Case presentation

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Case presentation

• Dr. Amr Marzouk
• Assistant lecturer of anesthesia
• Faculty of medicine
• Ain shams university

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• A 68-year-old female, 231 lbs and 5'1? tall, with
  a history of hypertension (HTN), diabetes
  mellitus, and large joint chronic arthritis, is
  scheduled for a laparoscopic cholecystectomy.
• The patient is non-compliant with her treatment
  atenolol and glyburide.
• On the morning of the surgery, the patients
  blood pressure (BP) was 145/86 mm Hg, heart rate
  (HR) 88, respiratory rate (RR) 20, oxygen
  saturation 97 on room air, and temperature 36.8
  C. Her blood glucose was 186 mg/dL.
• .

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• Physical examination revealed no abnormalities
  and the airway was assessed as a Mallampati class
  II.
• After a smooth induction of general anesthesia
  with midazolam, fentanyl, propofol, and
  rocuronium, a 7.0 endotracheal tube was placed
  atraumatically. Anesthesia was maintained with
  mechanical ventilation, isoflurane, oxygen, air,
  fentanyl boluses, and rocuronium
• About 30 minutes after the incision, the
  patients HR increased to 112 beats/minute and
  her BP became 184/99 mm Hg. The anesthesiologist
  also noticed a depression of the ST segment in
  the monitored V5 cardiac lead.

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Questions

• What would you do?
• What treatment would you give?
• Could this event have been prevented?
• Would you extubate this patient?
• What is your plan for the post-operative care of
  this patient?

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What would you do?

• Risk factors in this patient
• 68 years old.
• Morbid obese (BMI 45.6) wt 104kg, height
  155cm.
• Diabetic.
• Hypertensive on atenolol (pulse rate 88 b/min).
• Intraoperative events
• Blood pressure 184/99.
• Heart rate 112b/min.
• Depression of the ST segment in the monitored V5
  cardiac lead.
• (Lead V5 is the most sensitive single
  lead for intraoperative myocardial ischemia).
•  

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• To be sure of diagnosis
• Lead II is the best compliment to lead V5 because
  it significantly improves the sensitivity for
  ischemia.
• Reliable automated ST segment analysis has
  arrived and been incorporated into many monitors.
• 12 lead ECG
• Cardiac enzymes.
• TEE. To see SWMA. 

Data above is suggestive for intraoperative
myocardial ischemia
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Management

• As myocardial ischemia can be a manifestation of
  inappropriate anesthetic management so
• Evaluate the adequacy of ventilation,
  oxygenation, and anesthetic depth.
• Control of hemodynamics.
• Antianginal agents.
• Finally institution of invasive measures such as
  intra-aortic balloon counter-pulsation or
  angioplasty.
•  

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Control of Hemodynamics Anti-anginal Agents

• Increases in heart rate not only increase
  myocardial oxygen demand, but also decrease
  myocardial oxygen supply because the duration of
  diastole is shortened by increases in heart rate
  and it is during diastole that coronary blood
  flow occurs

Management of Heart Rate Takes Priority.
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Control of Hemodynamics Anti-anginal Agents

• Heart rate can be controlled by addition of a
  small dose of narcotic such as fentanyl but may
  also require the use of a ß blocker.
• Esmolol is a cardioselective ß-adrenergic
  antagonist. It is rapidly metabolized in blood
  and liver by hydrolysis and has a much shorter
  duration of action than other available ß
  blockers

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• Next, IV nitroglycerin Is easily titrated because
  of its very rapid onset and short duration of
  action. It produces marked venodilation with
  limited arterial dilation.
• Thus, left ventricular filling volume and
  pressure are usually reduced to a much greater
  degree than arterial blood pressure.
• Obviously, this is of a substantial advantage in
  enhancing effective coronary perfusion
  pressure.In addition, nitroglycerin dilates
  larger coronary arteries and even the residual
  lumen within coronary constrictions.

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• Because of these facts, IV nitroglycerin is
  usually the first pharmacologic agent chosen for
  control of intraoperative myocardial ischemia
  after basic anesthetic management and
  hemodynamics have been optimized.

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Institution of Invasive Measures

• If myocardial ischemia still persists or is
  accompanied by left ventricular failure, we will
  request the placement of an intra-aortic balloon
  pump, coronary angioplasty, and/or coronary
  thrombolysis.
• An interventional cardiologist will be needed for
  such endeavors, but failure to treat persistent
  myocardial ischemia or delay in its treatment may
  result in unnecessary loss of myocardium, cardiac
  reserve, or viable cardiac function

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Could this event have been prevented?

• Yes, this event might have been prevented by
  adequate preoperative preparation.
• ACC/AHA guidelines for the sample case
• a. Intermediate risk surgery
• b. Minor clinical risk secondary to her
  uncontrolled
• hypertension
• These guideline require no further cardiac
  work-up
• unless patient had symptoms of cardiac ischemia
  (i.e.,
• chest pain).

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Perioperative Cardiac Risk Reduction Therapy
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What is your plan for the post-operative care of
this patient?

• Hemodynamically stable
• Resolution of patients ST-depression
• b. Extubate
• i. Closely monitor the patient and treat any
  hypertension and tachycardia.
• ii. Be prepared to abort the extubation if the
  patient develops ST-changes.
• c. Maintain hemodynamics.
• d. Send the patient to a cardiac-monitored floor.
• e. Cardiology consult

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• 2. Hemodyanmically unstable
• a. Keep intubated.
• b. Coronary care unit (CCU)
• c. Cardiology consult

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• ICU admission
• Factors that may increase the likelihood of
  postoperative myocardial ischemia that we can
  control include tachycardia, anemia, hypothermia,
  shivering, hypoxemia, endotracheal suctioning,
  and less-than-optimal analgesia.
• Coronary angioplasty
• Immediate coronary angioplasty has been favorably
  compared with thrombolytic therapy in the
  treatment of acute MI, but of greater importance
  is that the risk of bleeding at the surgical site
  is believed to be less with direct angioplasty
  than with thrombolytic therapy.

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• In addition, these reperfusion procedures should
  not be performed routinely on an emergency basis
  in postoperative patients in whom MI is not
  related to an acute coronary occlusion.
• For instance, in cases of increased myocardial
  demand in a patient with postoperative
  tachycardia or hypertension, lowering the heart
  rate or blood pressure is likely to be of greater
  benefit, and certainly less risk.

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• MEDICAL TREATMENT
• Therapy with aspirin, a beta blocker, and an ACE
  inhibitor, particularly for patients with low
  ejection fractions or anterior infarctions, may
  be beneficial, whether or not the patients are
  rapidly taken to the catheterization laboratory.
  Although not intended specifically for patients
  who have a postoperative MI, they are nonetheless
  appropriate for these high-risk patients

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THANK YOU