How
would you monitor this patient during the perioperative period?
Electrocardiographic monitoring is essential in
the management of patients with dilated cardiomyopathies, particularly in those
with myocarditis. Ventricular dys-rhythmias are common, and the development of
complete heart block requires rapid diagnosis and treatment. The
electrocardiogram (ECG) is also useful for monitoring of ischemic changes when
CAD is associated with the car-diomyopathy, as in amyloidosis. Direct
intra-arterial blood pressure monitoring during surgery provides continuous
blood pressure information and a convenient route for obtaining arterial blood
gases.
Any patient in CHF with a severely compromised
myocardium who requires anesthesia and surgery should have central venous
access for monitoring and vasoactive drug administration. The use of a
pulmonary artery catheter is much more controversial, but is probably of value
in patients with severely compromised left ventricular function. While there is
no evidenced-based medicine to support outcome differences, left-sided filling
pressures should be monitored, if at all possible. Monitoring right-sided
filling pressures is of equal importance in patients with pulmonary
hypertension or cor pulmonale. In addition to measuring filling pressures, a
thermodilution pulmonary artery catheter can be used to obtain cardiac outputs
and the calculation of systemic and pulmonary vascular resistances, which allow
for serial evaluation of the patient’s hemodynamic status. Additionally, there
are pulmonary artery catheters with fiberoptic oximetry, and rapid-response
thermistor catheters that calculate right ventricular ejection fraction. Pacing
catheters and external pacemakers provide distinct advantages in man-aging the
patient with myocarditis and associated heart block.
Two-dimensional transesophageal
echocardiography pro-vides useful data on the response of the impaired
ventricle to anesthetic and surgical manipulations. The short-axis view of the
left ventricle would provide real-time information on preload and ventricular
performance that would be valuable in judging the need for inotropic support or
vasodilator therapy. The degree of mitral regurgitation could also be followed
intraoperatively.
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