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CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 134-137

Anesthesia management of elderly woman suffering with severe mitral regurgitation, pulmonary artery hypertension, and severe left ventricular dysfunction scheduled for hemiarthoplasty


Department of Anaesthesia, Govt. Medical College, Ananthapuramu, Andhra Pradesh, India

Date of Submission01-Apr-2015
Date of Acceptance21-Jun-2016
Date of Web Publication30-Jul-2019

Correspondence Address:
Dr. A Naveen Kumar
15/51, Flat No. 301 Jayam Paradise, Kamalanagar, Ananthapuramu, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.263640

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  Abstract 


We present a case of an elderly woman aged 76 years suffering from severe mitral regurgitation, moderate tricuspid regurgitation, and moderate pulmonary hypertension associated with severe left ventricular dysfunction scheduled for right hemiarthoplasty. Hypertension and diabetes were associated comorbid factors. Patient had grade IV exertional dysponea. Patient was on cardiovascular treatment and nebulization therapy since 4 years. We opted for graded epidural anesthesia as an anesthetic technique of choice for the patient because of its intraoperative hemodynamic stability and postoperative analgesia. Graded epidural provides minimal effects on the contractility and heart rate providing ideal intraoperative conditions. We used ropivacaine as a local anesthetic for graded epidural anesthesia for its cardiovascular stability compared to other local anesthetics. This case highlights the advantage of graded epidural anesthesia over general anesthesia and spinal anesthesia in patients suffering from valvular heart disease, pulmonary artery hypertension, and severe left ventricular dysfunction.

Keywords: Graded epidural, ischemic heart disease, ropivacaine, valvular heart disease.


How to cite this article:
Kumar A N, Vijayabhaskar B, Charlu S J, Madhusudan T. Anesthesia management of elderly woman suffering with severe mitral regurgitation, pulmonary artery hypertension, and severe left ventricular dysfunction scheduled for hemiarthoplasty. J NTR Univ Health Sci 2019;8:134-7

How to cite this URL:
Kumar A N, Vijayabhaskar B, Charlu S J, Madhusudan T. Anesthesia management of elderly woman suffering with severe mitral regurgitation, pulmonary artery hypertension, and severe left ventricular dysfunction scheduled for hemiarthoplasty. J NTR Univ Health Sci [serial online] 2019 [cited 2019 Aug 18];8:134-7. Available from: http://www.jdrntruhs.org/text.asp?2019/8/2/134/263640




  Introduction Top


Extensive knowledge of abnormal pressure and volume loads imposed by abnormal valves and structural and functional changes adopted by the heart to compensate, triggering events such as ischemia, arrhythmias, and cardiac failure that may lead to decompensation of heart and secondary complications such as infective endocarditis and thromboembolism is essential for successful intraoperative management. Severe mitral regurgitation coexists with ischemic heart disease. The demands of this thickened muscle mass exceed the ability of even normal coronary arteries to deliver adequate amounts of oxygen. The following considerations should be taken in the intraoperative management of mitral regurgitation.[1] Prevent bradycardia and increase in systemic vascular resistance and myocardial depression.

Medical treatment for ischemic heart disease is designed to decrease myocardial oxygen requirements, improve coronary blood flow, stabilize plaque, prevent thrombosis, and remodel the injured myocardium. These are achieved by the usage of bête blockers, nitrates, calcium channel blockers, statins, antiplatelet drugs and angiotensin-converting-enzyme inhibitors.

The use of clopidogrel and ticlopidine precludes the use of regional anesthesia in emergency surgery.[2] These drugs should be discontinued 5 days before surgery; Surgery should be deferred until the prothrombin time and international normalized ratio (INR) is 13–15 seconds and less than 1.5, respectively.

The basic goals in the induction and maintenance of anesthesia in patients with ischemic heart disease are to prevent myocardial ischemia by optimizing myocardial oxygen supply and reducing myocardial oxygen demand, as well as to monitor for ischemia and to treat it if it develops; maintenance of the balance between myocardial oxygen supply and demand is more important than the specific anesthesia technique or drugs selected to produce anesthesia. It is important to avoid persistent and excessive changes in heart rate and systemic blood pressure.

Pulmonary artery hypertension is defined as a mean pulmonary artery pressure higher than 25 mm Hg. The risk of right heart failure is significantly increased during the perioperative period in patients with pulmonary artery hypertension.[3]

Graded epidural anesthesia with slow sensory incremental blockage provides ideal intraoperative conditions,[4] however, close attention should be paid to intravascular volume and systemic vascular resistance.


  Case Report Top


A female patient aged 76 years was admitted in our hospital with complaints of pain, swelling, and deformity in the right hip joint since 4 days. On examination, the patient was diagnosed with intercapscular fracture of the right hip joint.

Patient was referred to preanesthetic check-up, and past history revealed cardiac disease since 5 years. The patient was on clopidigril 75 mg once daily, digoxin 0.25 mg once daily 5 days a week, atenolol 50 mg twice a day, and nebublization therapy. Exertional dysponea Grade IV was present. The patient had a history of diabetes and was on insulin.

The patient was advised to stop clopidigril and was prescribed injection enxoparin 40 mg subcutaneous twice a day. Patient was evaluated with the help of investigations such as complete blood count, urine analysis, liver function tests, chest X-ray posteroanterior view, prothrombin time, INR, electrocardiography (ECG), and two-dimensional echocardiography.[5] On clinical examination, normal heart sounds were present with systolic murmur in the mitral area radiating to the axilla. Basal crepitations were heard. Other systems were normal.

ECG revealed ST and T depression in V2-V6 leads and left bundle block [Figure 1]. Chest X-ray showed cardiomegaly [Figure 2]. Two-dimensional echocardiography revealed global hypokinesia, severe left ventricular dysfunction, severe mitral regurgitation, moderate tricuspid regurgitation, and moderate pulmonary artery hypertension. There was a small calcified plaque in aorta; ejection fraction was 34%. Prothrombin time and INR on the day of surgery were 14 seconds and 1.2, respectively.
Figure 1: Electrocardiography showing ischemic changes and left bundle branch block

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Figure 2: Chest X-ray poteroanterior view showing gross cardiomegaly

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Attenders were explained about the high morbidity and mortality incidence during surgery. Patient was posted for surgery with overnight fasting. Lorazepam 2 mg was administered orally at night.

Intravenous cannula was secured on the left dorsum of the hand. Infective endocarditis prophylaxis was given; ampicillin 2 g and gentamycin 80 mg 1 hour before the surgery and 1 a ampicillin after 12 hours of surgery.[6] Midazolam 1 mg was given intravenously as a premedicant. Central vein line was secured on the right side of the neck. Monitors were connected to the patient for monitoring SpO2, pulse rate central venous pressure, noninvasive blood pressure, 6 lead ECG, and temperature.[7]

Patient was kept in a sitting position with strict aseptic precautions. L3-L4 epidural space was identified with the help of loss of air resistance and hanging drop test. Three milliliters of 0.5% ropivacaine was administered and epidural catheter was threaded into the epidural space and was firmly secured. Patient was kept in a lying dwon posture. After 3 minutes, 3 mL of 0.5% ropivacaine was administered; after a further gap of 3 minutes, 3 mL of 0.5% ropivacaine was administered to achieve sensory level of T12.[8] Butorphanol 1 mg was given as an intraoperative analgesic. Onset of anesthesia was 9 minutes after the first dose of ropivacaine. Time taken for start of the surgery was 20 minutes after the first dose of ropivacaine administration. Duration of surgery was 40 minutes. 0.25% ropivacaine was administered epidural at the rate of 6 mL/hour for postoperative analgesia. Injection buprenorphine 60 μg was administered epidurally twice dialy for 2 days. Ringer lactate (500 mL) and dextrose normal saline (500 mL) was transfused for intraoperative fluid management. There was a sudden fall of blood pressure after a period of 22 minutes [Graph 1], which was managed by ephedrine administration. Hemodynamics was maintained well. After satisfactory recovery, patient was kept in the intensive care unit for 48 hours. After 48 hours of epidural, catheter was removed, and the patient was shifted to the postoperative ward. Rest of the hospital stay was eventful. Patient was discharged on the 9th postoperative day.




  Discussion Top


The main aim of anesthesia management is to maintain hemodynamic stability and prevent ischemic attack, infective endocarditis, and heart failure. Anesthesia management highlights the safety and efficacy of graded epidural anesthesia in patients with severe mitral regurgitation, severe left ventricular dysfunction, and pulmonary hypertension.[9] The duration of intensive care unit is reduced compared to general anesthesia, and is uneventful due to effective management of postoperative pain by continuous low dose epidural analgesia. Low volume incremental doses of local anesthetic has more cardiovascular stability and less mortality compared to single dose higher volumes of local anesthetic. Low incremental dose of ropivacaine prevented sudden changes in blood pressure and heart rate; sensory level upto T12 avoided the involvement of cardiac fibers producing excellent intraoperative cardiac stability.[10] Preoperative assessment of cardiac status, optimizing cardiac status, good postoperative analgesia, and monitoring are vital parameters which have to be given prime importance for reducing the mortality.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Herrera A. Valvular Heart Disease. In: Hines RL, Marschall KE, Editors. Stoelting Anesthesia &Co-Existing Disease. 5th ed. Reed Elsevier India private limited; 2012. p. 35-43.  Back to cited text no. 1
    
2.
Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery. N Engl J Med 1997;336:1506-11.  Back to cited text no. 2
    
3.
Blaise G, Langleben D, Hubert B. Pulmonary arterial hypertension: Pathophysiology and anesthetic approach. Anesthesiology 2003;99:1415-32.  Back to cited text no. 3
    
4.
Bromage PR. Spread of analgesic solution in the epidural space and their site of action: A statistical study. Br J Anaesth 1962;34:161.  Back to cited text no. 4
    
5.
Vahanian A, Baumgartner H, Bax J, Butchart E, Dion R, Filippatos G, et al. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J 2007;28:230-68.  Back to cited text no. 5
    
6.
WilsonW, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis, Guidelines from the American heart association. Circulation 2007;116:1736-54.  Back to cited text no. 6
    
7.
Fleisher LA. Real-time intraoperative monitoring of myocardial ischemia in noncardiac surgery. Anesthesiology 2000;92:1183-8.  Back to cited text no. 7
    
8.
Rosenberg PR, Veering BT, Urmey WF. Maximum recommended doses of local anesthetics: A multifactorial concept. Reg Anesth Pain Med 2004;29:564-75.  Back to cited text no. 8
    
9.
Yeager M, Glass D, Neff R, Brinck-johnsen T. Epidural anesthesia and analgesia in patients in high-risk surgical patients. Anesthesiology 1987;66:729.  Back to cited text no. 9
    
10.
Stewart J, Keller N, Castro D. The central nervous system and cardiovascular effects of levobupivacaine and ropivacaine in healthy volunteers. Anesth Analg 2002;97:412.  Back to cited text no. 10
    


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