2 Agnoists; Benzodiazepines).

PRE-OXYGENATION: Provision of supplemental oxygen for at least 3 minutes prior to induction increases the time until oxygen desaturation in the event of apnoea or respiratory obstruction8. Delivery via a face mask is ideal, but only if the patient does not become stressed by this method. Alternative solutions (flow-by oxygen, oxygen cage) are not as effective, but may provide some benefit. (Also visit: Ambros (2018) - Pre-oxygenation Study Highlights).

INDUCTION: Adverse cardiovascular effects are common amongst induction agents, and therefore it is important to monitor the patient closely throughout induction. Where possible, it is a good idea to attach monitoring equipment prior to induction, provided this does not add to patient stress. The use of a short acting induction agent with minimal cardiorespiratory effects such as Alfaxan® is ideal in these patients. Consider the use of a benzodiazepine as a co-induction agent to reduce dose requirements of the anaesthetic agent. Ensure an adequate depth of anaesthesia is reached prior to attempting endotracheal intubation, as inadvertent stimulation of the larynx may result in cardiovascular responses such as tachycardia, hypertension and increased myocardial oxygen demand.

MAINTENANCE: Inhalant anaesthetics all decrease cardiac output in a dose-dependent manner, through a depression in myocardial contractility. The use of isoflurane or sevoflurane are considered clinically acceptable for use in cardiac patients. A suitable alternative is the use of total intravenous anaesthesia with Alfaxan®, which has been shown to be safe and efficacious as a maintenance agent, and has little effect on the cardiovascular system9,10,11. Spontaneous ventilation is usually adequate for these patients, but close monitoring for hypercapnia and hypoventilation is important, and appropriate manual or mechanical ventilation started if such derangements are detected. (Also visit: TIVA or not? Total intravenous anaesthesia; Alfaxan for induction and maintenance of anaesthesia - User GuideAlfaxan for maintenance - FAQs; Alfaxan for maintenance of anaesthesia - clinical papers; Dose guide for CRI & intermittent bolus).

PERI-OPERATIVE FLUID THERAPY: Cardiac patients have unique peri-operative fluid requirements. Dehydration and fluid overload should both be avoided, so it is important to assess hydration status prior to administration of any drugs or fluids. Fluid therapy in cardiac patients is designed to help maintain intravascular volume, and therefore ensure adequate cardiac output and oxygen delivery to the tissues. Unless a patient is expected to lose significant blood volume throughout the anaesthetic, rates of 2 – 5 mL/kg/ hr of a balanced electrolyte solution are generally sufficient for peri-operative fluid therapy. As cardiac patients will often be receiving diuretics, it is important to ensure that maintenance rates of intravenous fluid therapy are continued during the recovery period and until the patient is able to drink on their own accord.

MONITORING: Out outlined above, the maintenance of adequate cardiac output is vital in the anaesthesia of cardiac patients. The essential physiological parameters to be measured are heart rate and rhythm via continuous electrocardiograph (ECG), oxygen saturation (SpO2) via pulse oximetry, respiratory rate, end-tidal CO2, temperature, and blood pressure via either a non-invasive method or by direct arterial catheterisation. (Also visit: Nuances in CV Monitoring; Capnography 1; Capnography 2)

RECOVERY: The recovery period is when most anaesthetic deaths have been shown to occur12. Reduce level of stress of the animal by ensuring the patient has appropriate analgesia on board, and by allowing them to recover in a quiet area away from general activity. Monitor these patients closely until they have regained normal homeostasis, most importantly, body temperature, ventilation, blood pressure, and heart rate.  (Also visit: The Big Chill - Temperature Management)

Cardiac medications 

The following provides a list of the most commonly used medications in cardiac disease, and a brief description of how they may influence anaesthesia.

The following provides a list of the most commonly used medications in cardiac disease, and a brief description of how they may influence anaesthesia

ACE inhibitors e.g. benazepril, enalapril. Cause vasodilation and may lead to significant hypotension during anaesthesia

Positive-inotropes (Ca2+ sensitisers) e.g. pimobendan May increase incidence of cardiac arrhythmias, very few documented interactions with anaesthetic drug

Diuretics e.g. furosemide. Ensure adequate fluid intake prior to, during, and after anaesthesia

K+ sparing diuretics e.g. spironolactone Ensure adequate fluid intake prior to, during, and after anaesthesia

Article by
Miranda Tiong
BSc BVMS GradDipEd

Technical Services Veterinarian

Originally published: Wednesday, 11th September 2019

References

1. Muir W, Lerche P, Wiese A, Nelson L, Pasloske K, Whittem T. 2008. Cardiorespiratory and anesthetic effects of clinical and supraclinical doses of alfaxalone in dogs. Vet Anaesth Analg. 35(6): 451–62.

2. Muir W, Lerche P, Wiese A, Nelson L, Pasloske K, Whittem T. 2009. The cardiorespiratory and anesthetic effects of clinical and supraclinical doses of alfaxalone in cats. Vet Anaesth Analg. 36(1): 42–54.

3. Psatha E, Alibhai HI, Jimenez-Lozano A, Armitage-Chan E, Brodbelt DC. 2011. Clinical efficacy and cardiorespiratory effects of alfaxalone, or diazepam/fentanyl for induction of anaesthesia in dogs that are a poor anaesthetic risk. Vet Anaesth Analg. 38(1): 24–36.

4. Nelson RW, Couto CG. 2014. Small Animal Internal Medicine. Fifth edition. St. Louis, MO: Elsevier/Mosby. 1473.

5. Duke-Novakovski T, Vries M de, Seymour C. 2016. BSAVA Manual of Canine and Feline Anaesthesia and Analgesia. Third edition. Quedgeley: British Small Animal Veterinary Association. 464

6. Grimm KA, Lamont LA, Tranquilli WJ, Greene SA, Robertson SA. 2015. Veterinary Anaesthesia and Analgesia. Fifth edition. Ames, Iowa: Wiley Blackwell. 1061.

7. Clarke KW, Hall LW, Trim CM. 2014. Veterinary Anaesthesia. 11th ed. Edinburgh; New York: Saunders/Elsevier. 694.

8. McNally EM, Robertson SA, Pablo LS. 2009. Comparison of time to desaturation between preoxygenated and nonpreoxygenated dogs following sedation with acepromazine maleate and morphine and induction of anesthesia with propofol. Am J Vet Res. 11: 1333–8.

9. Schwarz A, Kalchofner K, Palm J, Picek S, Hartnack S, Bettschart-Wolfensberger R. 2014. Minimum infusion rate of alfaxalone for total intravenous anaesthesia after sedation with acepromazine or medetomidine in cats undergoing ovariohysterectomy. Vet Anaesth Analg. 41(5): 480–90.

10. Pasloske KS, Gazzard B, Perkins N, Dunlop C, Whittem T. 2005. A multicentre clinical trial evaluating the efficacy and safety of Alfaxan®-CD RTU administered to dogs for induction and maintenance of anaesthesia. Abstract accepted for the British Small Animal Veterinary Association Congress.

11. Waelbers T, Vermoere P, Polis I. 2009. Total intravenous anaesthesia in dogs. Vlaams Diergeneeskd Tijdschr. 78(3): 160–9.

12. Brodbelt DC, Blissitt KJ, Hammond RA, Neath PJ, Young LE, Pfeiffer DU, Wood JL. 2008. The risk of death: the confidential enquiry into perioperative small animal fatalities. Vet Anaesth Analg. 35(5): 365–373.

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