Patient with Critical Triple Vessel Disease posted for open Cholecystectomy

A Case Report

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.

PREOPERATIVE PLANING:

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.

INTRA OPERATIVE MANAGEMENT:

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.

• Arterial line was placed in left radial artery for continuous blood pressure monitoring.
• Two peripheral 18 gauge and 16-gauge i. v cannula were placed.
• Right subcostal block was given with 0.2% ropivacaine 20ml and 4mg dexamethasone under ultrasound guidance.
• Preoxygenated with 100% oxygen via facemask for 3 minutes.
• He was anaesthetized with inj. Fentanyl 100 mcg iv, inj. Etomidate 10 mg iv, inj. Ciastracurium 8 mg and successfully intubated with 7. 5 mm ID endotracheal tube in first attempt with assistance of video laryngoscope.
• Ryle’ s tube inserted and kept for continuous aspiration.
• The patient was strapped with belt to prevent fall down during positioned for cholecystectomy( Head up and right tilt).
• Anaesthesia was maintained with inhalational agent desflurane and intermittent muscle relaxant.
• Minimal inj. Noradrenaline infusion support and inj. Epidrine bolus required to maintain diastolic pressure above 60 mm hg.
• Mechanical ventilation was performed by volume control ventilation with fio2 40%, and respiratory rate was adjusted to maintain end tidal co2 between 30- 40 mmhg.
• Intravenous fluid maintained at 30 ml / hr. Analgesics such as inj. Paracetamol and inj. Tramadol 50 mg iv were used.
• Surgery was completed without any haemodynamic instability.
• The patient was reversed with neostigmine and glycopyrolate and extubated after regular respiration with good tidal volume.

POST OPERATIVE MONITORING:

• After successful extubation, oxygen mask was kept with 5 litres of o2 and inj. Noradrenaline infusion tappered and stopped.
• Post operative analgesics such as inj. Paracetamol, inj. Tramadol were suggested.
• Patient was shifted to CCU for monitoring.
• Post operative Ecg and cardio review were asked to regarding restart antiplatelets and anticoagulants.
• He was successfully shifted to ward on Pod 3 without any significant post operative complications.

CASE DISCUSSION:

• The management of patients developing acute cholecystitis following or concurrent with myocardial infarction is particularly challenging.
• Patient with coronary artery disease undergoing non cardiac surgery are at increased risk for perioperative complications such as myocardial ischemia, Cardiac failure, arrhythmias, cardiac arrest and increased mortality and morbidity. These complications are much higher in patients with recent MI.
• Recent myocardial infarction defined as MI occurs between 7 – 6 weeks.
• An assessment of perioperative cardiac risk requires consideration of type of surgery planned, and the patient’s functional status.
• Here, Lee’s revised cardiac index was used for risk stratification. He came under class IV (High risk)
• The primary goal of the anaesthetic management is avoidance of myocardial ischemia and MI. This is by avoiding the factors which impair myocardial o2 supply- demand balance.
• The causes of imbalance in myocardial oxygen supply and demand are:-

• Anticoagulation or thrombolytic therapy for MI increases the risk of surgical and post operative bleeding.
• Laparoscopy in patients with poor cardiac function has been the subject of controversy and is considered by many surgeons a relative contraindication.
• In severe cardiac disease and cardiac failure patients in view of laparoscopy, effect on decreasing venous return, decrease in left ventricular stroke volume, cardiac index.
• Pneumoperitonium may lead to sudden increase in venous return and subsequent congestive heart failure and acute pulmonary oedema.
• Delaying surgical intervention for gall stones might also delaying coronary artery bypass procedure (patient actually needs)

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
2^nd Year DNB Resident, Anaesthesia
Kauvery Hospital, Chennai