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The Dilemma: Whether to Proceed or Postpone a Patient With Pyrexia at Induction of Anesthesia for Coronary Artery Bypass Graft Surgery
Routine surgery may be postponed if a patient has high white blood cells (WBC) and/or pyrexia. However, postponement carries the risk of myocardial ischaemia or infarction in a patient having coronary artery bypass graft (CABG) surgery. Our case raises this dilemma in a high-risk patient that was fu...
Autores principales: | , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
Cureus
2021
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8752342/ https://www.ncbi.nlm.nih.gov/pubmed/35036186 http://dx.doi.org/10.7759/cureus.20343 |
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author | Bennett, Sean R Alnouri, Muneeb Fernandez, Jose A |
author_facet | Bennett, Sean R Alnouri, Muneeb Fernandez, Jose A |
author_sort | Bennett, Sean R |
collection | PubMed |
description | Routine surgery may be postponed if a patient has high white blood cells (WBC) and/or pyrexia. However, postponement carries the risk of myocardial ischaemia or infarction in a patient having coronary artery bypass graft (CABG) surgery. Our case raises this dilemma in a high-risk patient that was further compromised by acute right ventricular (RV) dysfunction. A 51-year-old diabetic with end-stage renal failure, chest pain, and a recent non-ST elevation myocardial infarction (NSTEMI) who had previously refused surgery now presented for urgent CABG. During central line insertion, he started shivering and stated that he felt cold. His temperature was not measured pre-intubation, but he felt warm to the touch with no chest pain. Blood pressure (BP) 190/80 mmHg and HR 110 bpm. Iv glyceryl nitrate (GTN) and fentanyl controlled the BP. Cerebral oximetry was used to measure brain regional saturation (rSO(2)) with probes placed on the forehead pre-induction. Post-intubation his temperature was 38.1°C, end-tidal carbon dioxide (EtCO(2)) 9.2 kPa, heart rate (HR) 120 bpm. His recent NSTEMI and surgical referral two years previously meant that his ischaemic risk was high, and we decided to proceed with the surgery. During the internal mammary artery (IMA) harvesting and use of a retractor (IMAR), there was a steady fall in the rSO(2) readings along with hypotension and an increase in central venous pressure (CVP) becoming critical after 60 minutes. At this point, the patient went onto cardiopulmonary bypass (CPB). The patient required triple vasoactive support to wean off CPB. In the intensive care unit (ICU), he required immediate support for RV failure, including nitric oxide. The next day, the patient grew Gram-negative blood cultures. In hindsight, we should have checked his temperature before induction and postponed or postponed post-induction. Regarding the IMAR or any retractor, the operating team will pay much closer attention to any haemodynamic changes resulting from their use and act accordingly. |
format | Online Article Text |
id | pubmed-8752342 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2021 |
publisher | Cureus |
record_format | MEDLINE/PubMed |
spelling | pubmed-87523422022-01-14 The Dilemma: Whether to Proceed or Postpone a Patient With Pyrexia at Induction of Anesthesia for Coronary Artery Bypass Graft Surgery Bennett, Sean R Alnouri, Muneeb Fernandez, Jose A Cureus Anesthesiology Routine surgery may be postponed if a patient has high white blood cells (WBC) and/or pyrexia. However, postponement carries the risk of myocardial ischaemia or infarction in a patient having coronary artery bypass graft (CABG) surgery. Our case raises this dilemma in a high-risk patient that was further compromised by acute right ventricular (RV) dysfunction. A 51-year-old diabetic with end-stage renal failure, chest pain, and a recent non-ST elevation myocardial infarction (NSTEMI) who had previously refused surgery now presented for urgent CABG. During central line insertion, he started shivering and stated that he felt cold. His temperature was not measured pre-intubation, but he felt warm to the touch with no chest pain. Blood pressure (BP) 190/80 mmHg and HR 110 bpm. Iv glyceryl nitrate (GTN) and fentanyl controlled the BP. Cerebral oximetry was used to measure brain regional saturation (rSO(2)) with probes placed on the forehead pre-induction. Post-intubation his temperature was 38.1°C, end-tidal carbon dioxide (EtCO(2)) 9.2 kPa, heart rate (HR) 120 bpm. His recent NSTEMI and surgical referral two years previously meant that his ischaemic risk was high, and we decided to proceed with the surgery. During the internal mammary artery (IMA) harvesting and use of a retractor (IMAR), there was a steady fall in the rSO(2) readings along with hypotension and an increase in central venous pressure (CVP) becoming critical after 60 minutes. At this point, the patient went onto cardiopulmonary bypass (CPB). The patient required triple vasoactive support to wean off CPB. In the intensive care unit (ICU), he required immediate support for RV failure, including nitric oxide. The next day, the patient grew Gram-negative blood cultures. In hindsight, we should have checked his temperature before induction and postponed or postponed post-induction. Regarding the IMAR or any retractor, the operating team will pay much closer attention to any haemodynamic changes resulting from their use and act accordingly. Cureus 2021-12-11 /pmc/articles/PMC8752342/ /pubmed/35036186 http://dx.doi.org/10.7759/cureus.20343 Text en Copyright © 2021, Bennett et al. https://creativecommons.org/licenses/by/3.0/This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. |
spellingShingle | Anesthesiology Bennett, Sean R Alnouri, Muneeb Fernandez, Jose A The Dilemma: Whether to Proceed or Postpone a Patient With Pyrexia at Induction of Anesthesia for Coronary Artery Bypass Graft Surgery |
title | The Dilemma: Whether to Proceed or Postpone a Patient With Pyrexia at Induction of Anesthesia for Coronary Artery Bypass Graft Surgery |
title_full | The Dilemma: Whether to Proceed or Postpone a Patient With Pyrexia at Induction of Anesthesia for Coronary Artery Bypass Graft Surgery |
title_fullStr | The Dilemma: Whether to Proceed or Postpone a Patient With Pyrexia at Induction of Anesthesia for Coronary Artery Bypass Graft Surgery |
title_full_unstemmed | The Dilemma: Whether to Proceed or Postpone a Patient With Pyrexia at Induction of Anesthesia for Coronary Artery Bypass Graft Surgery |
title_short | The Dilemma: Whether to Proceed or Postpone a Patient With Pyrexia at Induction of Anesthesia for Coronary Artery Bypass Graft Surgery |
title_sort | dilemma: whether to proceed or postpone a patient with pyrexia at induction of anesthesia for coronary artery bypass graft surgery |
topic | Anesthesiology |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8752342/ https://www.ncbi.nlm.nih.gov/pubmed/35036186 http://dx.doi.org/10.7759/cureus.20343 |
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