Ischaemic heart disease for rectal cancer surgery72-year-old man, 84 kg, for open anterior resection of rectal cancer

The patient

The examiner asks

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1. Consider

   What are your anaesthetic considerations?

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   • A 72-year-old with angina, insulin-treated diabetes and kidney disease, for time-sensitive open rectal cancer surgery. Patient
   • At 72 with diabetes and creatinine 2.3, I screen his frailty and cognition; delirium risk rises past 60.
   • Open bowel resection is intraperitoneal surgery, which carries high cardiac risk. Surgery
   • He's a coronary patient having non-cardiac surgery; throughout, I protect his coronary perfusion. Disease

2. Prepare

   Take me through his cardiac risk assessment.

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   • I'd use the ACC/AHA stepwise pathway, applied to him. Disease
   • Urgency first: time-sensitive cancer surgery, so there's time to assess but not to delay. Stem trigger
   • Active cardiac conditions? He has none: no acute coronary syndrome, decompensated failure, severe valve lesion or significant arrhythmia. Disease
   • Risk score: intraperitoneal surgery, coronary disease, insulin and creatinine 2.3 give an RCRI of 4, so elevated.
   • Functional capacity: angina after one flight of stairs puts him under 4 METs.
   • So, elevated risk and poor capacity: NT-proBNP now; further tests only where the result alters his care; then proceed.

3. Prepare

   What tests will you order, and will you delay his surgery?

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   • Time-sensitive means up to three months is allowed, but his cancer should not wait for routine tests. Stem trigger
   • NT-proBNP for him; 300 ng/L or more confirms raised risk and supports troponin checks after. Disease
   • Baseline ECG; echo only if his breathing has worsened or a new murmur appears.
   • A stress test only if left main or severe multivessel ischaemia is suspected and would change his care.
   • Revascularisation before surgery doesn't reduce his perioperative cardiac events, so no routine angiography.
   • His BP of 168/96 is under 180/110, so I proceed rather than postpone.
   • Basal insulin cut by 20%, morning short-acting insulin omitted, glucose checked on arrival.

4. Plan

   How do you manage his medicines and the anaesthetic?

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   • He takes bisoprolol and atorvastatin as usual on the morning of surgery. Disease
   • Ramipril is withheld for 24 hours to reduce hypotension after induction.
   • No stent, so aspirin is held for this bleeding-risk resection.
   • Induction with reduced propofol; over 1.5 mg/kg causes severe hypotension in older adults.
   • His coronary perfusion is diastolic pressure minus LVEDP, so I protect diastolic pressure and avoid tachycardia.
   • MAP below 65 for about 15 minutes is linked to myocardial injury, so I keep him above it.
   • Troponin checks after surgery, because he has known coronary disease and high-risk surgery. After surgery

5. Crisis

   The morning after surgery he is pain-free, but his troponin is three times the upper limit. BP 128/70, HR 88, SpO2 95%, Hb 9.8 g/dL. What do you do?

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   • This is MINS until proven otherwise: a troponin rise, presumed ischaemic, without symptoms. Crisis
   • Twelve-lead ECG now and a repeat troponin to confirm a rise and fall.
   • I exclude non-ischaemic causes in him: pulmonary embolism, sepsis and stroke.
   • Restore his supply-demand balance: treat pain, tachycardia and low pressure, and look at his anaemia.
   • Silent MINS still carries real 30-day mortality, so cardiology sees him today. After surgery
   • Continue his statin and restart aspirin once the surgeon accepts the bleeding risk.