< Back CME Module 9: Peri-Operative Cardiac Risk Reduction Next >


Case 1 : Introduction


An 80 year old man presents to hospital for total colectomy for multiple polyps and rectal bleeding. Anesthesia is consulted to assess him in the preoperative clinic.

His past medical history includes:

Cardiovascular system:

In 1997 this man had coronary artery bypass surgery with good results for 7 years. However, 10 years later he required a redo bypass with a left internal thoracic anastomosis to the LAD. Postoperatively, he remained relatively asymptomatic with good exercise tolerance. His medications included ASA 81 mg, metoprolol, cardiozem and enalapril.

Six months ago he was admitted to hospital for atrial fibrillation and CHF. He required cardioversion three times for rhythm control and was started on coumadin and amiodarone. During that admission he was found to be anemic with a Hgb of 95gm/dl and was transfused to 110gm/dl.

Two months later he was readmitted to hospital with rectal bleeding. On colonoscopy he was found to have multiple polyps which were not biopsied due to the fact that he was on coumadin. General surgery was consulted and recommended that he have surgery, which he refused. During that admission the coumadin was discontinued and he remained in sinus rhythm.

One month later he was once again admitted to hospital in CHF. During that admission his Hgb was found to be decreased to 98gm/dl. He was again transfused with one unit of PRBC’s.

After returning home he continued to experience rectal bleeding and has now decided to proceed with surgery. His present medications include metoprolol 25mg bid, cardizem 5mg bid, lasix 40mg od, enalapril 2.5 mg dose, ASA 81mg od, and amiodorone. Current lab investigations revealed Hgb108, electrolytes Na 139, K 3.4, Cl 103, and creatinine 200mmol/dl. The EKG revealed normal sinus rhythm at 60 BPM and inferior Q waves. He has no known allergies to drugs.

The functional inquiry was otherwise unremarkable except for a history of mild type II diabetes controlled by diet alone and chronic renal failure. Physical examination was within normal limits.


< Back Next >