APPROACH TO ANESTHESIA

Preoperative Evaluation

Preoperative evaluation ( Table 50-10 ) begins with identification of the indication for surgery (coronary revascularization, valve replacement) and determination of the pathophysiologic implications of the underlying disease processes, for example, the specific coronary lesions in a patient scheduled for revascularization (left main disease, left main equivalent, coronary artery disease with/without secondary cardiomyopathy, coronary artery disease with/without ischemic mitral regurgitation); these implications are discussed earlier in the context of each specific lesion. The preoperative assessment should also include an evaluation of whether to continue medications. These issues are discussed in the context of each condition, but evidence is increasing that some medications previously considered to be contraindicated before surgery may in fact have a positive impact on outcome, for example, antiplatelet agents.^[38] In general, if the indication for initiating therapy was appropriate and the underlying condition persists, one has to make a risk-benefit analysis regarding the appropriate action. As in a patient undergoing any surgery, the airway, allergy status, and noncardiac medical issues should be evaluated before the cardiac procedure.

In patients with coronary artery disease, evaluation of potential concurrent vascular disease is critical. Though much debated, there are as yet no clear data to indicate if outcome in patients with coexisting significant cerebrovascular and coronary disease is optimized by performing combined carotid endarterectomy and coronary artery bypass grafting or sequential surgeries in either order.^{[166] [167]} Anticipation of cardiac surgery is anxiety-provoking for patients, and the hemodynamic response (tachycardia, hypertension) may even precipitate symptoms in those with susceptible conditions such as coronary artery disease or aortic stenosis. Thus, allaying anxiety is an essential feature of preoperative management and incorporates both an honest, sensible, and appropriate explanation to the patient and family of what to anticipate and the administration of premedications ( Table 50-11 ). Clearly, the same-day-admission approach now used for most patients limits one's options with regard to effective premedication, but perhaps it amplifies the importance of the preoperative interview, even with inherent time constraints.