hrvatski

Preoperativna priprema bolesnika s latentnom insuficijencijom miokarda za veliki kirurški zahvat

A classification of patients according to the function of the cardiovascular system into manifestly decompensated, into patients with out sings of cardiopathy and patients suspect of latent myocardial insufficiency was undertaken on the basis of cardiologic examinations and treatment of 141 orthopaedic patients of advanced age, hospitalized for the purpose of alloarthroplastic surgery of the hop joint and the knee in the course of 1981 and 1982.Preoperative treatment with Digitalis Glycosides was prescribed for the patients suffering from latent and manifest myocardial insufficiency with the aim of reducing perioperative complications. All the parameters observed in the three groups of patients were investigated befor and after surgery. These were subsequently compared with the identical parameters in a randomly selected group of 120 patients who had undergone the same surgical operation 1979 and 1980, in order to obtain an insight into the efficacy of Digitalis Glycosides and to investigate the beneficial influence of operative surgery on the development of postoperative complications. Suspect of latent myocardial insufficiency were patients with anamnestic data of dyspnea induced by mild of more strenuous physical exertion, patients with stenocardia, arterial hypertension, cardiac arrhythmia, hypertrophy of the left ventricle showing in the electrocardiogram and with cardiomegaly appearing in the roentgenogram. Testing these patients for exercise tolerance by means of the ergometric test showed moderate functional aerobic impairment (FAI) in 20 – 49 (40, 81 %) patients, marked in 23 (46, 93%) patients and greatly marked in 6 (12, 24 %) patients. Classification of the patients according to NYHA( New York Heart Association) resulted in placing 27 (55, 10 %) of the patients in the second group, 21 (42, 85 %) of the patients in the third group and 1 (2, 04%) patient in the first group. A low level ergometric activity was found in 22 (44, 89 %) of 49 patients. Preoperative prophylactic digitalization was undertaken 3 to 5 days prior to the surgical operation, in the course of induced anaesthesia and on the average some 4 days following the surgical operation in patients with manifest and latent myocardial insufficiency by administering a low dosis of 0, 2 mg daily. The efficacy of Digitalis Glycosides was checked by observation of the clinical picture, watching the electrocardiogram and by the determination on Digoxin in the plasma before and after surgery. Observation of the clinical picture did not reveal sings of digitalis intoxication. The values of Digoxin concetrations in the plasma were 0, 65 / umol/L before and 0, 94 /umol/L after the operations. These values obtained were aimed at low levels in view of the advanced age of the patients with reduced quantity of cardial receptors and reduced renal function. Alterations of heart rate, ST segment depression T-wave, corrected QT interval and PTQ index, obtained from clinical electrocardiogram, potassium and creatinine clearance before and after a surgical operation are considered to be important parameters in the evaluation of the Digitalis Glycosides efficacy in digitalized patients and of the effect of surgery in the non-digitalized patients. Analyses of the heart rate in digitalized patients with latent myocardial insufficiency have shown that no statistically significant differences were present before and after the operation, while in the non-digitalized patients a significant difference was seen.We have therefore concluded that Digitalis Glycosides may prevent and control the postoperative heart rate which might have complicated postoperative treatment even in those patients who previously had no history of cardiac arrhythmia. The incidence of perioperative cardiac complications in all three groups was significantly lower in relation to the control group. This indicates that digitalized patients with latent myocardial insufficiency tend to show better tolerance of the increased metabolic rate in the postoperative course. The results of comparative measuring of disorders of impulse formation and conduction prior to surgery, in the course of ergometry, after treatment with digoxin and following surgery indicate that the disorders of impulse formation were increased during ergometry, in the course of surgery and in the early postoperative period in the non-digitalized patients, where as no difference was found in the disorder of impulse formation after surgery in digitalized patients with latent myocardial insufficiency. We have reached the conclusion that in patients of advanced age, with dyspnea induced by exertion, with cardiomegaly and increased functional aerobic impairment it is necessary to administer treatment over a period of 3 to 5 days prior to a major surgical operation, i.e. to give small doses of Digoxin for the purpose of raising the inotropic reserve of the heart and preventing perioperative cardiac complications.

ergometrija ; latentna insuficijencija miokarda ; profilaktička digitalizacija ; perioperativne komplikacije

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