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Recurrent intraoperative silent ST depression responding to phenylephrine -Rajkumar S Guide: Dr.

Indira mam

Case Report

An unusual case of recurrent, symptomless inferior wall ischemia in an apparently healthy male with no history of coronary artery disease after a spinal block and its successful management

History
•A 46-year-old, 72 kg, man was scheduled for elective right knee replacement for post traumatic osteoarthritis. •No other significant present history •Past history • Known hypertensive, well controlled on oral amlodipine 5 mg OD. • Exercise tolerance mildly restricted since last 2 years due to pain associated with osteo arthritis, taking occaional NSAIDS. • No H/O angina, palpitaion, diaphoresis.

• Advised to remain NPO from midnight and 2 units of packed cells were arranged.Pre OP • • • • Hemoglobin was 12.3 mg% Biochemical profile / lipid profile were normal CXR / ECG showed no abnormality Intermediate risk was explained to the patient and a written informed consent was taken. .

Standard monitoring was connected which showed ECG with normal sinus rhythm with HR 74/ min. BP was 116/ 70 mm/Hg Saturation was 100% on room air A 16 G IV line was secured .

5 mg of 0.L4 interspace 18G catheter was threaded into the space and fixed to skin Patient was turned to supine position and sensory level of block was found to have reached around Your Logo T5 after 10 min.Your own footer CSE block was given in right lateral position with 12. .5 % hyperbaric bupivacaine along with 25 mcg fentanyl was given intrathecally through L3.

Later it showed a value of +0. the ecg started to show down sloping ST depression In the diagnostic mode monitor recognized the a ST depression of 2 mm Progressed to 3.2 in lead V5 and aVL respectively.Intra op events 1 After 15 min.4 mm in the next 5 minutes in the lead II alone. 2 3 4 5 6 .2 and +1. BP was 106/62 with HR 117 / min Patient was asked for any chest pain or heaviness which the patient denied.

• Pattern changed to normal. • Diagnosis of ischemia remained uncertain as the lowest BP was 106/ 62 mm / Hg. . besides augumenting fluids vasopressor was decided to use. • Phenyl ephrine 75 mcg bolus was given IV. HR dropped to 100 / min and BP picked up to 127/ 74 in next 5 minutes.? Ischemia • Since ECG pattern indicative of inferior wall ischemia and there was increasing tachycardia.

Image just after 1stdose of phenylephrine .

1 mm was seen.• After 10 minutes ST depression of 3. .2 mm in lead II with reciprocal ST elevation in aVL of +1. • Till now patient received 1 litre of crystalloid and 500 ml of colloid. • BP dropped to 101/ 59 mm / Hg with HR 110 / min • Another phenyl ephrine bolus of 75 mcg was given IV rhythm returned to normal in 5 minutes.

Image after normalization of ST segment .

• A similar episode reoccurred over next 20 minutes and a phenylephrine infusion was started @ 50 mcg/min • ST segment values became normal • HR became 84 / min • Surgeon was asked to withhold surgery after 2nd episode as blood loss could precipitate MI’ • Surgery was deferred .

Renormalization after phenylephrine .

PCI An elective coronary stenting was done subsequently. Angiography Cardiology evaluation later revealed a 70 % occlusion of RCA. .Post op Troponins Negative Quantitative assay of troponins were sent immediately. A qualitative troponin after 4 hours Both of which turned out to be negative for MI.

Coronary perfusion pressure = aortic diastolic pressure – left ventricular end diastolic pressure .

Pathophysiology of intraoperative MI is different than commonly seen ST depression MI where plaque instability is the cause of ischemia. Intraoperative MI is more of a demand-supply failure and hence the treatment lines are different as well .Why Phenyl ephrine? Your own sub headline • Administering nitrates in this case may have aggravated the tachycardia and increased myocardial workload. • Short acting beta-blockers are recommended to control this tachycardia but they did not administer it as the blood pressure was falling.

- Phenylephrine is a directly acting pure alpha 1 agonist which not only increases the blood Templates pressure but also lowers the heart rate and thus Your own sub headline was the drug of our choice in the given situation. - Ischemia is often associated with hypotension that lowers cardiac perfusion pressure for a normal heart.

Phenylephrine preferentially acts on arterial alpha-receptors as compared to venous. This is a potential disadvantage for a diseased heart as it would increase afterload and increase cardiac oxygen demand.

Why it didn’t progress to infarction
- A prolonged ST depression of >20-30 min or a cumulative duration 1-2 h can lead to MI. - Our patient showed three episodes of significant ST depression but the duration of each was limited to less than 10 minutes and hence did not lead to a MI.

Absence of symptoms..
• Patient felt no chest pain or heaviness.. • The spinal block given to the patient may be responsible for obscuring the manifestations of ischemic pain. • The highest sensory block noted was up to T5; the autonomic block may have been higher due to differential blockade and involving the cardiac sympathetic plexus T1-T4.

.Ischemia Discussion. Ischemia When demand exceeds supply Toxic metabolites Inadequete myocardial oxygenation leading to accumulation of anaerobic metabolites Myocardial infarction is defined as the death of myocardial myocytes due to prolonged ischemia Death of Myocytes .

6% • Most often the intraoperative cardiac ischemia involves the left coronary artery and presents as ST segment depression in the left sided leads . • In patients without previous history of coronary artery disease (CAD)..Ischemia Discussion. the incidence of perioperative myocardial infarction (PMI) amounts to 0.

? Non specific ST elevation Specific ST segment elevation 1) Up sloping ST segment depression 2) lower than 1.5 mm 3) No reciprocal lead involvement Down sloping ST segment depression 2) More than 1.5 mm 3) Reciprocal lead involvement 4) Associated with symptoms / signs 1) .

• Real-time detection may allow therapeutic intervention. • Ischemia duration strongly associated with peak cTn-I level (concept of troponin leak) • Ischemia preceded in all cases by heart rate increase .Are perimyocardial ischemia different? • • • • Long-term mortality is higher Frequently Non-Q wave 50% SILENT! Perioperative ischemia (esp prolonged) is associated with adverse cardiac events.

Clinical predictors Your own footer Your Logo .

ECG almost always indicated.General Approach to the Patient  History – angina. S3 gallop. blood chemistries and chest X-ray based on history and physical findings . carotid and other arterial pulses. HF. murmurs  Comorbid Diseases – – – – Pulmonary Diabetes Mellitus Renal Impairment Hematologic Disorders  Ancillary Studies . rales. recent or past MI. symptomatic arrhythmias. elevated JVP. presence of pacemaker or ICD  Physical Examination – general appearance.

0 Diabetes severe angina -Large ischemic burden (stress testing) -Decompensated CHF -Significant Your own footer arrhythmias -Abnormal ECG. -Low functional capacity. Rhythm other than sinus.Clinical Predictors of Increased cardiac morbidity in Templates perioperative period Your own sub headline Major -Acute Intermediate Low or recent Remote MI ( >1 -Advanced Age. -Uncontrolled systemic hypertension Your Logo . MI (< one month) -Unstable or month) Stable angina Compensated CHF Creatinine  2. -History of stroke.

Revised Goldman Cardiac Risk Index Independent predictors of major Perioperative cardiac complications: 1 Intraperitoneal.4%. 2 predictors = 2. ≥3 predictors = 5.0 mg/dL 0 predictors = 0. Suprainguinal vascular procedures 2 H of ischemic heart disease Hx of heart failure 3 4 Hx of cerebrovascular disease DM requiring insulin 5 6 Preoperative serum creatinine > 2. Intrathoracic. 1 predictor = 1%.4% 7 .4%.

Templates -Emergent -Aortic Types of surgery and associated cardiac risks Low risk ( <1% ) Your own High risk ( > sub 5% ) headlineIntermediate (1-5%) -Intraperitoneal /intrathoracic -Orthopedic -Head & neck -Carotid endarterectomy -Prostrate surgery -Peripheral vascular -Prolonged surgery with large fluid shifts -Endoscopic -Breast -Skin -Cataracts -Superficial procedures Your own footer Your Logo .

prior MI based on history or pathological Q waves. perfusion imaging.Supplemental Preoperative Evaluation Noninvasive testing in preoperative patients indicated if 2 or more of following present: – Intermediate clinical predictors (Canadian Class I or II angina. aortic repair or peripheral vascular. Stress imaging. or diabetes) – Poor functional capacity (<4 METs) – High surgical risk procedure (emergency major surgery*. prolonged surgical procedures with large fluid shifts or blood loss) Angiography. compensated or prior HF. Holter monitor . ECG ETT. exercise echo.

Importance of exercise tolerance .

Pathophysiology of perioperative Cardiac Ischemia .

venous return compression. release of tourniquet ) . blood loss.Intraop factors • Unstable plaque / CAD • LVH • Hypercoagulable state and thrombosis • Catecholamines – Pain / stimulus – anemia • Depth of anesthesia • BP swings – pain – anemia/HYPOVOLEMIA ( neuraxial block.

Your own footer Your Logo .

arrhythmias. diastolic dysfunction.How to Monitor for Ischemia • Symptoms: usually none – Pain. sweating. shortness of breath. altered mentation • Clinical signs: usually none – Sweating. new V waves on PCWP tracing • TEE – SWMA. CHF. change in mitral regurgitation. HR changes. nausea and vomiting. hypotension • ECG: key perioperative monitor • Pulmonary artery catheter – Increased PCWP. decrease in global contractility .

ECG Monitoring for Ischemia • Lead selection II and V4 or V5 • ST SEGMENT CHANGES (most specific) • T wave changes – esp inversion in high risk groups • • • • Arrhythmias New conduction abnormalities New atrioventricular block Heart rate changes .

ECG .

poor localization • Horizontal / downsloping depression > 0. good localization > 0.15 mV at 80 msec after J point • Elevation: transmural ischemia.1 mV Your own footer Your Logo .ECG • Depression: subendocardial ischemia.1 mV (1 mm) at 60-80 msec after J point • Upsloping depression > 0.

ECG monitoring for Ischemia Other Causes of Acute ST Segment Changes • • • • • • • • • • Conduction disturbances R wave amplitude changes Hyperventilation Electrolyte changes. spinal Myocardial infarction or contusion Neurological changes (trauma. hypoglycemia Hypothermia (< 30º) Body position changes / retractors Autonomic NS changes e.g. SAH) Acute pericarditis .

• Limitations Pre-intubation events are missed Image plane may miss events in other areas of the myocardium .TEE • TEE is a highly sensitive for monitoring ischemia • In the event of ischemia there is development of new regional wall motion abnormalities • decreased systolic wall thickening • ventricular dilation • It can detect ischemia much earlier than ecg.

• impaired systolic function can lead to decreased cardiac output which can be detected. • PCWP > 18-20 mm Hg • Limitations: It is not sensitive for myocardial ischemia Pulmonary artery cathetrisation may lead to increased morbidity .Pulmonary artery catheter • Myocardial ischemia reduces left ventricular compliance that results in increased pulmonary artery occlusion pressure and presence of V waves.

Arterial pressure waveform analysis • Hypotension along with decreasing cardiac output can result from either 1) hypovolemia 2) ventricular dysfunction • Measurement of stroke volume variation can rule out hypovolemia .

Arterial wave form • Hypotension along with decreasing cardiac output can result from either 1) hypovolemia 2) ventricular dysfunction • Measurement of stroke volume variation can rule out hypovolemia .

If we can rule out hypovolemia. indicates Your own sub headline hypovolemia. • The greatest clinical use of systolic pressure variation has been in the early diagnosis of hypovolemia.• Systolic pressure variation (SPV) particularly increased D down. systolic dysfunction can be diagnosed .

marker for platelet-monocyte aggregation as thrombus is being formed . • TnT and TnI levels may rise more than 20 times above the reference range within 3 hrs after onset of chest pain and may persist for up to 10-14 days • CPK-MB is not useful intraoperatively because the leakage of these enzymes into the circulation can occur 8-24 hours after an MI.Markers • MI may be best detected with cardiac Troponin T concentrations. • CD40 ligand .

Monitoring for ischemia .

Clonidine) • Statins • Control BP • Antiplatelets and anti coagulants (if indicated) • Prophylactic placement of intra-aortic balloon counterpulsation device . Dexmedetomidine.Management (prevention) • Pre op procedures PCI CABG • B blockers • Alpha-2 Agonist (Mivazerol.

Reduced Hemodynamic Stress Plaque stabilization ??? Platelet Action ??? Metabolic Increased Diastole Spectrum of Spectrum of potential potential benefits of benefits of beta-blockade beta-blockade Decreased Ventricular Arrhythmias Improved oxygen supply/demand Improved myocardial blood flow Antiarrhythmic action Reduced VF threshold .

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Management of Suspected Intraoperative Ischemia • FIRSTLY – Secure system ensure adequate oxygenation. alter surgical plan Postoperative management .especially tachycardia and blood pressure • THIRDLY. PCWP. Hb • SECONDLY – Optimize hemodynamics . consider – – – – – Increase FiO2 NTG Increased monitoring CVP. TEE Inform surgeon. BP. volume.

hypotension – Increased filling pressures or new V waves – TEE changes (check all LV segments) • Consider – Other causes of ECG change – Patient’s risk of CAD . previous ECG printouts) • Verify automatic ST segment analyses • Look for associated features – Arrhythmias. mode.Management of Suspected Intraoperative Ischemia • Check ECG (calibration.

20–100 mg.5–2. 0. 2.Hypertension. 33–330 μg/min .5–10 mg • IV nitroglycerin Nitroglycerin.5 mg Labetalol. tacycardia • Deepen anesthesia • IV β-blockade Esmolol. 50–200 μg/kg/min Metoprolol.

Normotension tachycardia • Ensure adequate anesthesia • Change anesthetic regimen • IV β-blockade .

normal heart rate • Deepen anesthesia • IV nitroglycerin or • Nicardipine.Hypertension. 1–10 μg/kg/min . 1–5 mg.

g. tachycardia • • • • IV α-agonist Phenylephrine. 2–4 μg Alter anesthetic regimen (e.. lighten) IV nitroglycerin when normotensive . 25–100 μg Norepinephrine.Hypotension.

0.3–0.6 mg IV nitroglycerin when normotensive . bradycardia • • • • • Lighten anesthesia IV ephedrine Ephedrine. 5–10 mg IV epinephrine Epinephrine. 4–8 μg IV atropine Atropine.Hypotension.

.No hemodynamic abnormalites • IV Nitroglycerin • IV Nicardipine.

It stipulates that patients suffering from coronary stenosis are at particular risk of myocardial ischemia when their mean arterial pressure is less than the heart rate (MAP/heart rate <1) .• The ‘Buffington ratio’ is a useful index.

then 1000 U/hr) if surgery permits – beta-blockade (aspirin & beta-blockade reduce risk of infarct and mortality) – Observe for complications. CHF. infarct) – Aspirin or ketorolac – Heparin (5000 U bolus. PCWP.Management of Persistent Ischemia If Ischemia Persists with Optimal Hemodynamic • Keep increasing NTG (may combine with vasopressor if hypotension) • May increase monitoring CVP. infarct – Cardiology consult .urgent reperfusion . TEE • CONSIDER Acute Coronary Syndrome (unstable angina.within 12-24 hours (especially if persistent ST segment elevation) • PTCA most practical (thrombolysis CI after surgery) – ? IABP .arrhythmias.

beta-blockade. ACE inhibitors . statins.Postoperative Management of Perioperative Ischemia • CONSIDER – – – – ICU or CCU postop and/or cardiology referral Surveillance for periop MI ECG immediately postop and on day 1 and 2 Cardiac troponin at 24 hrs and day 4 (or hosp discharge) (CK-MB of limited use) • LONG TERM – cardiologist – Risk factor management – Aspirin.

the night has twin sons. The upper half of the emblem shows the rising or setting sun of consciousness. . who carry flaming torches pointing toward the floor.In Greek mythology. Thanatos (death) and Hypnos (sleep). to light a path through the dark Juan Marin placed a small light between Thanatos and Hypnos indicating the flame of life the anesthesiologist must guard.