Intraoperative Myocardial Ischaemia



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Emergency Quick Reference Guide

V. 1.02

01 – 2013



1



Intraoperative Myocardial Ischaemia

Sign: ECG: ST-Segment depression/elevation, new T-wave inversion, new dysrhythmias
Goal: Reduction in myocardial oxygen consumption & increase in myocardial oxygen delivery
Oxygenation


  • Increase FiO2 100% (SpO2 > 94%)

  • Correct anaemia.

Check Hb and consider transfusion (aim Hb 7 – 9 g/dl)
Stress Response


  • Check depth of anaesthesia (avoid stimulation if possible)

  • Sufficient analgesia

Myocardial Perfusion Pressure




  • Increase perfusion pressure

Consider Noradrenalin 5 – 10 mcg i.v. if HR > 90/min

Consider Ephedrin 5 mg i.v. if HR < 90/min
Heart Rate


  • Titrate to desired heart rate while avoiding Hypotension

  • Goal 60 – 80 beats/min

Consider Esmolol 0.25 - 0.5 mg/kg i.v. (± 50 – 200 mcg/kg/min)

Consider Metoprolol 2.5 mg i.v.
Contractility


Consider Dobutamin 2 – 4 mcg/kg/min
Preload


  • Decrease preload

Consider sublingual Nitroglycerine (NTG) initially or

NTG infusion 0.5 - 1 mcg/kg/min

Monitor carefully
Volume status


  • Avoid hypovolaemia

Consider volume load 20 ml/kg

Consider further actions




  • Anticoagulation (Heparin and/or Aspirin)

  • HDU/ICU admission

Multi-lead ECG monitoring, invasive monitoring, TEE, 12-lead ECG asap, repeated lab chek for troponin, CK, CK-Mb etc.



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