|Year : 2014 | Volume
| Issue : 1 | Page : 63-65
Intraoperative acute coronary syndrome in a patient during laprotomy
Jayashree C Patki, Pankaj Patel
Department of Anesthesia, Krishna Institute of Medical Sciences, Secunderabad, Andhra Pradesh, India
|Date of Web Publication||10-Mar-2014|
Jayashree C Patki
Swagat-2-1-437/5, Street No. 5, Nallakunta, Hyderabad - 500 044, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Incidence of coronary artery disease is on rise amongst the population, which is the major underlying pathology for acute coronary syndrome (ACS). So every anesthetist may encounter the patients with ACS and should know how to recognize and manage them. Its earliest detection and proper management can prevent further myocardial damage, thus preventing further morbidity and mortality. The patient described here had an increased risk for perioperative ischemia because of old age associated with history of hypertension, diabetes mellitus, chronic renal failure, and underwent a major surgical procedure (laprotomy). Beta-blockers were not administered and aspirin was discontinued during his preoperative preparation. All these factors might have contributed for the genesis of the myocardial ischemia in this patient.
Keywords: Anesthesia, beta blockers, coronary syndrome, chronic renal failure, laprotomy, myocardial ischemia, ST-segment elevation myocardial infarction (STEMI), transoesophageal echocardiogram
|How to cite this article:|
Patki JC, Patel P. Intraoperative acute coronary syndrome in a patient during laprotomy. J NTR Univ Health Sci 2014;3:63-5
| Introduction|| |
Intra operative myocardial ischemia is rare but is associated with very high mortality and morbidity. It is an emergency anesthetic crisis which poses a unique management challenge for the anesthetist. The case presented here illustrates the interaction of multiple perioperative factors that might be responsible for the ischemia in this patient.
| Case Report|| |
An 80-year-old male patient, diagnosed with carcinoma rectum was posted for anterior resection of rectum. He had a history of noninsulin-dependent diabetes mellitus, chronic hypertension, and chronic renal failure. Current medications included aspirin which was discontinued 5 days before the surgery. Preoperative blood investigations were normal except high creatinine level of 1.95 mg/dL.  Electrocardiography was normal and two-dimensional echocardiogram (ECHO) findings showed EF 62%, no regional wall motion abnormality (RWMA) and grade 1 diastolic dysfunction. General anesthesia using propofol, fentanyl, atracurium, and desflurane in titrating doses was administered. Monitoring consisted of pulse oxymetry, automatic blood pressure measurement, cardioscope, and capnograph. Hemodynamics were quiet stable for almost 2 h, till the major resection was over. At the time of closure of abdomen, the patient suddenly became hypotensive which was treated with 2 doses intravenous ephedrine (5 mg). The patient did not respond to this, there was further hypotension with bradyarrhythmias. So, dopamine infusion (5 mcg/kg) was started. Still, the patient remained hypotensive and had significant ST depressions. The rate of dopamine infusion was titrated, but after a few minutes, the patient developed complete atrioventricular block leading to asystole. These were treated with atropine, adrenaline, soda bicarbonate accompanied by cardiac massage, and ventilation with 100% O2. The patient developed temporary tachycardia. Mean arterial pressure (MAP) was elevated to 50-60 mm of Hg. Surgery was completed and patient was shifted to intensive care unit (ICU) with elective ventilation. After a few minutes, patient regained sinus rhythm with MAP within normal limits. Two-dimensional ECHO was repeated, which did not show any abnormalities like RWMA or cardiac dysfunction. Trop-T test was found to be positive after 6 h. CPK-MB levels were also elevated. Patient was further treated with nitroglycerine infusion and inj. Heparine 5000 units t.i.d. He did not develop any major cardiac complications till discharge but suffered with a mild stroke on 7 th postoperative day.
| Discussion|| |
The term acute coronary syndrome (ACS) refers to any group of clinical symptoms compatible with acute myocardial ischemia and includes unstable angina, non-ST-segment elevation myocardial infarction and ST-segment elevation myocardial infarction (STEMI).  ACS is more frequent in the elderly than in the general population and is associated with very high morbidity and mortality.
The two most significant risk factors for developing coronary artery disease are increasing age and male gender. Other risk factors include cigarette smoking, hypertension, obesity and sedentary lifestyle, high cholesterol, diabetes mellitus, family history of premature coronary artery disease.  Chronic kidney disease and peripheral arterial disease are significantly associated with peri operative myocardial infarction (PMI).  Higher Global Registry of Acute Coronary Events (GRACE) score predicts in-hospital events and more severe coronary artery disease.
Anesthesia and surgery may provoke ACS because of harmful effects of hypoxia, hypotension, hypertension, hypothermia, pain, blood loss causing anemia, arrhythmogenic electrolyte disturbances, inflammation, blood sugar instability in diabetics, acute stress response, and avoidance of anticoagulation.
Preoperative myocardial damage occurs with a high incidence depending on the operative procedure and is considered to be among the most relevant risk factors for increased peri-operative morbidity and mortality in patients undergoing non cardiac surgery.  Although older patients represent a group at high risk of complications, they are often excluded from major/invasive diagnostic tests such as treadmill, stress test, or coronary angiography.
Diagnosis of ACS in an unconscious patient under general anesthesia is quiet challenging. Here, the anesthetist has to recall for clinical history, relevant risk factors, physical examination, and intraoperative findings during monitoring [including electrocardiography (ECG) and hemodynamics]. Transesophageal echocardiography (TOE) is very sensitive for detecting acute segmental wall motion abnormalities and can be detected before ECG changes occur.
| Intraoperative Management|| |
Intraoperative myocardial infarction (MI) is an emergency. Intraoperative MI requires prompt and accurate management to prevent further myocardial damage or patient death.
Anesthesiologist should always be alert for early detection of intraoperative complications. Continuous monitoring of heart rate, blood pressure and ECG trends are mandatory. The anesthetist must be vigilant for warning signs. If intra operative MI is suspected, this emergency situation should be discussed between the surgical and anesthetic team. Cardiologist involvement in management is advisable.
The main anesthetic aims in managing intraoperative MI are: Oxygenation, maintain optimal hemodynamics, minimize cardiac work, treat arrhythmias, consider use of aspirin and heparin, consider use of gylceryl trinitrate, and an intra aortic balloon pump (where available). Use of intra operative TOE to be considered for diagnosis. The priorities are to detect intraoperative MI early, give effective treatment, and transfer the patient to ICU urgently for further cardiac care.
Treatment is different depending on the clinical classification. Patients with STEMI are in the need of urgent attempt at reperfusion. Percutaneous coronary intervention is the preferred treatment if available. ACS patients not having a STEMI are often stratified into low- and high-risk groups and are considered for conservative medical management. Diabetic patients with STEMI have greater risk for death. In the patients with STEMI, females, elderly individuals, and those with diabetes mellitus should be managed more carefully to reduce the mortality rates.  Some patients are considered for reperfusion treatment. Patients with cardiogenic shock not responding to pharmacologic support may require an intra aortic balloon pump.
Several prospective studies have demonstrated that patients with coronary artery disease seem to benefit from the preoperative administration of beta-blockers, and, more recently, statins because these drugs have proved to be effective on the prevention of ischemia and even death. ,,, The discontinuation of aspirin, before noncardiac surgeries, has been frequently questioned because its anti-inflammatory and antithrombotic effects seem to overcome its interference in platelet aggregation.
The pathophysiology of myocardial damage in the perioperative period is still not well-understood. As a result of this unexplained etiology of perioperative myocardial infarction, it remains an open question whether the contemporary diagnostic and therapeutic recommendations for the ACS can be extrapolated to the perioperative situation.  Given the current state of knowledge, biological age itself should not be the only limiting criteria when considering an invasive coronary procedure, but the existing quality of life and physical conditions of the individual should also be taken into account in the global management strategy.
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