|Year : 2018 | Volume
| Issue : 2 | Page : 110-111
Anesthetic challenges in a cardiac patient undergoing noncardiac surgery
Vaishali S Badge, Pankaj Patil
Department of Anaesthesia, Apollo Hospitals, Mumbai, Maharashtra, India
|Date of Web Publication||5-Jul-2018|
Vaishali S Badge
Apollo Hospitals, Navi Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
We report a case of a patient with coronary artery disease (ejection fraction [EF] = 20%) with automatic implantable cardioverter-defibrillator (AICD) implanted, hypertension, diabetes mellitus, chronic kidney disease, and peripheral vascular disease for vitrectomy. This patient was diagnosed as a case of bilateral retinal detachment with proliferative vitreoretinopathy Grade III. He developed hyphema in the right eye due to long-standing uncontrolled diabetes with complete loss of vision. This case was very complex to manage as the patient had comorbidities with low EF. The case was done on an urgent basis thinking that the patient might lose eyesight if he is not operated quickly. A 55-year-old male presented with complaints of breathlessness, chest discomfort, and cough and diagnosed as left ventricular failure with cardiogenic shock. He complained of sudden onset loss of vision after 2 days of admission while in Intensive Care Unit. This patient had vitreous hemorrhage due to end-stage diabetic disease. The patient was suffering from triple vessel coronary artery disease (EF = 20%, regional wall motion abnormalities), AICD in situ, diabetes, hypertension since 10 years, and peripheral vascular disease with peripheral plasty. He was a chronic alcoholic and smoker as well. His renal function tests showed serum creatinine 1.8 mg/dl. Patient was planned for right eye vitrectomy to save vision. The patient was operated without any complications.
Keywords: Automatic implantable cardioverter-defibrillator, coronary artery disease, vitrectomy
|How to cite this article:|
Badge VS, Patil P. Anesthetic challenges in a cardiac patient undergoing noncardiac surgery. Apollo Med 2018;15:110-1
| Introduction|| |
The incidence of ischemic heart disease (IHD) is increasing. The number of patients with IHD with or without interventions coming for noncardiac surgical procedures is also increasing. The administration of anesthesia to the patients with preexisting cardiac disease is a challenge. These patients have increased risk of myocardial infarction (MI), conduction disturbances, morbidity, and mortality during the perioperative period. The risks of these events are even higher in patients with heart failure and recent MI. Among the estimated 25 million patients in the United States who undergo surgery each year, approximately 7 million are considered to be at high risk of IHD. Indian figures are not available. Goldman et al. reported that 500,000–900,000 MIs occur annually worldwide with subsequent mortality of 10%–25%. Care of these patients requires identification of risk factors, preoperative evaluation and optimization, medical therapy, monitoring, and the choice of appropriate anesthetic technique and drugs. An anesthesiologist should be aware of the pathophysiology and must thoroughly evaluate the patients for their perioperative management.
| Case Report|| |
A 55-year-old male presented with complaints of breathlessness, chest discomfort, and cough and diagnosed as left ventricular (LV) failure with cardiogenic shock. He complained of sudden onset loss of vision after 2 days of admission while in Intensive Care Unit (ICU). This patient had vitreous hemorrhage due to end-stage diabetic disease. The patient had triple-vessel coronary artery disease (ejection fraction [EF] = 20%, regional wall motion abnormalities) with automatic implantable cardioverter-defibrillator (AICD) implanted in November 2016, diabetes, hypertension since 10 years, and peripheral vascular disease with peripheral plasty on November 10, 2016. He was a chronic alcoholic and smoker. His renal function tests showed serum creatinine of 1.8. Patient was planned for right eye vitrectomy to preserve the vision.
On clinical examination, patient had bilateral basal crepitations on chest auscultation. He was on BIPAP support. He also had episodes of delirium in ICU. Patient was pale. Airway examination was within normal limits.
Investigations showed hemoglobin (Hb) – 8.7 g%, total leucocyte count – 10,700/cmm, and platelets within normal limits. Renal profile serum creatinine – 1.8 mg/dl, blood urea nitrogen – 28 mg/dl, serum sodium – 142 mmol/l, and serum potassium – 3.8 mmol/l. Coagulation profile was within normal limit. Biomarker NTproBNP was 30352. Echocardiography showed EF was 20%, presence of regional wall motion abnormalities, Grade III diastolic dysfunction, severe LV dysfunction, and dilated left ventricle. This patient was transfused 1 unit of blood before subjecting him for surgery. The antiplatelets were stopped 2 days before surgery.
Patient was advised coronary artery bypass grafting surgery in view of triple-vessel disease. Patient was accepted for vitrectomy as the American Society of Anesthesiologists Grade IV E. This patient was an ideal candidate for surgery under local anesthesia, but patient became breathless on the operating table; hence, the decision was taken by the surgeon to operate under general anesthesia. The risks and complications were explained to the relatives and high-risk consent was taken.
Induction of anesthesia included hemodynamic monitoring such as right radial arterial cannulation and right internal jugular venous cannulation, which was done under local anesthesia. All emergency drugs and defibrillator were kept ready. After 3 min of preoxygenation, the patient was induced with injection midazolam 1 mg, injection fentanyl 50 mcg, and injection etomidate 6 mg intravenously. After checking ability to ventilate, injection cisatracurium 6 mg was given intravenous (IV) and patient was intubated. For maintenance, mixture oxygen + air + sevoflurane were used, and minimum alveolar concentration was maintained around 0.6. The hemodynamic parameters remained stable throughout the procedure. Surgery lasted for 2 h and 30 min. Urine output was 250 ml. The fluid management was done using 50 ml/h of IV crystalloid. Intraoperative arterial blood gas analysis was within normal limits. IV neostigmine 2.5 mg and IV glycopyrrolate 0.5 mg were given to reverse the effect of muscle relaxant cisatracurium. After adequate recovery, patient was extubated. Patient was shifted to ICU with oxygen supplementation by face mask for further management.
| Discussion|| |
IHD represents a significant and growing health-care burden. The prevalence of morbidity and mortality is high in patients with IHD undergoing noncardiac surgery. Moreover, the prognosis worsens in patients with LVEF <35%. Cardiovascular complications account for the majority of the cause for postoperative morbidity and mortality with incidence ranging from 0.5% to 30%. The present patient had triple-vessel coronary artery disease, LVEF = 20%, and AICD which possessed a great challenge for anesthetic management. The primary goal of anesthetic management of a patient with coronary artery disease for noncardiac surgery is avoidance of myocardial ischemia and MI. This is achieved by avoiding the factors which impair myocardial oxygen-supply demand ratio. Anything which increases cardiac work such as physical work, emotional stress, surgical and anesthesia stress increases myocardial oxygen demand which is compensated in normal individuals by increasing coronary blood flow. However, it is compromised in patients with coronary artery disease. The anesthetic technique must aim to keep myocardial oxygen supply greater than demand and thus avoid ischemia. The essential requirements of general anesthesia for IHD are avoiding tachycardia and arrhythmias, extremes of blood pressure, anemia (Hb > 8.5 g/dl), and maintenance of fluid and electrolyte balance. The essential requirement is to achieve effective pain relief to reduce stress. This patient was stable throughout the procedure and did not suffer any insult during the perioperative period.
| Conclusion|| |
As the incidence of IHD increases in the population, the number of patients coming for cardiac surgery is also increasing. A thorough evaluation as regards history, physical examination, and investigations avoids risks and complications in the perioperative period. This case was managed in a multidisciplinary approach involving cardiologist, ophthalmologist, anesthesiologist, and intensivist which led to successful outcome in such a complex case.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hedge J, Balajibabu PR, Sivaraman T. The patient with ischaemic heart disease undergoing non cardiac surgery. Indian J Anaesth 2017;61:705-11.
] [Full text]
Kaul TK, Tayal G. Anaesthetic considerations in cardiac patients undergoing non cardiac surgery. Indian J Anaesth 2007;51:280-6. [Full text]
Butler J, Fonarow GC, Gheorghiade M. Need for increased awareness and evidence-based therapies for patients hospitalized for heart failure. JAMA 2013;310:2035-6.
Bakker EJ, Ravensbergen NJ, Poldermans D. Perioperative cardiac evaluation, monitoring, and risk reduction strategies in noncardiac surgery patients. Curr Opin Crit Care 2011;17:409-15.