PERIOPERATIVE MANAGEMENT OF A CARCINOMA OF STOMACH CASE PRESENTING WITH GASTRIC OUTLET SYNDROME AND RECENT MYOCARDIAL INFARCTION-ASSESSMENT, RISK STRATIFICATION, OPTIMISATION AND ANAESTHETIC MANAGEMENT

Abstract

The patients with perioperative myocardial infarction (PMI) have increased risk of myocardial ischemia, myocardial infarction (MI), conduction disturbances, cardiac failure, morbidity and mortality. The risks of these events are even higher in patients with recent MI. Here, we report 53year old female diagnosed with carcinoma of stomach presenting with gastric outlet obstruction symptoms. The surgery planned was distal gastrectemy, lymhadenectomy and feeding jejunostomy. During preoperative assessment detailed history, physical examination was carried out. She gave a history of chest discomfort and breathlessness along with presenting complaints. Her ECG showed ST/T wave changes. Cardiologist opinion was obtained. The Troponin I was positive. A diagnosis of NSTMI was made. The Echocardiogram revealed Ejection Fraction of 45% and regional wall motion abnormality. She was started on blood thinners, unfractionated heparin, anti-angina drugs, anti diuretics, beta blockers and statins .The cardiologist gave moderate to high risk for surgery. The deranged coagulation parameters and electrolyte imbalance were corrected. The blood thinners were stopped ve days before surgery. Anaesthesiologist reviewed the patient and gave tness for surgery under ASA classication IV. A high risk written informed consent, repeat serum electrolytes, coagulation prole and 12 lead ECG on day of surgery were asked. Heparin was stopped 4-6 hours before surgery. Patient underwent a high risk procedure (calculated RCRI of ≥ 2) with an elevated risk of adverse perioperative cardiac outcome (MACE-moderate risk score). The perioperative management of this patient is reported