ST Depression in the Post Anesthesia Care Unit – or – “Hey doc, could you just quickly check the patient in slot 13?”
Chad Stine MD and David A. Paulus MD
Department of Anesthesiology, University of Florida, Gainesville, Florida
The recovery room of a tertiary care referral center is a highly dynamic
environment that regularly provides difficult clinical challenges. We
present a case of ST depression in a patient, who had undergone left
adrenalectomy for Conn’s syndrome
Our case is a 72 year old male with a history significant of adult-onset
diabetes mellitus and long standing hypertension, which was poorly
controlled despite several antihypertensive medications. Based on lab tests
which showed elevated aldosterone levels and a CT scan which showed a 1 cm
mass in his left adrenal gland he was diagnosed with an aldosterone
secreting tumor of his adrenal causing him to have Conn syndrome. He
underwent a laparoscopic left adrenalectomy complicated by technical
difficulties exposing the adrenal gland and low intraoperative urine output.
In the PACU he developed ST segment depressions in the two leads of his
continuous electrocardiogram. A 12 lead electrocardiogram verified these
findings. He hypertensive with a systolic blood pressure of 190 mmHg and a
heart rate of 90 beats/min. His oxygen saturation was 94% on 40% inspired
oxygen. He reported no pain in his chest or surgical site. On physical exam
he had bibasilar crackles and a chest X-ray showed pulmonary edema. With a
presumptive diagnosis of myocardial ischemia, diastolic dysfunction and
pulmonary edema, the patient’s inspired oxygen concentration was increased
to 100%, the pulmonary edema was treated with 30 mg of furosemide and
sublingual nitroglycerine. Blood pressure and heart rate were initially
treated unsuccessfully with metoprolol (10 mg) and labetalol. Therefore, an
infusion of esmolol was started. This combination of therapies normalized
blood pressure, heart rate, and ST segments. Cardiology was consulted. A
transthoracic echocardiogram showed normal left ventricular function without
regional wall motion abnormalities. The patient was transferred to the
intermediary care unit, where a myocardial infarction was ruled out and
where the pulmonary edema resolved. He was discharged from there on the
second postoperative day.
This case demonstrates the diagnosis and treatment of postoperative cardiac
ischemia in a patient with Conn’s syndrome. Individualized assessment in the
PACU and appropriate disposition of this medically complex patient
contributed to a safe perioperative course.
