REPEATED EPISODES OF MYOCARDIAL-ISCHEMIA DURING COMBINED THORACIC EPIDURAL-ISOFLURANE ANESTHESIA

A patient with a history of coronary artery diseasedeveloped new ST segment depressions in the ECG registration during a low dose (0.7%) isoflurane anaesthesia that was combined with a continuous thoracic epidural analgesia. Simultaneously a small decrease in mean arterial blood pressure (MAP) was noted. During the next 5 min these changes were followed by a severe drop in MAP (from 88 to 60 mmHg) and in cardiac output from 5.5 to 3.2 L/min. When isoflurane was discontinued both the ECG and the cardiovascular changes returned to the previous condition. Later, when 0.5% isoflurane was restarted, the ECG changes reappeared within ten min, but disappeared once again when isoflurane administration was discontinued. Thus, this patient had repeated episodes of myocardial ischaemia which were associated with the use of low dose isoflurane. Although isoflurane-induced ''coronary steal'' may appear as a likely cause of these ischaemic episodes, it is possible that the thoracic epidural had synergistic action and rendered the patient exceptionally sensitive to minor changes in perfusion pressure.