A 78-yrs-old man with a history of coronary artery disease

Discussion in 'MRCS Forum' started by Lona., Oct 25, 2007.

  1. Lona.

    Lona. Guest

    A 78-yrs-old man with a history of coronary artery disease and an asymptomatic reducible inguinal hernia requests an elective hernia repair. You explain to him that valid reasons for delaying the proposed surgery include-
    a- Coronary artery bypass surgery 3 months earlier
    b- A history of cigarette smoking
    c- Jugular venous distension
    d- Hypertension
    e- Hyperlipidaemia
  2. Lona.

    Lona. Guest

    Answer: c- Jugular venous distension. (Goldman, J Cardiothorac Anesth 1:237, 1987)
    The work of Goldman and others has served to identify risk factors for perioperative myocardial infarction. The highest likelihood is associated with recent myocardial infarction: the more recent the event, the higher the risk up to 6 months. It should be noted, however, that the risk never returns to normal. A non-Q-wave infarction may not have destroyed much myocardium, but it leaves the surrounding area with borderline perfusion; thus the particular high risk of subsequent perioperative infarction. Evidence of congestive heart failure, such as jugular venous distension, or S3 gallop also carries a high risk, as does the frequent occurrence of ectopic beats. Old age and emergency surgery are risk factors independent of these others. Coronary revascularization by coronary artery bypass graft (CABG) tends to protect against infarction. Smoking, diabetes, hypertension, and hyperlipidemia (all of which predispose to coronary artery disease) are surprisingly not independent risk factors, although they may increase the death rate should an infarct occur. The value of this information and data derived from further testing is that it identifies the patient who needs to be monitored invasively with a systemic arterial catheter and pulmonary arterial catheter. Most perioperative infarcts occur postoperatively when the third-space fluids return to the circulation, which increases the preload and the myocardial oxygen consumption. This generally occurs around the third postoperative day.

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