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.

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. Advised to remain NPO from midnight and 2 units of packed cells were arranged.

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

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CSE block was given in right lateral position with 12.5 mg of 0.5 % hyperbaric bupivacaine along with 25 mcg fentanyl was given intrathecally through L3- 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.

Intra op events
1

After 15 min, the ecg started to show down sloping ST depression

In the diagnostic mode monitor recognized the a ST depression of 2 mm Progressed to 3.4 mm in the next 5 minutes in the lead II alone. Later it showed a value of +0.2 and +1.2 in lead V5 and aVL respectively. BP was 106/62 with HR 117 / min Patient was asked for any chest pain or heaviness which the patient denied.

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

Image just after 1stdose of phenylephrine

 After 10 minutes ST depression of 3.2 mm in lead II with reciprocal ST elevation in aVL of +1.1 mm was seen. 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. Till now patient received 1 litre of crystalloid and 500 ml of colloid.

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

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.

Angiography

Cardiology evaluation later revealed a 70 % occlusion of RCA.

PCI

An elective coronary stenting was done subsequently.

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

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.

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

- 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 didnt 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

Ischemia Discussion..

In patients without previous history of coronary artery disease (CAD), the incidence of perioperative myocardial infarction (PMI) amounts to 0.6% Most often the intraoperative cardiac ischemia involves the left coronary artery and presents as ST segment depression in the left sided leads

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)

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. 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

Clinical predictors

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General Approach to the Patient

History angina, recent or past MI, HF, symptomatic arrhythmias, presence of pacemaker or ICD Physical Examination general appearance, rales, elevated JVP, carotid and other arterial pulses, S3 gallop, murmurs Comorbid Diseases
Pulmonary Diabetes Mellitus Renal Impairment Hematologic Disorders

Ancillary Studies - ECG almost always indicated, blood chemistries and chest X-ray based on history and physical findings

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.

MI (< one month) -Unstable or

month)
Stable angina Compensated CHF Creatinine 2.0 Diabetes

severe angina
-Large ischemic burden (stress testing) -Decompensated CHF -Significant
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-Abnormal ECG. Rhythm other than sinus. -Low functional capacity. -History of stroke. -Uncontrolled systemic hypertension

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Revised Goldman Cardiac Risk Index

Independent predictors of major Perioperative cardiac complications:
1

Intraperitoneal, Intrathoracic, Suprainguinal vascular procedures

H of ischemic heart disease

Hx of heart failure

Hx of cerebrovascular disease
DM requiring insulin

Preoperative serum creatinine > 2.0 mg/dL

0 predictors = 0.4%, 1 predictor = 1%, 2 predictors = 2.4%, 3 predictors = 5.4%

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

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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, prior MI based on history or pathological Q waves, compensated or prior HF, or diabetes) Poor functional capacity (<4 METs) High surgical risk procedure (emergency major surgery*, aortic repair or peripheral vascular, prolonged surgical procedures with large fluid shifts or blood loss)
Angiography, ECG ETT, perfusion imaging, exercise echo, Stress imaging, Holter monitor

Importance of exercise tolerance

Pathophysiology of perioperative Cardiac Ischemia

Intraop factors
Unstable plaque / CAD LVH Hypercoagulable state and thrombosis Catecholamines
Pain / stimulus anemia

Depth of anesthesia
BP swings
pain anemia/HYPOVOLEMIA ( neuraxial block, blood loss, venous return compression, release of tourniquet )

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How to Monitor for Ischemia

Symptoms: usually none
Pain, shortness of breath, sweating, nausea and vomiting, altered mentation

Clinical signs: usually none

Sweating, CHF, HR changes, arrhythmias, hypotension

ECG: key perioperative monitor Pulmonary artery catheter

Increased PCWP, new V waves on PCWP tracing

TEE
SWMA, change in mitral regurgitation, diastolic dysfunction, 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

ECG

Depression: subendocardial ischemia, poor localization

Horizontal / downsloping depression > 0.1 mV (1 mm) at 60-80 msec after J point Upsloping depression > 0.15 mV at 80 msec after J point

Elevation: transmural ischemia, good localization

> 0.1 mV

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ECG monitoring for Ischemia

Other Causes of Acute ST Segment Changes

Conduction disturbances R wave amplitude changes Hyperventilation Electrolyte changes, hypoglycemia Hypothermia (< 30) Body position changes / retractors Autonomic NS changes e.g. spinal Myocardial infarction or contusion Neurological changes (trauma, SAH) Acute pericarditis

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. Limitations Pre-intubation events are missed Image plane may miss events in other areas of the myocardium

Pulmonary artery catheter

Myocardial ischemia reduces left ventricular compliance that results in increased pulmonary artery occlusion pressure and presence of V waves. 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

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

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

Markers

MI may be best detected with cardiac Troponin T concentrations. 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. CD40 ligand - marker for platelet-monocyte aggregation as thrombus is being formed

Monitoring for ischemia

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

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

Management of Suspected Intraoperative Ischemia

FIRSTLY
Secure system ensure adequate oxygenation, BP, volume, Hb

SECONDLY
Optimize hemodynamics - especially tachycardia and blood pressure

THIRDLY, consider
Increase FiO2 NTG Increased monitoring CVP, PCWP, TEE Inform surgeon, alter surgical plan Postoperative management

Management of Suspected Intraoperative Ischemia

Check ECG (calibration, mode, previous ECG printouts) Verify automatic ST segment analyses Look for associated features
Arrhythmias, hypotension Increased filling pressures or new V waves TEE changes (check all LV segments)

Consider
Other causes of ECG change Patients risk of CAD

Hypertension, tacycardia

Deepen anesthesia IV -blockade Esmolol, 20100 mg, 50200 g/kg/min Metoprolol, 0.52.5 mg Labetalol, 2.510 mg IV nitroglycerin Nitroglycerin, 33330 g/min

Normotension tachycardia

Ensure adequate anesthesia Change anesthetic regimen IV -blockade

Hypertension, normal heart rate

Deepen anesthesia IV nitroglycerin or Nicardipine, 15 mg, 110 g/kg/min

Hypotension, tachycardia

IV -agonist Phenylephrine, 25100 g Norepinephrine, 24 g Alter anesthetic regimen (e.g., lighten) IV nitroglycerin when normotensive

Hypotension, bradycardia

Lighten anesthesia IV ephedrine Ephedrine, 510 mg IV epinephrine Epinephrine, 48 g IV atropine Atropine, 0.30.6 mg IV nitroglycerin when normotensive

No hemodynamic abnormalites

IV Nitroglycerin IV Nicardipine,

 The Buffington ratio is a useful index. 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)

Management of Persistent Ischemia If Ischemia Persists with Optimal Hemodynamic

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

? IABP

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, statins, beta-blockade, ACE inhibitors

In Greek mythology, the night has twin sons, Thanatos (death) and Hypnos (sleep), who carry flaming torches pointing toward the floor, 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. The upper half of the emblem shows the rising or setting sun of consciousness.