MANAGEMENT ANESTHESIA IN PATIENT WITH DOUBLE
ANTIPLATELET AGENT POST PCI UNDERWENT EXTENDED
PYELOLITHOTOMI
Iqbal M, Mujahidin, Yasir T, Jamal F
DEPARTEMENT OF ANESTHESIA AND INTENSIVE CARE
FACULTY OF MEDICINE SYIAH KUALA UNIVERSITY BANDA ACEH
BACKGROUND
The most common cause of myocardial ischemia is atherosclerosis
of the coronary arteries. Coronary Arterial Disease (CAD) is
responsible for about 26.4% of all deaths in Indonesia and is a
major cause of perioperative morbidity and mortality. Percutaneous
Coronary Intervention (PCI), initially used in the treatment of
patients with stable angina and discrete lesions in a single coronary
artery. With the combination of sophisticated equipment,
experienced operators, and modern drug therapy, PCI has evolved
into an effective nonsurgical modality for treating patients with
CAD, and recommended to receive double antiplatelet agent.
CASE REPORT
Male, 46 years old, with history of percutaneous coronary intervention
with bare metal and drug eluting stent 11 month ago, diagnosed with
staghorn calculi and prepared for extended pyelolithotomy. With history
of hypertensive and coronary heart disease one and a half years ago and
received 5 coronary stent and consume double antiplatelet agent
continuously (Clopidrogel and Aspilet, Both stopped a week before
surgery). Mild chest pain is still complained 4 months ago. ECG shows
elevated QRS complex and T inverted on V5 and V6, echocardiography
shows hypokinetic inferior extensive with ejection fraction 73%. He also
has a controlled Type 2 Diabetes Mellitus on insulin therapy. The patient
admitted to the hospital for nausea and vomiting, elevated urea and
creatinine level with estimated GFR 22.3 mL/min/1.73m2. Plain
abdominal X-ray shows a staghorn calculi and planned for elective
surgery.
Intraoperative, before induction, monitor shows blood pressure 140/90
mmHg, pulse 89 bpm, respiratory rate 18 times/minute and oxygen
saturation 99%, given 4 mg Midazolam and 200 mcg Fentanyl for co-
induction, 100 mg Propofol titrated for induction, intubation facilitated
by 40 mg Rocuronium, maintenance by volatile Isofluran 0.8-1 vol%.
Intraoperative bleeding is up to 2 liters, unstable hemodynamic
resuscitated by fluid and blood product then supported by Dobutamin 1-5
mcg/KgBW/h, surgery took 3 hours and post operative admitted to the
intensive care unit (ICU). The patient developed to AKI, reperfusion
injury due to previous bleeding, severe diastolic dysfunction, hemostasis
problem, and infection. Managed by CRRT on CVVHDF mode for 6
days, hemodynamic stabilization by fluid resuscitation and vasopressor
guided by advanced hemodynamic monitoring (Echocardiography), and
full dose Vancomycin for MRSA infection. Weaned from ventilator,
extubated, and discharged from ICU on seventh day with stable
hemodynamic and good renal function.
DISCUSSION
Patients who undergo anesthesia for non cardiac surgery have increased
rates of morbidity and mortality when coronary artery disease is present.
The incidence of myocardial reinfarction in the perioperative period is
related to the time elapsed since the previous myocardial infarction.
Antiplatelet agents like Aspirin and Clopidogrel are widely used for
indications ranging from primary and secondary prevention of
myocardial infarction of coronary stent thrombosis after percutaneous
coronary interventions. When patients receiving antiplatelet drugs are
scheduled for surgery, perioperative withdrawal of these drugs routinely
advised to decrease the hemorrhagic risks that may be associated if such
therapy is continued in the perioperative period. This approach may be
inappropriate as stopping antiplatelet drugs often exposes the patient to a
more serious risk. Depleted hemoglobin due to bleeding associated with
worse outcome in patients with established CAD and could be used as an
independent predictive factor of mortality.
induction start with high dose opioid to avoid hemodynamic instability
during intubation, sympathetic tone is dulled and no sign of reinfarction,
bleeding intraoperative seemed hard to managed, patient resuscitated
with packed red cell and fresh frozen plasma, and admitted to the ICU.
CONCLUSION
the patient with double antiplatelet agent post PCI who underwent
elective surgery should be concerned for perioperative bleeding, for the
use of antiplatelet agent which is required to prevent coronary event.
Intraoperative bleeding prevention by stopping double anti platelet agent
in this patient is not significant.
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