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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.57 no.4 Campinas July/Aug. 2007
Acute coronary syndrome in a patient with severe coronary artery disease after laparoscopic cholecystectomy*
Síndrome coronario agudo en paciente con enfermidad coronaria de alto riesgo en el postoperatorio de colecistectomía videolaparoscópica
Adriano Bechara de Souza Hobaika, TSAI; Émerson Seiberlich, TSAII; Márcia Rodrigues Néder IssaIII
da Santa Casa de Belo Horizonte; Mestrando em Medicina pela Fundação
Santa Casa de Misericórdia de Belo Horizonte
IIAnestesiologista do Hospital SOCOR
IIIAnestesiologista da Santa Casa de Belo Horizonte
OBJECTIVES: Perioperative myocardial ischemia is rare, being frequently
related with tachycardia and/or hypotension in patients with severe coronary
CASE REPORT: A male patient, 71 years old, with diabetes, hypertension, and coronary artery disease underwent laparoscopic cholecystectomy. Anesthesia was induced with propofol, cisatracurium, and remifentanil and maintained with sevoflurane and remifentanil. During closure of the abdominal wall, the patient became hypotensive without ECG changes. The rate of remifentanil infusion was increased and, after five minutes, the patient developed complete atrioventricular block and reduction in mean arterial pressure (MAP). After the administration of 1.0 mg of atropine and 0.1 mg of adrenaline, the patient developed temporary tachycardia and MAP returned to normal. He was transferred to the ICU awake and after being extubated; after 12 hours, the patient complained of chest pain and the ECG demonstrated depression of the ST segment from V4 to V6. The echocardiogram demonstrated good systolic function without segmental changes. The CPK-MB curve was normal. The patient was treated with the protocol for unstable angina.
CONCLUSIONS: The patient presented a high risk for postoperative ischemia and underwent a surgical procedure with important hemodynamic changes. It is known that perioperative hemodynamic instability in patients with coronary artery disease increase the risk of postoperative coronary syndrome, which may happen up to 72 hours after the procedure and, in the majority of the cases, it is silent. The preoperative administration of beta-blockers and, more recently, statins have proved to be effective in reducing perioperative ischemia in these patients.
Key Words: ANESTHETICS, Venous: propofol, remifentanil; COMPLICATIONS, Cardiac: arrhythmia, myocardial ischemia; DISEASES, Cardiac: coronary; surgery, Abdominal: laparoscopic cholecystectomy
Y OBJETIVOS: La isquemia miocárdica perioperatoria es un evento no
común y está relacionada frecuentemente con la taquicardia y/o
hipotensión arterial en pacientes con enfermedad coronaria de alto riesgo.
RELATO DEL CASO: Paciente del sexo masculino, 71 años, diabético, hipertenso y con enfermedad coronaria, sometido a colecistectomía videolaparoscópica. La anestesia fue inducida con propofol, cisatracurio y remifentanil y mantenida con sevoflurano y remifentanil. Durante el cierre de la pared el paciente presentó hipertensión arterial sin alteraciones al ECG. La velocidad de infusión de remifentanil fue aumentada y después de cinco minutos, el paciente presentó bloqueo atrio ventricular total asociado a la reducción de la presión arterial promedio (PAM). Después de la administración de 1.0 mg de atropina y 0.1 mg de adrenalina, el paciente presentó taquicardia temporal y la PAM se normalizó. Fue transferido consciente y extubado para la UTI, y después de 12 horas, presentó dolor precordial y ECG con infra desnivelación ST de V4 a V6. El ecocardiograma reveló una buena función sistólica sin alteraciones segmentarias. Curva de CK-MB normal. El paciente fue tratado en protocolo de angina inestable.
CONCLUSIONES: El paciente presentaba riesgo aumentado para isquemia postoperatoria y fue sometido a un procedimiento en el cual las alteraciones hemodinámicas son profundas. Se sabe que inestabilidades hemodinámicas perioperatorias en pacientes con enfermedad coronaria aumentan el riesgo de síndromes coronarias en el postoperatorio y estas pueden ocurrir hasta 72 horas después de la cirugía, presentándose, en la mayoría de los casos, de forma silenciosa. La administración preoperatoria de beta-bloqueadores y más recientemente, estatinas se han mostrado eficiente en la reducción de eventos isquémicos perioperatorios en esos pacientes.
Perioperative myocardial ischemia is rare, and is frequently related with tachycardia and/or hypotension in patients with coronary artery disease 1. The case presented here illustrates the interaction of multiple perioperative factors that might be responsible for the ischemia in a patient with severe coronary artery disease.
A male patient, 71 years old, weighing 79 kg, underwent laparoscopic cholecystectomy and umbilical herniorrhaphy. He had a history of non-insulin dependent diabetes mellitus, chronic hypertension, and coronary artery disease (three years before the current surgery a stent was placed in the anterior descending coronary artery and right coronary artery). Current medications included metformin, losartan, diltiazem, nitroglycerin, and aspirin (which was discontinued 10 days before the surgery). Preoperative exams: hemoglobin 15.7 mg.dL-1, platelets 162,000.dL-1, INR 1.02, creatinine 1.2 mg.dL-1, urea 37 mg.dL-1, sodium 144 mEq.L-1, potassium 4.4 mEq.L-1. Chest X-rays showed calcification of the aorta; ECG with normal sinus rhythm and widespread changes in ventricular repolarization. Past surgical history of total prostatectomy. Monitoring consisted of pulse oxymetry, automatic blood pressure measurement, cardioscope (DII and V5 with monitoring of the ST segment), capnograph, and analyzer of the concentration of inhaled anesthetics. Anesthesia was induced with propofol (160 mg), cisatracurium (12 mg), and remifentanil (0.3 µg.kg-1) and maintained with sevoflurane, with an expiratory concentration of 2% to 3% with FiO2 = 1.0, and remifentanil, 0.1 to 0.3 µg.kg-1.min-1. The patient was intubated and mechanical ventilation was set to keep PETCO2 close to 33 mmHg. Eight minutes after induction, the patient became hypotensive (MAP = 45 mmHg), which was treated successfully with intravenous ephedrine (5 mg). There were no intercurrences during peritoneal insufflation, cholecystectomy, and peritoneal desufflation. The umbilical hernia was then corrected when the patient developed hypertension (MAP = 130 mmHg), without changes in the cardioscope. The rate of infusion of remifentanil was increased to 0.4 µg.kg-1 and, after five minutes, the patient developed severe bradycardia (HR = 30 bpm) and complete atrioventricular block associated with a significant reduction in MAP, to approximately 35 mmHg. Atropine, 1 mg, was administered immediately, without response; after 1 minute, 0.1 mg of adrenaline was administered, resulting in severe transient tachycardia (HR = 120 bpm) and MAP remained within acceptable levels. The surgery was concluded and the patient was extubated, without complications. He was conscious when he was transferred to the ICU where, 12 hours later, he complained of chest pain and the ECG showed T wave inversion and depression of the ST segment from V4 to V6. An echocardiogram revealed good cardiac function, without segmental changes, and the CK-MB curve was normal. The patient was treated for unstable angina and discharged from the unit after three days.
Most cases of perioperative acute coronary syndrome (PACS) present with silent angina (> 80%) shortly after the surgical procedure, of the non-Q wave type, with depression of the ST segment, being frequently preceded by tachycardia. These factors suggest that PACS results primarily from an increase in myocardial work. The PACS is often masked by the postoperative pain, administration of analgesics and/or gastric distention 1,2. Ischemia usually occurs at the end of the procedure or upon awakening from anesthesia, when there is an increase in sympathetic tonus (tachycardia and hypertension) associated with a proclotting activity 3. Anemia, pain, and hypothermia also contribute for the genesis of PACS.
Several prospective studies have demonstrated that patients with coronary artery disease seem to benefit from the preoperative administration of beta-blockers, because these drugs have proved to be effective on the prevention of ischemia and even death2-7. A meta-analysis published recently concluded that the preoperative administration of beta-blockers reduces the incidence of myocardial ischemia in 65% and infarction in 56% of the cases 8. Several of their effects, cardiovascular or not (antiarrhythmic, anti-inflammatory, and protection against apoptosis) are associated with the cardiac protection of beta-blockers. These drugs decrease the consumption of oxygen by decreasing the heart rate, preload, postload, and contractility. In surgical interventions that lead to wide variations in blood volume, atenolol, a hydrophilic drug, seems to be more stable than propranolol because the pharmacokinetics of the first is not influenced as much by changes in the volume of distribution 9.
Other promising drugs on decreasing PACS include the a2-adrenergic agonists 10 and the statins. Statins stabilize the atherosclerotic plaque and decrease the inflammatory reaction 11. The discontinuation of aspirin, before non-cardiac surgeries, has been frequently questioned because its anti-inflammatory and antithrombotic effects seem to overcome its interference in platelet aggregation.
The patient described here had an increased risk for postoperative ischemia (hypertension) and underwent a surgical procedure in which the hemodynamic changes are profound peritoneal insufflation with CO2 decreases venous return and increases postload, increasing workload even more. Beta-blockers were not administered and aspirin was discontinued during his preoperative preparation.
Another factor to consider is that increasing the dose of remifentanil during a hypertensive crisis might have induced the complete atrioventricular block, and this might have been the primary event leading to myocardial ischemia. There are two reports of severe bradycardia associated with remifentanil 12,13. All these factors might have contributed for the genesis of the myocardial ischemia in this patient.
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Adriano Bechara de Souza Hobaika
Rua Desembargador Jorge Fontana, 214/2502 Belvedere
30320-670 Belo Horizonte, MG
Submitted em 21
de junho de 2006
Accepted para publicação em 18 de abril de 2007
* Received from Hospital SOCOR