Patients with recent myocardial infarction (MI), congestive heart failure, severe angina, or uncorrected multivessel coronary artery disease are at increased risk of cardiac complications after urgent major non-cardiac surgery. Although invasive haemodynamic monitoring and preoperative optimization of cardiac status may lead to some reduction in the rate of perioperative cardiac events, the mortality from such events still remains high. The use of an intra-aortic balloon pump (IABP) may play a role in such patients by improving the function of the injured heart. We report our experience with the use of perioperative IABP in a patient with unstable angina and recent MI who underwent urgent cholecystectomy. There were no perioperative cardiac events while the IABP was in place. The anaesthetic concerns, intraoperative and postoperative monitoring and care and usefulness of IABP will be discussed

Khan, Fauzia Anis

Samad, Khalid

English

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eCommons@AKUDepartment of Anaesthesia Medical College, PakistanJanuary 2006The role of prophylactic intra-aortic balloon pumpcounterpulsation (IABP) in emergency non-cardiac surgeryKhalid SamadAga Khan University, khalid.samad@aku.eduFauzia Anis KhanAga Khan University, fauzia.khan@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_anaesthPart of the Anesthesia and Analgesia Commons, and the Anesthesiology CommonsRecommended CitationSamad, K., Khan, F. A. (2006). The role of prophylactic intra-aortic balloon pump counterpulsation (IABP) in emergency non-cardiacsurgery. Journal of Pakistan Medical Association, 56(1), 42-43.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_anaesth/314Case ReportThe Role of Prophylactic Intra-Aortic Balloon Pump Counterpulsation (IABP) inEmergency Non-Cardiac SurgeryKhalid Samad, Fauzia Anis KhanDepartment of Anaesthesia and Intensive Care, Aga Khan University, Karachi.AbstractPatients with recent myocardial infarction (MI), con-gestive heart failure, severe angina, or uncorrected multi-vessel coronary artery disease are at increased risk of car-diac complications after urgent major non-cardiac surgery.Although invasive haemodynamic monitoring and preoper-ative optimization of cardiac status may lead to some reduc-tion in the rate of perioperative cardiac events, the mortali-ty from such events still remains high. The use of an intra-aortic balloon pump (IABP) may play a role in such patientsby improving the function of the injured heart. We reportour experience with the use of perioperative IABP in apatient with unstable angina and recent MI who underwenturgent cholecystectomy. There were no perioperative car-diac events while the IABP was in place. The anaestheticconcerns, intraoperative and postoperative monitoring andcare and usefulness of IABP will be discussed.  IntroductionPatients with recent myocardial infarction, conges-tive heart failure, severe angina, or uncorrected multivesselcoronary artery disease are at an increased risk of cardiaccomplications during and after undergoing urgent majornoncardiac surgery. Invasive haemodynamic monitoringand preoperative optimization of cardiac status may lead tosome reduction in the rate of perioperative cardiac events,but the mortality from such events still remains high.1 Theuse of an intraaortic balloon pump (IABP) may play a rolein such patients by improving the function of the injuredheart. We report our experience with the use of periopera-tive intra-aortic balloon counterpulsation in a patient withunstable angina and recent myocardial infarction whounderwent urgent noncardiac surgery. There were no peri-operative cardiac events while the IABP was in place. Theanaesthetic concerns, intraoperative and postoperative mon-itoring and care and usefulness of IABP are discussed in thecontext of anaesthetic management.Case ReportA 69 years old female was admitted for urgent chole-cystectomy due to acute cholecystitis complicated by prob-able biliary sepsis. Past medical history was significant forunstable angina, diabetes mellitus and hypertension. Shewas initially admitted under the surgical service with acutecholecystitis, but developed atrial fibrillation and a rapidventricular rate of 190 per minute.  Intravenous boluses ofmetoprolol were given to control the heart rate and she wasstarted on 100 milligrams metoprolol eight hourly and nitro-glycerin 40 milligram per hour intravenously. Patient wasshifted to the Coronary Care Unit with a diagnosis of unsta-ble angina following acute myocardial infarction (MI) andatrial fibrillation. Troponin I was sent which was found tobe positive (18.5 i.u.). Ultrasound revealed pus in the gallbladder therefore an urgent open cholecystectomy wasplanned. In view of her unstable cardiac status, an IABPwas inserted by the cardiologist and set at 1:1 augmentationin an attempt to improve oxygen supply and to reduce loadon the injured myocardium.Her preoperative vitals signs were as follows, bloodpressure 140/70 mmHg, pulse 70 beat/min, and respiratoryrate 16 breaths/min. She was afebrile. After application ofroutine monitoring, right radial artery was cannulated underlocal anaesthesia. Fentanyl 2ug/kg, thiopentone sodium4mg/kg and suxamethonium 1mg/kg were given at induc-tion and tracheal intubation was done with rapid sequenceinduction and application of cricoid pressure. Swan Ganzcatheter sheath was passed after induction for central pres-sure monitoring and subsequent Swan Ganz catheter inser-tion if needed. Anaesthesia was maintained with isoflurane0.6-1%, oxygen and nitrous oxide were used in 50:50 mix-ture, pancuronium 0.1mg/kg was used for muscle relaxationand end tidal CO2 was maintained between 30-34mmHg.Glyceryl trinitrate infusion                1-2ug/kg/min was con-tinued throughout surgery.  A total dose of 60mg of lasixwas given intravenously to maintain urine output.The patient remained stable during the intraoperativeperiod without pharmacological inoptropic support.Postoperative ventilation was planned until she becamehemodynamically stable without the support of IABP.Morphine infusion was used to control her pain. IABP wasremoved after 48 hours. She was extubated on the fourthpostoperative day, remained stable and was shifted to thespecial care unit on the sixth postoperative day and dis-charged from hospital on the ninth postoperative day.42 J Pak Med AssocDiscussionMyocardial ischaemia and perioperative myocardialinfarction are the most frequent causes of major morbidityand mortality in patients with ischaemic heart diseaseundergoing non cardiac surgery.2 Newer anaesthetic agentsand improvement in invasive monitoring have markedlyreduced this percentage from 7.7% to 1.9%.1 However,myocardial ischaemia can still occur in the perioperativeand in the postoperative period because of anaemia,hypothermia and pain. All these factors will activate sympa-thetic tone with the adverse effects on cardiovascular func-tion and coagulation. The result will be an increase inmyocardial oxygen consumption in the presence of decreasein delivery2. Although the risk of myocardial ischaemiaappears to be lower when a patient undergoes coronaryrevascularization before an elective surgery, but situationsdo arise when this is not feasible, possible or desirable.These clinical situations include coronary artery diseasewhich is not amenable to surgery or coronary angioplasty,multivessel coronary artery disease when emergent noncar-diac surgery is needed, severe comorbid diseases, or in apatient who may be a poor candidate for cardiac surgery.Intra-aortic balloon pump (IABP) support has beensuggested to decrease the risk of cardiac complications inpatients with ischaemic heart disease who are undergoingnoncardiac surgery.3-6 IABP drive console is a mechanical,circulatory device consisting of a pressurized gas reservoirconnected to a slender polyurethane balloon which is con-trolled electronically. The balloon catheter is inserted intothe patient's aorta either surgically or per-cutaneously. Thefemoral artery is the preferred route for insertion, but alter-native routes are via the subclavian or iliac artery. The pro-cedure is usually performed under fluoroscopic guidance toensure correct placement of IABP so that the tip is about1cm distal to the origin of the left subclavian artery.During diastole, the balloon is inflated leading to anincrease in the aortic diastolic pressure. This leads to anaugmentation of the coronary artery blood flow resulting inan increase in myocardial oxygen supply without anincrease in myocardial workload. In systole, the balloon isdeflated and this leads to a reduction in aortic root pressure.This produces a reduction in the after load.7, 8Although the value of prophylactic placement ofIABP for high-risk noncardiac surgery remains to be deter-mined, the successful use of IABP to maintain hemodynam-ic stability has been reported in many high-risk cardiacpatients by several authors.9 Most of these reported patientshad a history of uncontrolled hypertension, congestive heartfailure, ventricular ectopy, atrial fibrillation or unstableangina with diffuse coronary artery disease and recentmyocardial infarction at the time of surgery. Georgeson etal. reported the successful prophylactic use of IABP anddecision analysis.10 According to their analysis, patients inGoldman class IV or Detsky class III who were undergoingmajor surgical procedures may benefit the most from theIABP during surgery. Our patient came for an urgent open cholecystecto-my with the history of unstable angina and recent myocar-dial infarction (Goldman Class III and Detsky Class III), therationale for using IABP was to provide haemodynamic sta-bility without inotropic support and at the same timeimprove the oxygen supply to demand ratio by decreasingthe after load, thus preventing myocardial ischemia. Withthe support of IABP along with aggressive invasive moni-toring, we successfully managed the patient perioperativelywithout any complications. ConclusionIABP if available should be considered in the periop-erative management of patients with multivessel or leftmain coronary artery disease, recent MI, severe or unstableangina who must undergo major non-cardiac surgery.References1. Detsky AS, Abrams HB, McLaughlin JR, Drucker DJ, Sasson Z, Johnston N,et al. Predicting cardiac complications in patients undergoing non-cardiac sur-gery. J Gen Intern Med 1986;1:211-19.2. Priebe H-J. Triggers of perioperative myocardial ischaemia and infarction. BrJ Anaesth 2004;93:9-20.3. Buckley MJ, Craver JM, Gold HK, Mundth ED, Daggett WM, Austen WG.Intra-aortic balloon pump assist for cardiogenic shock after cardiopulmonarybypass. Circulation 1973;48 (Suppl III):90-4.4. Foster ED, Olsson CA, Rutenburg AM, Berger RL. Mechanical circulatoryassistance with intra-aortic balloon counterpulsation for major abdominal sur-gery. Ann Surg 1976;183:73-6.5. Bonchek LI, Olinger GN. Intra-aortic balloon counterpulsation for cardiacsupport during noncardiac operation. J Thorac Cardiavasc Surg1979;110:147-9.6. Miller MG, Hall SV. Intra-aortic balloon counterpulsation in a high-risk car-diac patient undergoing emergency gastrectomy. Anesthesiology1975;42:103-5.7. Amsterdam EA, Awan NA, Lee G, Low R, Joye JA, Foerster J, et al. Intra-aortic balloon counterpulsation: rationale, application and results. CardiovascClin 1981;11:79-96.8. Grotz RL, Yeston NS. Intra-aortic balloon counterpulsation in high-risk car-diac patients undergoing noncardiac surgery. Surgery 1989;106:1-5.9. Siu SC, Kowalchuk GJ, Welty FK, Benotti PN, Lewis SM. Intraaortic ballooncounterpulsation support in the high-risk cardiac patient undergoing urgentnoncardiac surgery. Chest 1991;99:1342-5.10. Georgeson S, Coombs AT, Eckman MH. Prophylactic use of intra-aortic bal-loon pump in high-risk cardiac patients undergoing noncardiac surgery: adecision analytic view. Am J Med 1992;92:665-78.Vol. 56, No. 1, January 2006 43

The role of prophylactic intra-aortic balloon pump counterpulsation (IABP) in emergency non-cardiac surgery

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The role of prophylactic intra-aortic balloon pump counterpulsation (IABP) in emergency non-cardiac surgery

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