title: Anesthetic management of a patient with deteriorated cardiac function following cardiopulmonary resuscitation.
abstract: A 73-year-old woman suffering from an abdominal aortic aneurysm (AAA), unstable angina, and low cardiac function (32% of ejection fraction) was scheduled for abdominal aortic replacement and coronary artery bypass grafting. However, before the scheduled operation the patient fell into cardiopulmonary arrest with ventricular fibrillation due to rupture of the AAA. Immediate cardiopulmonary resuscitation (CPR) using epinephrine and electrical defibrillation restored the spontaneous circulation. Following CPR, a continuous high-dose dopamine infusion (15 µg/kg/min) was initiated and emergent abdominal aortic replacement was performed. On arrival at the operating room, the patient showed serious hypotension, atrial fibrillation with multifocal ventricular premature contractions, and metabolic acidosis. Transesophageal echocardiography (TEE) suggested that the circulatory collapse might have resulted from diastolic dysfunction and deteriorated compliance of the left ventricular (LV) wall, possibly due to myocardial stunning induced by myocardial ischemia, and tachycardia induced by hypovolemia, both of which are influenced by high doses of catecholamine. We accordingly transfused adequate amounts of blood products and gradually decreased the infusion rate of dopamine to 4 µg/kg/min, while carefully monitoring blood pressure, central venous pressure, and TEE. By the end of surgery hemodynamic parameters had recovered to near normal levels. In post-resuscitated and hypovolemic patients, caution should be taken when administering high levels of exogenous catecholamines, which can induce myocardial stunning and circulatory collapse.
authors.affiliation: Department of Anesthesiology, Kurume University School of Medicine, Kurume, Japan.
authors.forename: Tamaki
authors.initials: T
authors.lastname: Nagata
authors.forename: Yasunori
authors.initials: Y
authors.lastname: Mishima
authors.forename: Takahiko
authors.initials: T
authors.lastname: Ito
authors.forename: Maiko
authors.initials: M
authors.lastname: Sawada
authors.forename: Teruyuki
authors.initials: T
authors.lastname: Hiraki
authors.forename: Nobuya
authors.initials: N
authors.lastname: Hamada
authors.forename: Nao
authors.initials: N
authors.lastname: Miyawaki
authors.forename: Asuka
authors.initials: A
authors.lastname: Ito
authors.forename: Seiji
authors.initials: S
authors.lastname: Watanabe
authors.forename: Kazuo
authors.initials: K
authors.lastname: Ushijima
mesh_terms: D000368:Aged; D000771:Anesthesia, Intravenous / Q000379:methods*; D000789:Angina, Unstable / Q000150:complications; D017544:Aortic Aneurysm, Abdominal / Q000150:complications / Q000601:surgery; D001019:Aortic Rupture / Q000150:complications / Q000601:surgery; D016887:Cardiopulmonary Resuscitation / Q000009:adverse effects; D001026:Coronary Artery Bypass; D004298:Dopamine / Q000008:administration & dosage / Q000009:adverse effects; D005260:Female; D006323:Heart Arrest / Q000628:therapy; D006801:Humans; D020896:Hypovolemia / Q000150:complications; D017682:Myocardial Stunning / Q000150:complications
chemical_list: D004298:Dopamine