Perioperative medicine by Prof Montage

Introducing...Prof Montage

Cardiology Roundswww.profmontage.com.auwww.cardiologyrounds.com.au

DISCLOSURE

Over the years Prof Montage has taken lot$ of money from pharmaceutical companies.

He would prefer this was not widely publicised.

meet the characters

troponins

Case history

84yo female, 45 kg

Past history:hypertension

Renal artery stenosis Cr 115

Polymyalgia on steroids

Macular degeneration

March 2014

Peri-trochanteric #NOF

‘just twisted’ while bending

Medical review

I-V hydrocortisone

Theatre: gamma nail

12 hrs postop

Rapid response, low BP

Acute AF, preexisting LBBB

d/w Cardiology ‘could be nonSTEMI’

Transfuse 1 unit

6 hours later

1300ml I-V so far

Fast AF, give Mg infusion

80 ml/hour

Now sats <90%

JMO: ‘not fluid overloaded’

Coronary perfusion pressure

3 days later

Cardiology review re: raised troponin

Raised venous pressure

d/w Cardiologist: give aspirin & clopidogrel

Supply / demand

4th post-op day

Sudden abdo pain

Laparotomy: perforated gall bladder, biliary peritonitis

Postop: low BP, fluid bolus…etc

Days 7-11 post-admission

Rapid AF; i-v amiodarone

Fever ?sepsis

low BP, desaturation ?PE

Echo dilated hypocontractile LV

‘consolidation’

Pleural tap

15-18 days post admission

Transudate

‘CCF’ :Diuretics and digoxin

Fast AF: amiodarone, K, Mg

Waiting for rehab

Home day 22

Late July 2014

Still on bisoprolol / amiodarone

Bradycardia 35/min

Isoprenaline 4 days

Chest pain, troponin rise

Queue for pacemaker and cath

Day 5

Angio 2 vessel disease, no ventriculogram

Permanent pacemaker

Postop hypertension & bleeding

Transfused, stopped clopidogrel

Day 6

Sudden visual loss

Retinal artery occlusion

Aspirin. “Consider warfarin”

Discharged for GP care

8 days later

Chest pain, ambulance

Raised troponin

Diagnosis ‘nonSTEMI’

….and so on

End August 2014

Heart failure treated

Near-blindness

Adrenal insufficiency

Heading home…..

Right ventricle

3 minute Cardiology

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