A12 Ischemic Heart Disease and Weaning from Mechanical Ventilation, how efficient Esmolol can be when Extubation is unsuccessful?

Abstract

Background and Goal of Study: Patients with ischemic heart disease are known to tolerate hemodynamic stress poorly. As a consequence of their coronary artery disease, ischemic episodes may develop during, or shortly after tracheal tube removal. We describe a case with coronary artery disease that developed repeated episodes of pulmonary oedema each time extubation was attempted. We describe a case of patient with ischemic heart disease and the difficulties in weaning and extubation. Methods: A 70 year old male was submitted urgently because of an abdominal aneurysm. The patient was hemodynamically stable throughout the intervention that lasted 4 hours and on ICU admission, (Heart rate 100/min, and blood pressure 130/65mmHg). Despite trying twice the patient did not achieve successful extubation, in both instances, after extubation, he presented with a rapid shallow breathing and low arterial oxygen saturation. On auscultation, he presented crepitations in middle zones of both lung fields and the chest X-ray was indicative for pulmonary oedema. A trans-thoracic echo that was performed showed normal systolic ventricular function and diastolic dysfunction with abnormal relaxation, patient was therefore given initially esmolol 500 μg/kg/min (iv.) followed by an infusion of 50 μg/kg/min. Sedation was gradually decreased and infusion rate of esmolol was increased. Patient was extubated successfully under 100 μg/kg/min and was discharged from the ICU two days later. Results: Extubation stress in patients with coronary artery disease cause excessive increases in myocardial oxygen consumption thereby altering the supply/demand ratio. Our patient was experiencing ischemic left ventricular dysfunction during weaning, secondary to catecholamine release due to upper airway stimulation by the tracheal tube. This was manifested as hypertension, tachycardia and episodes of pulmonary oedema, which were rapidly resolved with sedation. Conclusions: Using esmolol, a short/acting beta/blocker, allowed successful extubation of patient who developed repeated episodes of pulmonary oedema each time extubation was attempted.