Intra-op MI

[arkgolfer]

Had my first (and hopefully last) one of these today. Pt. was in for p*****-implant. My MDA and CRNA had been gone awhile since induction, succ had long worn off, no real need for non-depolarizers in this case. All was going well until.... Pt. bucked one time, very little, I had about 5.8% ET Des going, plus about 7 cc fentanyl on board. I turned up the gas to settle him back down, looked at my monitor to see if we had HR increase, then saw his ST segments starting to rise, then saw ET CO2 start to plummet, BP followed soon after. CRNA and MDA back in the room within 30 seconds. Too far along to abort the case, surgeon had to finish while we started a-line, worked on BP, etc... Pt. to the cath lab with a 98% proximal RCA lesion. Seems to be doing ok now, on IABP in CVICU. Had normal stress test 2 months ago.

Anyone else have this happen?????

Lot-o-learnin today!!!!

[mwbeah]

Sounds like you had a great learning day. Just goes to show you that you might not find out until the patient undergoes anesthesia about underlying co-existing diseases. In the absence of visible end organ damage and with a normal stress test there was no indication which would have required cancellation of the operation. Sounds like you handled the situation very well. You gotta reperfuse the heart and "get outta town". Eventually, after performing enough anesthetics, this happens to almost everyone 'cuz there are patients that are sick out there and do not realize it or they are poor historians and may not relate that "tightening in my chest" to a prior MI.

Mike

[Tenesma]

you should hope that every day as a student is like this - because you only learn by doing things you haven't experienced before....

another thing to consider is a paradoxical coronary embolus (either air or tissue/clot) via a venous sinus near the member.... that may also tie in with the cough/bucking you saw which could have been a "gasping" reflex (pulm. embolus). I would recommend a bubble study echo to eval for PFO.

the reason i bring this up is that true Acute Coronary Syndrome (ACS) due to plaque rupture in a patient is relatively rare intra-operatively, and is a lot more common post-operatively in the thrombotic state.... a lot more common is demand ischemia/infarction, but it sounds like he had a normal stress test and was relatively stable until he bucked/coughed.

[snakebitten]

Better the MI happened during your case then using his new woody

[Pete495]

Sounds like a great learning experience, but at the same end, I hope it never happens to me, even though I'm sure I would learn a lot from it. What drips did you start? What a case for an MI to occur in. Kind of ironic, you go in for some work on your unit, and you come out with a heart attack.

I see Tenesma's point on the coughing mechanism. I was curious as to why the patient would have coughed. If he had an MI though, what would the cough have been from? Was the pt. starting to wake up a little?

Sounds like excellent learning material. Hope you can share with us some more info if you have the time.

Thanks for sharing the case.