Anesthetic Consideration in Patient With Heart Failure

Anesthetic Consideration in Patient With Heart Failure

Heart failure is a complex pathophysiologic state described by the inability of the heart to fill with or eject blood at a rate appropriate to meet tissue requirements. The clinical syndrome is characterized by symptoms of dyspnea and fatigue and signs of circulatory congestion or hypoperfusion.

Heart failure arises from diverse causes. The principal problem of heart failure is the inability of the heart to fill or empty the ventricle which decreases the cardiac output and tissue perfusion. Ischemic heart disease, cardiac valve abnormalities, systemic hypertension, cardiomyopathy (disease of the heart muscle) is the most common causes of heart failure.

Because the failing ventricle does not empty the blood which will accumulate in the lung to produce pulmonary congestion (accumulation of fluid in the lung tissue which can affect oxygenation) in left sided heart failure. The patient complains of dyspnea, orthopnea (a condition in which a person has great difficulty in breathing while lying down), and paroxysmal nocturnal dyspnea (an attack of breathlessness at night, usually caused by congestive heart failure), which can evolve to pulmonary edema. Right-sided heart failure causes systemic venous congestion. Peripheral edema, raised jugular vein and congestive hepatomegaly are the most prominent clinical manifestations.

Anesthetic management of patient with congestive heart failure: Elective surgery should not be performed on patients with congestive heart failure unless optimally treated. Patient with congestive heart failure should be managed in central hospitals which have many specialty and other resources to optimize patient condition preoperatively, manage anesthesia and provide critical care postoperatively.

When surgery cannot be delayed, however, you should weight the merits and de merits of the surgery and drugs and techniques chosen to provide anesthesia must be selected with the goal of minimizing detrimental effects on cardiac output. Discus with the operating physician and other who can have an impact on the management of the patient

Etomidate or small dose ketamine may be useful for the induction of anesthesia in the presence of congestive heart failure because of its limited effect on the sympathetic nervous system. Small concentrations of volatile anesthetics can maintain anesthesia, but cardiac depression should be avoided if possible. Positive-pressure ventilation of the lungs may be beneficial by decreasing pulmonary congestion, improving arterial oxygenation, and eliminating the work of breathing. The resumption of negative intrathoracic pressures with spontaneous ventilation following extubation can lead to increased filling pressures and worsening heart failure. Invasive monitoring of intra-arterial blood pressure is helpful.