Rupinder Kaur Kaiche
Biography
I am currently associated with MVP Medical college and Pioneer hospital Nashik.I am a cardiac anaesthesiologist and intensivist based in Nashik since last 10 years.Over these years I have anaesthesized more than 5000 cardiac surgery patients,many of them high risk with ejection fraction of less than 20%. I have also given anaesthesia to Chronic Renal Failure patients for CABG followed by Renal Transplants. Successful patients include CABG on and off pump, valve surgeries, CABG + valve, congenital defects. I am well versed with intra operative trans-oesophageal echocardiography. I have also managed high Risk,unstable patients on ventilator for angioplasties. High risk cardiac patients for non-cardiac surgeries have also been successfully managed. This included pre- operative optimization, anaesthesia and post operation ICU management.
I did my MBBS from LTMMC and Sion hospital Mumbai and post graduation from KEM hospital Mumbai.
I stood first in the university. I then worked in the prestigious TATA memorial hospital where I became
proficient in difficult airway management and percutaneous tracheostomy. I had the opportunity to
work with Dr.Divatia, Dr Kulkarni and Dr Gehdoo.
To gain experience of international standards,I went to UK.There I worked with some of the stalwarts of anaesthesia and utilized the latest equipment. I returned back after 5yrs to bring international standards to my patients in Nashik.I also completed my fellowship in Intensive care medicine .
I was a certified trainer for BLS,ACLS and PLS in UK.
Research Interest
Growing public health concerns associated with HTN,mandates anaesthesiologist have a working knowledge about implications,management and treatment options available.
Abstract
Hypertension: Opening the pandoras box for the Anaesthesiologist.
Background
Hypertension, global health crisis,affecting 1 in 4 men and 1 in 5 women effectively 1 billion people,1expected to reach 1.6 billion by 2025.2 WHO estimates 1 in 5 are well controled.1Research published in European Heart Journal shows two fold increase in death risk for hypertensive people with COVID-19.Prolonged uncontrolled HTN shows increased risk of heart attack,stroke,heart and kidney failure, premature mortality.1,4,5while controlled blood pressure translates risk reduction6,7 of 13% with 10 mmhg pressure control.6
Aim
Growing public health concerns associated with HTN,mandates anaesthesiologist have a working knowledge about implications,management and treatment options available.
Methods
Obtaining accurate B.P.measurement is key step in pre-op assessment7 which adheres to standard technique to obtain reproducible measurements representative of patients true pressure.The extent and severity of organ damage in pre-op period is important as-
1. Organ damage marks severity of HTN.
2. Such damage increases risk of renal impairment,heart failure,coronary artery disease,cognitive impairment,cerebrovascular disease and premature death.7
Patients with secondary HTN having clinical indicators as renal disease,hyperthyroidism,obstructive sleep apnoea,hyperaldosteronism1 need investigation,diagnosis and treatment pre-op.Investigations recommended are-
-Hb
-Plasma glucose
-Serum Sodium,potassium and creatinine
-Serum total Cholesterol,high-density lipoprotein and low-density lipoprotein.
-Serum uric acid
-Dipstick urine test for microalbuminuria
-12 lead ECG
Common anti-HTN medications with anaesthetic implications-
1.Diuretics - hyponatremia causing decreased extracellular fluid osmotic pressure causing hypovolemia.Hypokalemia causing tachycardia, arrythmias.
Prudent volume augmentation helpful.
2.ACE inhibitors block conversion of angiotension 1 to angiotension II in renin-angiotension system,hence refractory hypotension,so avoided pre-op.
3.Calcium channel blockers(CCBs) inhibit opening of voltage-gated calcium channels and inward calcium flux causing decreased smooth muscles contraction in peripheral arteries hence B.P. falls from decreased afterload.Inhalational anaesthetics decrease availability of intracellular calcium enhancing hypotension.CCBs activate neuromuscular blocking agents, impairing hypoxic pulmonary vasoconstriction.To continue except in history of malignant hyperthermia.
4.Beta blockers block ?1 heart receptors causing bradycardia and decreased contractility.Kidne yreceptors block renin secretion by blocking renin-angiotensin-aldosteron system,should continue pre-op,to prevent rebound hypertension and tachycardia causing myocardial ischaemia and infarction.
Post-op period
1.Regular B.P. monitoring.
2.Post-op hypertension predisposse to bleeding.
3.Hypotension compromises organ perfusion
4.Start anti-HTN as clinically appropriate.
Result
Elevated B.P. upto 180/100 mmhg is not reason to defer elective surgery, decision should be made on case to case basis.Intra-op hypotension should be avoided.Post-op HTN may predispose to bleeding while hypotension may compromise organ perfusion.
Discussion
According to 2011 modified guideline classification of severity of hypertension,introducing threshold based on clinic,ambulatory and home B.P. measurements.
