Abstract PR398

Abstract

Case report: Background: Bariatric surgery has been shown to attenuate metabolic syndrome, especially insulin resistance. We report a case of an obese patient with refractory insulin-dependent diabetes and a previous heart transplantation, submitted to laparoscopic vertical gastrectomy to achieve metabolic control. Case report: A male patient with 38y, 117Kg, 174cm, BMI 38.64, ASA P3, hypertension (165/98 mmHg), previous myocardial infarction and heart transplantation 8 years ago was submitted to laparoscopic vertical gastrectomy under general anesthesia. Preoperative findings: glucose 254mg.dl-1, glycated hemoglobin (GHb) 8.4%, hematocrit 29.4%, creatinine 1.7mg.dl-1, ejection fraction 49%. At theater, central venous and left radial artery catheterization were inserted. Monitoring included electrocardiography with ST analysis, pulse oximetry, central venous pressure, continuous invasive arterial pressure, cardiac output and index (CI), BIS, neuromuscular activity, capnography, temperature and urinary output. Infusion of 3ml.kg-1.h-1 per ideal body weight (IBW) Ringer’s lactate solution. Anesthesia was induced with midazolam 0.15mg.kg-1, fentanyl 0.2µg.kg-1 and rocuronium 0,6mg.kg-1 IBW. Lungs ventilated with 6ml.kg-1 IBW tidal volume and 10ml PEEP. Respiratory frequency adjusted to maintain target ETCO2 38 mmHg. Target-controlled infusion of propofol and remifentanil for maintenance according to hemodynamic and BIS parameters. Dexmedetomidine 0,3 µg.kg-1.h-1 for sympatholysis. Isoflurane 1-2% in 50% air for myocardial conditioning. IV insulin started and dosed according to capillary glucose monitored each 30 min and 100ml.h-1 5% dextrose in saline infusion to prevent hypoglycemia. Dobutamine 3-5µg.kg-1.min-1, norepinephrine 0.02-0.05µg.kg-1.min-1 IBW and Ringer’s lactate were administered, according to hemodynamic and cardiac values. Patient remained stable during surgery, with MAP 78±27(75-80)mmHg, HR 62±15(49-80), SvO2 65±17(60-75)%, CI 2,5±1.0(1,5-3,5), SpO2 98±1(96-99)%, BIS 55±23(48-60)%. After surgery, the patient was transferred to ICU. The postoperative period was uneventful. Four months later, he had lost 16kg, insulin was stopped and GHb fell to 6.4%, with metformin 500mg.day-1. Conclusions: There are more long-term cardiac transplant recipients undergoing noncardiac surgery. Although still controversial, metabolic surgery for diabetes control is now a more common practice. Data regarding the association of these 2 clinical scenarios are still scarce, implying new challenges to the management of these patients.