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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