Key words: coronary artery spasm, anesthesia) Coronary artery spasm is often reported in the perioperative period 1 -ll • Myocardial ischemia caused by coronary artery spasm as characterized by ST-segment elevation occurs suddenly and is not preceded by an increase in blood pressure or heart rate. This may frequently result in premature contractions, atrioventricular block, severe hypotension and even cardiac arrest. We report a case of coronary artery spasm occurred 4 times during a noncardiac surgical procedure.
Case HistoryA 65-year-old man (weight 56 kg, height 160 em) was scheduled for colonostomy for a sigmoid concer. The patient had no history of ischemic heart disease. No abnormal finding was noted in the recent chest X-ray, electrocardiograph and other laboratory data. Physical examination revealed also no special finding. The patient was premedicated with 3 mg midazolam and 0.5 mg atropine intramuscularly one hour before induction of anesthesia. In the operating room, a needle was inserted at the LI-L2 interspace and an epidural catheter was placed cephalad through the needle.Anesthesia was induced with 5 mg increments of midazolam. Following loss of consciousness, vecuronium of 8 mg was administered intravenously and the tracha was intubated uneventfully with only a slight change in blood pressure and heart rate. Anesthesia was maintained with a combination of epidural anesthesia and general anesthesia with isoflurane, nitrous oxide and oxygen. Ventilation was controlled to maintain the Paco 2 between 35 and 40 mmHg. Epidural anesthesia was induced with 6 ml of 2% lidocaine, following a test dose of 2 ml of 1% lidocaine. Fifteen minutes after injection of the lidocaine, arterial blood pressure gradually decreased from 120/60 to 80/40 mmHg and the heart rate from 90 to 70 bpm. The hypotension was treated with a rapid intravenous fluid infusion and dopamine of 5 ttg·kg-l·min-l. Arterial blood pressure gradually increased to 120/50 mmHg and was maintained between 130/80 and 120/50 mmHg. Two and a half hours after the start of the operation, ST segment elevation appeared suddenly in lead II. One minute later, QRS complex widening, multifocal VPC and a short run of ventricular premature contractions (VPC) appeared (flg.L) and arterial blood pressure then decreased to 60/40 mmHg. Since coronary spasm was suspected, 0.2 mg bolus of nitroglycerin was injected over 10 min and followed
