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I don't think we can ignore patients with elevated preoperative troponins




76 year old male for vascular surgery: fem-aorta bypass for ischemic foot


PMHx:

CAD and history of CABG 2004

ESRD on dialysis and still produces urine

Type 2 DM, HTN

Hyperlipidemia

PVD

Active smoker: 1 ppd with 60+ smoking history

Heavy ETOH historical use

Recent diagnosis of critical left carotid stenosis

Intraop:

Challenging airway: McGrath 4 blade used

CVC and arterial line

EBL 200 ml, 1 unit PRBC (Hgb preop 104), 800 ml crystalloid

Lowest systolic blood pressure 110 and goal SBP 150 which was maintained with 1-6 mcg/min norepinephrine infusion throughout the case

Postop:

Admitted to our anesthesiologist-run High Acuity Unit. Asymptomatic; no chest pain or SOB except for transient episode of epigastric pain that resolved with almagel.

Troponins:

Pre-op: 58

POD 0: 174-249

POD 1: 479-495

POD 2: 535

POD 3: 616

POD 4: 857

POD 5: 864

Angio POD 3:

Mild LV impairment with inferior wall hypokinesis, DES to distal RCA graft and recommended one year of DAPT

POD 13: ?TIA? during dialysis and hypotension: IR placed carotid stent for critical carotid stenosis

POD 14: Discharged home with follow ups

Conclusion:  This high risk vascular patient has known ESRD and elevated troponins preoperatively. This population wasn't included in the VISION trial but they are a high risk surgical group. We do not know what NT-proBNP or troponin cut-offs should be used for the perioperative population and this warrants further investigation. This patient had an asymptomatic NSTEMI which was only diagnosed with troponin elevation only. How do you monitor for MINs in patients with elevated troponin preoperatively?


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