Week 1 – Case 2
68 years old male patient, ex smoker with background of HTN CKD. He never had any cardiac symptoms. He was found to have 6.8 cm AAA on US that he has had for RUQ pain. All of his blood tests came back as normal apart for eGFR of 29. Patient is not keen on surgery.
How would you approach his consultation?
What is the risk of rupture?
What is your recommendation of treatment?
How would you assess his risk for surgery?
Is there any pre op medication that can be used to reduce the risk of surgery?
Patient had CPET to assess his general fitness
Main finding on this was, He stopped after a total of 9.44 minutes of exercise on reaching a peak work rate of 116 Watts . There is no ECG changes showed on exercise. Anaerobic threshold 15.1 ml.kg-1.min-1 and FEV1/FVC is 81%
please comment on these finding and indicate the suitable clinical plan.
What is the definition of Anaerobic threshold? what is the cut off that indicate higher risk for open surgery?
A1:
History
Family history
Op history
Social history
Medical diseases and medication
Analysis of complaints
Examination
General cardiac resp
Local vascular and abdominal
Investigation
Labs
Imaging PAUS MRA regarding his CKD
A2:
6.8 AAA has 6% risk of rupture at 3 years
A3:
EVAR regarding ptn preference and to be done by co2 not contrast due to CKD
A4:
Assessment of risk for surgery by
CPET
Cardiac ECG ECHO
respiratory PFT
Renal
A5:
Pre op medications
Anti platelets statins anti htn b blockers mainly antibiotics
A6:
All the parameters concluded that the patient is fit for intervention and anesthesia with low risk regarding cardiac and pulmonary functions
A7:
The AT is the point during exercise when your body must switch from aerobic to anaerobic metabolism, at which the O2 demand of the muscles exceeds the ability of the cardiopulmonary system to supply O2. process that produce lactic acid
The cut off for OSR Deficiencies in CPET-derived variables—specifically ventilatory anaerobic threshold (AT), peak O2 consumption (O2peak), and ventilatory efficiency for carbon dioxide
A1.. I will start by addressing some pints in the history .
If there is any family history of AAA
His life style and if he is active or not
I will ask for CT aortography for accurate measurements and for planning for intervention
I will do tests to exam cardiac and pulmonary functions
To balance between the risk of rupture and intervention
A2..t
he rupture risk of an aneurysm size of 6-7 CM is 6%
A3..
Recommendation of treatment is proper risk factors controle and preparation of the patient for elective repaire
A4..
I will assess his
Cardiac condition by ECG, ECHO
pulmonary condition by pulmonary function test
Renal status by serum creatinine
Alumin level to assess his nutritional status
A5..
Pre operative antipletles , statine, and anti hypertensive drugs to improve his cardiac status and to lower the risk
Doxycycline is claimed to decrease the expansion rate by reducing Matrix metalloprotenase activity and thus decreasing extra cellular matrix degradation
A6..
To comment on patient total time 9.15 and peak work rate of 116 the patient predicted values should be knows based on patient age weight and sex.
There is on ECG change which indicates good cardiac functions
Also as general speaking aneropic time more than 11 ml/kg/min is good and since patient value is 15 it indicates his surgical risk is low
WHEN FEV1/FVC >70% IT INDICATES good pulmonary function and since the patient value is 81% he is in the normal side
By interpreting the above results the patient seems to have good surgical risk
A7..
Anaerobic time is the time at which the metabolism will be shifted to anaerobic type and lactic acid will be produced and CVS cannot provide oxygen to tissues any more to get rid of produced lactic acid