A 72- year male known case of type 2 DM, Hypertensive, Hypothyroid, Parkinson and recently diagnosed as acute myocardial infarction on dual antiplatelet therapy, presented as retrosternal chest pain, diffuse abdominal pain and multiple episodes of vomiting (bilious).
The patient was admitted in CCU and vitals were stabilized. Ecg showed normal sinus rhythm and T wave inversion in lead 1, avl, v5,v6. Echo was done found to be EF- 35%, regional wall motion abnormality +, hypokinetic -lv apex, anterolateral, inferior wall, moderate LV dysfunction, moderate MR, mild pulmonary artery hypertension.
Antiplatelet therapy stopped and planned for coronary angiogram. It revealed Triple vessel disease.
Left main – 50 % stenosis, LAD – occluded
LCX – proximal – 90% stenosis, OM1 -90%, OM2- 90%
RCA – proximal – 80%, mid – 75%, PDA – occluded
Ultrasound abdomen was done for abdominal pain found to be acute calculous cholecystitis. Surgical gastro opinion sought – advised cholecystectomy under high risk.
Routine investigations were done and cardiologist opinion was sought – high risk was given and advised open cholecystectomy.
Blood investigations found to be within normal limits except total wbc count and TSH values were elevated.
Antibiotics initiated and physician opinion obtained for high TSH.
Antiplatelets was withold and bridged with injection heparin. Advised to stop inj. Heparin 12 hrs before surgery.
Advised to continue routine medications till day of surgery.
Plan of anaesthesia, high risk associated with anaesthesia and surgery, patient condition and post op icu stay were clearly explained to patient and attenders with written consent.
Preoperative glycemic control was optimized.
NPO guidelines followed.
Premedication’s – Inj.Pantoprazole 40 mg iv, Inj. Palanosteron 0.075 mg were given.
The patient was positioned supine and all ASA guidelines monitors were attached – pulse oximetry, non-invasive blood pressure (NIBP), electrocardiogram (5 lead Ecg) and ETCO2.
So, monitoring is important to detect early ischemia and rhythm disturbances.
Hence proper evaluation and management peri- operatively are the key to success.
Dr. Velmurugan Deisingh Head of Department of Anaesthesiology Kauvery Hospital, Chennai
Dr. Varalakshmy 2nd Year DNB Resident, Anaesthesia Kauvery Hospital, Chennai