INTRA OPERATIVE MYOCARDIAL INFARCTION MANAGEMENT

1.            Immediately communicate to the surgery team and the operating room (OR) staff that the patient’s status may be compromised.

2.            Ensure adequate oxygenation; increase the fraction of inspired oxygen (FiO2) to 100% to improve oxygen saturation as measured by pulse oximetry (SpO2)

3.            Decrease anesthetic depth

4.            Expand monitoring to include 12-lead ECG, or order it immediately if in the pre- or postoperative area

5.            Initiate fluid challenge, and give a routine dose of phenylephrine for temporizing management of hypotension

6.            Assess hemodynamic stability, and rule out other major acute causes of cardiovascular compromise (eg, hypovolemia, concealed hemorrhage, anaphylaxis, septic or neurogenic shock, anesthetic overdose, local anesthetic toxicity, and tension pneumothorax)

7.            Initiate supportive measures to maintain blood pressure – Give vasopressin or epinephrine to maintain coronary perfusion pressure (CPP) and cerebral perfusion pressure

8.            If necessarily, correct arrhythmias pharmacologically, electrically, or both – Amiodarone 150-300 mg bolus for ventricular or atrial arrhythmias, followed by subsequent infusion as needed; synchronized cardioversion or defibrillation as indicated; epinephrine 1 mg q3-5min for asystole per advanced cardiac life support (ACLS) guidelines

9.            Carry out standard cardiopulmonary resuscitation (CPR) per ACLS guidelines for cardiac arrest

10.          Minimize myocardial work and oxygen demand while optimizing supply – Ensure adequate oxygenation and ventilation; lower HR with beta blockers; transfuse blood products to replace hemoglobin for improved oxygen delivery; avoid hypothermia; and correct acidosis or other metabolic derangements

11.          Administer nitroglycerin to decrease preload while also dilating coronary arteries

12.          If possible, administer aspirin or another antiplatelet agent

13.          Immediately order laboratory tests, including arterial blood gases, electrolytes, basic metabolic panel (BMP), and complete blood count (CBC)

14.          Immediately order a cardiac biomarker assay (cTnT or, if available, fifth-generation hs-TnT)

15.          Consider the ACC/AHA guideline for surveillance for troponin

16.          Establish central access (or, if it is already present, confirm it) to permit large-volume supportive resuscitation with fluids or blood products and inotropic infusions with vasopressors, if indicated

17.          Use other invasive monitoring, if it is not already established – Initiate arterial line–based, real-time, continuous CO and SVV cardiac monitoring (eg, with Flotrac or Vigileo); if a pulmonary artery catheter is already in place, assess CI and systemic vascular resistance (SVR); look for pulmonary diastolic pressures and prominent a and v waves suggestive of papillary muscle dysfunction and acute mitral regurgitation (MR); use TEE to evaluate systolic and diastolic function, preload and afterload, and valvular function (specifically looking for evidence of new MR)

18.          Consider an intra-aortic balloon pump (IABP) for hemodynamic stability if the patient has a large anterior-wall MI

19.          Consider extracorporeal membrane oxygenation (ECMO)

20.          Notify cardiology for further treatment, and communicate the possibility of an emergency need for coronary reperfusion therapy – Few randomized studies have been specifically directed at PMI and the outcomes of treatment initiated postoperatively, and in most cases, guidelines for  treatment of spontaneous ACS are used, with obvious specific considerations in the perioperative setting; in the case of ST-segment elevation, thrombolytic therapy is contraindicated because of the risk of bleeding, and consequently, prompt primary angioplasty in a cardiac catheterization laboratory is indicated

21.          In patients who have asymptomatic NSTEMI, those in whom invasive reperfusion therapy is not indicated on the basis of angiography, and those with an isolated elevation in cardiac biomarkers (ie, MINS), guideline-directed medical management should be initiated in collaboration with the surgery team and cardiology; as is the case during intraoperative management, postoperative medical management of blood pressure (BP), HR, and pain should be aggressive to minimize stress and correct supply-demand imbalance.