Hemodynamic Uncoupling and Sympathetic Surge Attenuation in a Geriatric Patient with Cardiometabolic Multimorbidity During Open Cholecystectomy: A Case Report

Abstract

Background. Older surgical patients with cardiometabolic multimorbidity have little physiological reserve. Stiff arteries and diabetic autonomic neuropathy can separate heart rate from blood pressure during surgical stimulation and hide an afterload surge.

Objective. To describe hemodynamic uncoupling and a risk-adapted anesthetic plan in an older patient undergoing open cholecystectomy.

Methods. A 71-year-old man (ASA III, Clinical Frailty Scale 3) with hypertension, coronary disease, insulin-treated type 2 diabetes and left ventricular hypertrophy had an open cholecystectomy under general anesthesia. Blood pressure was measured by oscillometry every 1 to 2 minutes with continuous ECG ST-segment analysis. Fluids were restricted, extubation was deep against five criteria, and a low-dose fentanyl infusion with ward safety measures followed.

Results. Traction on the gallbladder mesentery raised blood pressure from 138/84 to 171/95 mmHg (MAP 120.3 mmHg) while heart rate rose only from 72 to 83 bpm. After sevoflurane was increased to 3.5% and fentanyl 50 mcg was given, systolic pressure was 148 mmHg 4 minutes after the surge began, and no ST-segment depression was recorded. Creatinine stayed stable (1.10 to 1.00 mg/dL) after 500 mL of crystalloid. Extubation was uneventful, resting pain stayed at or below 2/10, and he went home on postoperative day 3 without cardiovascular, pulmonary or renal events.

Conclusion. A rise in systolic pressure without tachycardia was the only sign of a visceral nociceptive surge. One-minute non-invasive pressure measurement, deeper volatile anesthesia and a small opioid bolus controlled it within minutes. One case cannot show that invasive monitoring is unnecessary.