INSUFICIENTA CARDIACA

PERIOPERATORIE
Heart failure (HF) is one of the most common conditions requiring evaluation and treatment in patients
undergoing noncardiac surgery. Ageing populations and progress in the treatment of chronic diseases
such as hypertension, diabetes, and coronary artery disease are increasing the prevalence of HF [1]. In
addition, elderly patients at risk for HF are undergoing noncardiac surgery at increasing rates. It is
estimated that HF is present in almost 20 percent of older adults undergoing common surgical
procedures in the United States [2]. HF is a major risk factor for adverse cardiac events, including death
following noncardiac surgery [3].

GENERAL APPROACH
 

The general approach to management of perioperative heart failure includes :

-preoperative evaluation and risk assessment,
-decision making regarding whether and when to proceed with surgery,
-pre-, intra-, and postoperative management.
The main overall goals of assessment are to:

Identify patients at increased risk of an

adverse perioperative cardiac event

Identify patients with a poor long-term

prognosis due to cardiovascular disease. Even
though the risk at the time of non-cardiac
surgery may not be prohibitive, appropriate
treatment will affect long-term prognosis.
The nature of the evaluation should be individualised to the
patient and the specific clinical scenario.

Patients presenting with an acute surgical emergency

require only a rapid preoperative assessment, with
subsequent management directed at preventing or
minimising cardiac morbidity and death. Such patients can
often be more thoroughly evaluated after surgery.

Patients undergoing an elective procedure with no surgical

urgency can undergo a more thorough preoperative
evaluation.
Patient-Related Predictors for Risk of
Perioperative Cardiac Complications
Surgery-Related Predictors for Risk of
Perioperative Cardiac Complications
 PREANESTHESIA CONSULTATION
Goals of the preanesthetic consultation include :
●Evaluating the severity and stability of
symptoms in patients with known chronic heart
failure (HF).
●Identifying patients with unsuspected HF by
careful history and physical examination.
●Assessing the risk of cardiac morbidity and
mortality in patients with HF.
 History and physical examination
• The history, including assessment of New York Heart
Association (NYHA) functional class, provides a
reasonable estimate of the severity of HF
• Symptoms of HF include: decreased exercise tolerance,
paroxysmal nocturnal dyspnea, cough, orthopnea,
peripheral edema, and nocturia
• Physical examination in patients with HF may reveal a
third heart sound (S3), elevated jugular venous pressure,
hepatomegaly, ascites, rales, wheezing, diminished
breath sounds, and a laterally-displaced apical impulse
 What workup does this patient need before
surgery?
The patient with HF presents in one of three ways:

1)A noticeable onset of exertional dyspnea or decrease

in exercise tolerance;
2) Fluid retention;
3) With no symptoms or with symptoms of another cardiac
disorder or noncardiac disorder.

The complete history and physical exam will delineate cardiac versus
noncardiac causes of presentation. The routine ECG and chest X-ray have
low sensitivity and specificity for diagnosing a cardiac cause of HF, but are
useful in the general assessment of cardiac and pulmonary pathology
 Preoperative testing
• preoperative resting 12-lead except for those
undergoing low-risk surgery
• a metabolic panel (sodium, potassium, chloride,
carbon dioxide, glucose, blood urea nitrogen,
creatinine)
• A chest radiograph is not routinely recommended in
patients with chronic stable HF,
• a chest radiograph should be obtained in patients with
acute decompensated HF to look for evidence of
pulmonary vascular congestion and pulmonary edema
• Measurement of brain natriuretic peptide (BNP) is not
routinely recommended

• Left ventricular (LV) function should be evaluated

preoperatively in patients with dyspnea of unknown
origin, worsening dyspnea, or other change in
functional clinical status
• Echocardiography in patients with symptoms or signs
of new or worsening HF useful to establish the
etiology.
• Diagnostic utility of BNP and NT-proBNP — B-
type natriuretic peptide (BNP) and N-terminal
pro-BNP (NT-proBNP) assays can supplement
clinical judgment when the cause of a
patient's dyspnea is uncertain, particularly
among patients with an intermediate
probability of HF
• Echocardiographic quantification of the severity of
both systolic and diastolic dysfunction may guide
perioperative management in patients with
symptomatic HF.
• For example, if severe systolic dysfunction is
identified, then inotropic therapy might be
preferable to fluid administration for ensuring end-
organ perfusion, and anesthetic agents causing
myocardial depression might be avoided or
administered in low doses
• If severe diastolic dysfunction in a small non-compliant
LV is identified, then it is important to maintain
adequate preload.
• Underfilling the LV may result in decreased cardiac
output and concomitant hypotension, even if the LV
ejection fraction is normal.
• Decompensated heart failure — In patients with
decompensated HF (NYHA Class IV, worsening, or new-
onset HF), surgery is postponed, if possible, to allow
treatment and stabilization of HF symptoms . However,
options may be limited in patients requiring urgent or
emergent surgery.
●Cardiogenic shock —
For patients with cardiogenic shock due to a recent
myocardial infarction (MI), unstable angina,
decompensated heart failure (HF), high-grade
arrhythmias, or hemodynamically important valvular
heart disease such as aortic stenosis, surgery is delayed if
possible, because of a high risk for postoperative
complications (eg, worsening of the MI and/or HF,
ventricular fibrillation, complete heart block, cardiac
arrest, cardiac death). If urgent or emergent surgery is
necessary, benefits and risks of timing strategies are
discussed among the cardiologist, surgeon, and
anesthesiologist
• If acute coronary syndrome is suspected,
serial ECGs and measurements of cardiac
enzymes should be performed and urgent
coronary angiography should be considered
when ischemia may be contributing to (rather
than a consequence of) HF
 PREOPERATIVE MANAGEMENT
Medications — In patients already taking the following
medications for treatment of HF, considerations for
anesthetic care include:
●Beta blockers – Chronically administered beta blockers are
continued perioperatively.
●Angiotensin converting enzyme inhibitors and angiotensin
receptor blockers – Angiotensin converting enzyme (ACE)
inhibitors and angiotensin receptor blockers (ARBs) are
generally continued perioperatively unless there is evidence
of hemodynamic instability, hypovolemia, or acute elevation
of creatinine
• One observational study in patients undergoing
noncardiac surgery found that withholding an ACE
inhibitor or ARB for 24 hours was associated with
reduced risk of intraoperative hypotension and
adverse outcomes
●Aldosterone antagonists – In HF patients receiving
an aldosterone antagonist, hyperkalemia is the most
important potential adverse effect, especially if
aldosterone antagonists have been chronically
administered in combination with ACE inhibitors.
The preoperative potassium level should be checked.
●Diuretics – Perioperative hypovolemia and
hypokalemia are the major physiologic effects of
concern in patients receiving chronic diuretic
therapy. Close attention to electrolytes is necessary.
●Digoxin – The role of digoxin in the perioperative
period is not well-defined. Although administration
of digoxin may decrease the incidence of
postoperative supraventricular arrhythmias, the
anesthesiologist must be prepared to treat other
digoxin-induced arrhythmias.
• Aldosterone antagonists (spironolactone),
digoxin, and longacting nitrates can be
continued on the day of surgery.
• PREOPERATIVE MANAGEMENT
In general, patients with a history of heart failure
(HF) who are asymptomatic at the time of surgery
should continue their current medical regimen.
Patients with symptomatic HF prior to surgery
should receive medical therapy to optimize their
clinical status. There is little evidence on how to
manage HF in the preoperative period
The goals of optimization to achieve stability in patients
with preoperative HF are similar to those of all patients
with decompensated HF
●Improve symptoms, especially congestion and low-
output symptoms
●Restore normal oxygenation
●Optimize volume status and improve end-organ
perfusion
●Identify etiology
●Identify and address precipitating factors
 Pacemaker interrogation
• to determine whether a patient’s heart rhythm is
pacemaker dependent and if so, the device should be
re-programmed to asynchronous demand pacing (e.g.,
VOO).
• a magnet placed on the chest should convert a
pacemaker to VOO
• If a biventricular pacemaker device has an ICD, a
• magnet should inactivate the defibrillator but may not
change the pacemaker settings. To prevent
unnecessary shocks the ICD should be inactivated
• Implantable cardioverter defibrillators and
pacemakers — Patients with HF frequently
have a pacemaker and/or implantable
cardioverter defibrillator or a biventricular
pacemaker inserted to provide cardiac
resynchronization therapy
 INTRAOPERATIVE MANAGEMENT
Cardiac output is determined by heart rate,
preload, afterload, and contractility. These
factors can be manipulated intraoperatively by:
●Control of heart rate and rhythm
●Fluid replacement and diuretics
●Vasopressor and vasodilator drugs
●Administration of positive and negative
inotropic drugs
Monitoring
• The aim of monitoring is the early detection of perioperative
cardiovascular dysfunction and assessment of the mechanism(s) leading to it

• Volume status is ideally assessed by ‘dynamic’ measures

of haemodynamic parameters before and after volume
challenge rather than single ‘static’ measures

• Heart function is first assessed by echocardiography

followed by pulmonary arterial pressure, especially in
the case of right heart dysfunction

• If both volaemia and heart function are in the normal

range, cardiovascular dysfunction is very likely related
to vascular dysfunction
With regard to managing perioperative HF, the four crucial components remain
measurements of heart rate, volaemia, myocardial function and vessel tone.
 Monitors
• ACCF/AHA guidelines recommend invasive
hemodynamic monitoring in HF patients
whose fluid status, perfusion, or systemic or
pulmonary vascular resistance is uncertain;
whose systolic pressure remains low, or is
associated with symptoms, despite initial
therapy; whose renal function is worsening
with therapy; or those who require parenteral
vasoactive agents
Hemodynamic monitoring — Hemodynamic
monitoring in patients with ventricular
dysfunction depends on patient-specific and
surgery-specific factors
●Electrocardiography (ECG) – Continuous ECG
monitoring is necessary to detect arrhythmias
and/or myocardial ischemia;computerized ST-
segment trending
●Intraarterial catheter – Invasive measurement
of arterial blood pressure (BP) is used when
moment-to-moment BP changes are anticipated
and rapid detection is vital. An intra-arterial
catheter is also useful for guiding management
of vasoactive drugs, including vasopressors,
vasodilators, and inotropic agents, as well as
facilitating the anesthesiologist's ability to obtain
frequent arterial blood gas measurements.
If possible, the intra-arterial catheter is inserted
prior to induction of anesthesia
●Central venous catheter – The decision to place a
central venous catheter (CVC) is based on the potential
for significant blood loss and/or large fluid shifts,
likelihood of administration of continuous infusions of
vasoactive drugs, and challenges in obtaining reliable
intravascular access.
• Monitoring the trend in CVP values may be helpful to
avoid extremes to enable maintenance of adequate
preload while preventing volume overload,
particularly in patients with right-sided heart failure
●Measurement of central mixed venous oxygen
saturation (ScvO2) in blood drawn from the
distal port of a CVC to serve as a surrogate for
adequacy of CO if a pulmonary artery catheter
(PAC) is not available
SCVO2>70 percent is considered to be a good
target during resuscitation efforts.
●Pulmonary artery catheter (PAC) – PAC
monitoring is not routinely recommended for
monitoring patients with cardiovascular disease.
• However, many clinicians insert a PAC for
patients with severe right ventricular (RV)
dysfunction, pulmonary hypertension, or
cardiogenic shock due to acute valvular
disease.
●Hemodynamic measurements such as CO (and
cardiac index), systemic vascular resistance (SVR),
pulmonary artery pressures, pulmonary artery
occlusion pressure (PAOP), CVP, and pulmonary
vascular resistance (PVR)
●Mixed venous oxygen saturation values in blood
drawn from the pulmonary arterial port (SvO2). This
blood includes drainage from the coronary sinus which
has a low saturation; thus, SvO2 will be slightly lower
than ScvO2 .
• The intrathoracic thermodilution method
utilizes a central venous line for injection of
iced saline, and a thermodilution catheter in a
proximal artery (i.e., femoral or axillary) to
sense the temperature change from the cold
saline injection
• estimates stroke volume and intrathoracic
blood volume and global end-diastolic volume
without dependence on the respiratory cycle
●Intermittent blood sampling to measure arterial
blood gases, pH, base deficit, serum lactate,
hemoglobin, electrolytes, glucose, and activated
clotting time (ACT). Additional tests of hemostasis
are obtained if there is evidence of coagulopathy or
significant bleeding
The most useful diagnostic test is echocardiography to
address three main questions:
1)ejection fraction;
2) left ventricular structure, dimension, wall motion;
3) non-left ventricular abnormalities (i.e., valve,
pericardium, right ventricle).
Additional echocardiography indices will
include atrial size and pressure, characteristics of
LV filling, and pulmonary arterial pressure.
●Transesophageal echocardiography (TEE) – Emergency
use of intraoperative or perioperative TEE is indicated to
determine the cause of any unexplained persistent or
life-threatening hemodynamic instability ("rescue echo")
when equipment and expertise are available
• TEE may identify hypovolemia, Left ventricular (LV)
and/or right ventricular (RV) dysfunction, pericardial
effusion or tamponade, intrapulmonary emboli,
valvular regurgitation, or LV outflow tract obstruction
• Even with minimal user training,
transesophageal echocardiography (TEE)
provides real-time image estimates of end-
diastolic ventricular volume, and global and
regional ventricular contractile function
• TEE is often considered the monitor of choice
to differentiate between cardiogenic,
hypovolemic, and vasodilatory causes of shock
• The most critical aspect of intraoperative and
postoperative monitoring for HF patients
involves careful fluid management.
“Static” variables are those that estimate cardiac
filling pressure or cardiac filling volume (as an
estimate of end-diastolic volume, or preload)
CVP, PAP, PCWP
Will not discriminate between changes in
ventricular dysfunction and volume overload
• “Dynamic” variables estimate changes in
intravascular volume based on characteristics of
the arterial waveform that vary with the
respiratory cycle
• A regular rhythm is also necessary
• Hypovolemia is suggested when systolic
pressure variation is greater than 10 mmHg.
Similarly, pulse pressure (PP) will vary over the
respiratory cycle in accord with hypovolemia.
• SVV or PPV >10% suggests that the patient is fluid
responsiveness as indicates that stroke volume is sensitive
to fluctuations in preload caused by the respiratory cycle
• CONDITIONS AND CAVEATS
• The patient must be in volume controlled ventilation,
without spontaneous breathing
• Tidal volume must be at least 8 ml/Kg
• If using SVV the SV must be measured beat to beat
• Should’t be used on a patient with an arrhythmia, right
heart failure or pulmonary hypertension, as those will lead
to an increased variation
• Module on the arterial line that analyzes the pulse contour
to estimate SV
• CAUSES OF INCREASED SYSTOLIC PRESSURE VARIATION

• Hypovolaemia
• Tamponade
• Constrictive pericarditis
• LV dysfunction
• Massive PE
• Bronchospasm
• Dynamic hyperinflation
• Pneumothorax
• Raised intrathoracic pressure
• Raised intraabdominal pressure
• FLUID RESPONSIVENESS
• SVV and PPV are not indicators of actual preload
but of relative preload responsiveness.
• Also, just because a patient is fluid responsive
does not mean they actually need fluid.
• SVV has a very high sensitivity and specificity
when compared to traditional indicators of
volume status (HR, MAP, CVP, PAD, PAOP), and
their ability to determine fluid responsiveness.
• Commercial modules exist that determine
variability in the amplitude of the pulse
oximetry waveform. The variability in pulse
oximeter plethysmography waveform (ΔPOP) is
calculated as the maximal minus minimal
plethysmographic amplitude, divided by the
maximal amplitude. This too can be
determined over one respiratory cycle
• Cardiac output monitors — Determining
whether a patient has a low or high CO state is
helpful to guide intraoperative resuscitative
efforts. Several invasive and noninvasive
technologies have been developed to measure
CO, including arterial pulse waveform analysis,
thoracic electrical bioimpedance, aortic
Doppler, point-of-care echocardiography, and
carbon dioxide rebreathing
How should I care for this patient during and
after surgery?

Induction and maintenance of anesthesia

• An awake arterial catheter prior to induction is
helpful for any patient in acute or
decompensated HF presenting for emergency
surgery, for any HF patient in a higher functional
class or stage of HF and for any HF patient with
severe systolic or diastolic dysfunction,
pulmonary hypertension, or significant valvular
disease.
• Rapid atrial fibrillation in a HF patient would also
indicate arterial line placement, with aggressive
attempts to adequately stabilize ventricular rate
control prior to surgery.
• Propofol or thiopental have the potential to cause
profound hypotension in the HF patient because of
the chronically elevated sympathetic nervous system
activity
• can be given simultaneously with pressor
administration
• Etomidate and ketamine have less effect on
sympathetic-mediated maintenance of blood
pressure
• Maintenance of anesthesia in HF patients is
generally dependent on the surgical
procedure, the expected duration of
procedure, blood loss, fluid shifts, and the
need for additional monitoring techniques
• Maintenance — Anesthetic agents for
maintenance of anesthesia are selected with
consideration of dose-dependent
cardiovascular effects. In most cases, a volatile
inhalation anesthetic agent is initiated at a
lower concentration than in healthy patients,
with titration to maintain anesthesia while
avoiding a further decrease in end-organ
perfusion
●Intraoperative resuscitation target values
include systolic BP ≥90 mmHg or mean arterial
pressure (MAP) ≥65 mmHg, urine output ≥0.5
mL/kg per hour, and decreasing serum lactate
levels.
Hemodynamic supportive infusions for
perioperative management
Decompensated heart failure 

Patients at increased risk for development of acute HF in

the immediate postoperative period include those with a
history of chronic left or right HF, as well as those with
diastolic HF (also called HF with preserved ejection fraction).
This is due to intraoperative factors such as fluid
overload resulting from fluid shifts during major surgery,
anemia, myocardial ischemia, severe hypertension, stress-
induced (Takotsubo) cardiomyopathy, or prolonged
unfavorable surgical positioning (eg, supine positioning of a
patient who cannot tolerate this position while awake).
Acute HF typically manifests as respiratory distress with
or without overt pulmonary edema. Respiratory distress may
be accompanied by hypertension due to hypervolemia or
hypotension due to cardiogenic shock or excess vasodilator
use.
TREATMENT GOALS FOR ACUTE VERSUS CHRONIC HF  
It is important to distinguish the management of acute decompensated heart failure (ADHF) from that of chronic HF. The treatment of chronic HF, particularly when due to systolic
dysfunction, is built around therapies that have been shown to reduce long-term mortality and improve symptoms (eg, angiotensin converting enzyme inhibitors and beta blockers).
In contrast, the goals of the initial management of ADHF are hemodynamic stabilization, support of oxygenation and ventilation, and symptom relief . Some of the cornerstones of
chronic HF therapy should not be added or should be used with caution in ADHF (eg, beta blockers), particularly during the period of initial stabilization. Such therapies may be initiated
or titrated upward later in a patient's course.
Acute Heart Failure

Definitions

CONGESTIVE HEART FAILURE (CHF): It is defined as the

inability of the heart to supply sufficient substrate to meet
the needs of the body.
CARDIOGENIC SHOCK (CS): It is end-stage CHF and is a
largely irreversible condition and as such is more often fatal
than not.
PULMONARY EDEMA: Accumulation of fluid in the
pulmonary air spaces and the interstitial spaces of the lungs,
which inhibits oxygen and carbon dioxide diffusion, leading
to impaired gas exchange and respiratory failure.
●Acute decompensated heart failure — Left,
right, or biventricular heart failure may cause
cardiogenic shock.
•Left-sided heart failure — In general, goals
during the intraoperative period are to reduce
preload and afterload, maintain sinus rhythm
and a normal to high heart rate (HR) of 80 to
100 beats per minute, and improve contractility
• Because decompensated left-sided heart
failure is often associated with pulmonary
edema, appropriate levels of positive end-
expiratory pressure (PEEP; eg, 5 to 10 cmH2O)
are employed to improve oxygenation.
However, high PEEP >10 cmH2O is generally
avoided, as this may deleteriously reduce
venous return and CO.
•Right-sided heart failure — Perioperative right-
sided cardiogenic shock is aggressively treated
since it rapidly leads to multiorgan system failure
Infusion of an inodilator agent such as milrinone
or dobutamine is usually indicated.
Concomitant use of a vasopressor infusion such as
norepinephrine or vasopressin is typically
required to maintain adequate coronary perfusion
• Pulmonary vascular resistance (PVR) should be
minimized by maintaining normal PaCO2,
PaO2, and pH levels. Excessive tidal volumes,
excessive PEEP, and atelectasis should be
avoided.
• It is also important to maintain normothermia.
If necessary, inhaled nitric oxide or prostanoids
(eg, epoprostenol) may be administered to
reduce PVR
A major cause of non-ischemic contractile dysfunction
is chronic volume overload due to either severe mitral
regurgitation or severe aortic regurgitation. This leads
to chamber dilation and eccentric hypertrophy.

Pressure overload is a functional cause of diastolic

HF, where chronic hypertension or chronic aortic
stenosis lead to ventricular remodeling which
increases wall thickness
What are defined as perioperative cardiac
complications?

Myocardial infarction
Pulmonary edema,
Ventricular fibrillation,
Primary cardiac arrest,
Complete heart block are
major perioperative cardiac complications.
TREATMENT GOALS FOR ACUTE VERSUS CHRONIC HF  
It is important to distinguish the management of acute decompensated heart failure (ADHF) from that of chronic HF. The treatment of chronic HF, particularly when due to systolic
dysfunction, is built around therapies that have been shown to reduce long-term mortality and improve symptoms (eg, angiotensin converting enzyme inhibitors and beta blockers).
In contrast, the goals of the initial management of ADHF are hemodynamic stabilization, support of oxygenation and ventilation, and symptom relief . Some of the cornerstones of
chronic HF therapy should not be added or should be used with caution in ADHF (eg, beta blockers), particularly during the period of initial stabilization. Such therapies may be initiated
or titrated upward later in a patient's course.
Monitoring
Group recommendations

• The aim of monitoring is the early detection of perioperative

cardiovascular dysfunction and assessment
of the mechanism(s) leading to it
• Volume status is ideally assessed by ‘dynamic’ measures
of haemodynamic parameters before and after volume
challenge rather than single ‘static’ measures
• Heart function is first assessed by echocardiography
followed by pulmonary arterial pressure, especially in
the case of right heart dysfunction
• If both volaemia and heart function are in the normal
range, cardiovascular dysfunction is very likely related
to vascular dysfunction
With regard to managing perioperative HF, the four crucial components remain
measurements of
heart rate,
volemia,
myocardial function and
vessel tone.
Pharmacological treatment of left ventricular
dysfunction after cardiac surgery
Group recommendations
• In case of myocardial dysfunction, consider the following three options either alone or
combined:
• Among catecholamines, consider low-to-moderate doses of dobutamine and epinephrine:
they both improve stoke volume and increase heart rate while PCWP is
moderately decreased; catecholamines increase myocardial oxygen consumption
• Milrinone decreases PCWP and SVR while increasing stoke volume; milrinone causes less
tachycardia than dobutamine
• Levosimendan, a calcium sensitizer, increases stoke volume and heart rate and decreases
SVR
• Norepinephrine should be used in case of low blood pressure due to vasoplegia to
maintain an adequate perfusion pressure. Volaemia should be repeatedly assessed to
ensure that the patient is not hypovolaemic while under vasopressors
• Optimal use of inotropes or vasopressors in the perioperative period of cardiac surgery is
still controversial and needs further large multinational studies
There is consensus that cardiogenic shock is the severest form of HF; regardless
of etiology, pathophysiology, or initial clinical presentation, it can be the final
stage of both acute and chronic HF, with the highest mortality
Preoperative poor LV function is the most important predictor of postoperative
morbidity and mortality after CABG
Cardiovascular problems in the post-anesthesia
care unit (PACU)

CARDIOVASCULAR COMPLICATIONS 

— Myocardial ischemia or decompensated heart failure (HF) may

occur in the post-anesthesia care unit (PACU) with or without
associated hemodynamic instability (eg, hypotension, hypertension,
arrhythmias).
Myocardial ischemia — Patients at high risk for perioperative myocardial ischemia or
infarction include those having in-hospital surgery with one or more additional risk factors
in the revised cardiac risk score .

The highest-risk patients are those having urgent or emergent surgery with:
●Recent myocardial infarction or unstable angina
●Recent percutaneous coronary intervention (PCI), particularly if dual antiplatelet therapy
was prematurely discontinued for surgery.
In high-risk patients, continuous electrocardiography (ECG) monitoring for myocardial
ischemia includes multiple leads (eg, II and V5) and computerized ST-segment analysis, if
available in the PACU.
Optimal myocardial oxygen (O2) supply and minimal O2 demand are achieved by maintaining
a low to normal heart rate, normal to high blood pressure (BP), and adequate arterial
oxygen content, as well as avoiding hypothermia and fluid overload .

In patients with symptoms or signs suggestive of myocardial ischemia, we recommend

obtaining a 12-lead ECG and troponin measurements. Also, a cardiologist is consulted since
urgent subspecialist interventions will be necessary if an acute coronary syndrome is
developing
Decompensated heart failure 

Patients at increased risk for development of acute HF in the immediate postoperative

period include those with a history of chronic left or right HF, as well as those with diastolic
HF (also called HF with preserved ejection fraction).
This is due to intraoperative factors such as fluid overload resulting from fluid shifts
during major surgery, anemia, myocardial ischemia, severe hypertension, stress-induced
(Takotsubo) cardiomyopathy, or prolonged unfavorable surgical positioning (eg, supine
positioning of a patient who cannot tolerate this position while awake).
Acute HF typically manifests as respiratory distress with or without overt pulmonary
edema. Respiratory distress may be accompanied by hypertension due to hypervolemia or
hypotension due to cardiogenic shock or excess vasodilator use.
 What is Pulse pressure(PP)? What is Proportional
pulse pressure(PPP)?
Pulse pressure = Systolic blood pressure - Diastolic blood
pressure( PP= SBP-DBP)
It indicates pulse volume
Average PP is 30- 40 mmhg
Proportional Pulse Pressure = Pulse pressure / Systolic blood
pressure(PPP= PP/SBP)
It is an indicator of LV function
If PPP < = 25% , indicates LVF and Cardiac index <= 2.2
l/min/m2

Clin Exp Hypertens. 2018;40(7):637-643. doi: 10.1080/10641963.2017.1416121. Epub 2017

Dec 21.
Proportional pulse pressure relates to cardiac index in stabilized acute heart failure
patients.
Petrie CJ1, Ponikowski P2,3, Metra M4, Mitrovic V5, Ruda M6, Fernandez A7, Vishnevsky A8, 
Cotter G9, Milo O9, Laessing U10, Zhang Y11, Dahlke M10, Zymlinski R3, Voors AA12.
Treatment for acute decompensated HF incudes :

●Administration of supplemental O2.

●For persistent respiratory distress, respiratory acidosis, and/or hypoxia despite oxygen therapy, initiation of noninvasive ventilation (NIV) or endotracheal intubation and mechanical ventilation, as
indicated.
●Administration of intravenous (IV) diuretics to relieve pulmonary congestion or fluid overload .
●Initiation of vasodilator therapy in the following settings: early IV nitroglycerin as a component of therapy in patients with refractory HF (eg, inadequate response to diuretics and/or low cardiac output),
or IV nitroprusside as arterial vasodilator therapy to reduce afterload in patients with severe hypertension .
●Initiation of an inotropic infusion (eg,  dobutamine or milrinone) in patients with known systolic HF and signs of cardiogenic shock, in combination with a vasopressor (eg, norepinephrine) if necessary to
maintain systemic BP.
 SUMMARY AND RECOMMENDATIONS

Hypotension in the post-anesthesia care unit (PACU) is treated when systolic blood pressure (BP) is
<90 mmHg or has decreased >20 percent of baseline, or if the patient develops symptoms or other
evidence of hypoperfusion (eg, change in mental status or decreased urine output).

•Initial treatment includes intravenous (IV) isotonic crystalloid solution administered in 250- to 500-mL
increments and, if necessary, IV vasopressor/inotropic agents (eg, phenylephrine 40 to 100 mcg or 
ephedrine 5 to 50 mg). Severe or refractory hypotension is treated with IV bolus doses of epinephrine 10
to 50 mcg, norepinephrine 5 to 10 mcg, or vasopressin 1 to 4 units, while
a vasopressor/inotropic infusion is prepared .

•Additional treatment of hypotension depends upon the specific etiology (eg, hypovolemia due to
inadequate fluid replacement or blood loss, drug effects due to antihypertensive or anesthetic agents,
allergic reaction, adrenal insufficiency, myocardial dysfunction).

•Severe hypotension or hemodynamic collapse requiring immediate lifesaving intervention may occur
due to anaphylactic shock, septic shock, local anesthetic toxicity, tension pneumothorax, pulmonary
embolus, cardiac tamponade, or dynamic left ventricular outflow tract obstruction. Support
with vasopressor/inotropic agents is necessary while definitive treatment is underway
Va multumesc!