Intraoperative Cardiac Ischaemia - Guidelines for Crises in Anaesthesia



If the patient is unconscious, signs of cardiac ischaemia primarily include:

 • ST elevation or depression

 • T wave flattening or inversion

 • Arrhythmias, particularly ventricular

 • Other haemodynamic abnormalities (hypo- or hypertension, tachy- or bradycardia)

 • New or evolving regional wall motion abnormalities if echocardiography is used

If the patient is conscious, symptoms may include chest pain, breathlessness, dizziness, nausea and vomiting.

Have a high index of suspicion in patients with a pre-existing history or risk factors for cardiac ischaemia



❶ Call for cardiac arrest trolley and 12-lead ECG machine.

❷ Ensure adequate oxygenation and anaesthesia/analgesia.

❸ Treat haemodynamic instability (Box A).

❹ Apply CM5 continuous ECG monitoring (Box B). Obtain a 12-lead ECG as soon as possible.

❺ If ischaemia does not resolve:

  • Call for help. Inform theatre team of problem. Stop or rapidly complete the surgery.

  • Start glyceryl trinitrate (GTN) (Box C).

  • EXTREME CAUTION with GTN if the patient is hypotensive.

❻ Consider invasive arterial blood pressure monitoring.

❼ Treat electrolyte abnormalities particularly potassium, magnesium and calcium.

❽ Treat anaemia aiming for haematocrit >30%.

  • CAUTION – beware volume overload especially in heart failure.

❾ If persistent ST elevation is present, consider need for anticoagulation, anti-platelet therapy and revascularisation in consultation with cardiology and surgical teams. 



By Association of Anaesthetists @ https://twitter.com/AAGBI

Quick Reference Handbook - Guidelines for crises in anaesthesia 



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