[ ISSN : 2573-3680 ]
TURP; Low Ejection fraction; Combined spinal epidural anaesthesia
Background: Anaesthetic management of patients with low ejection fraction secondary to dilated cardiomyopathy is a challenge to the anaesthetists as these patients are at increased risk of congestive cardiac failure, arrhythmias and sudden death.
Objective: To report a case of a 66 year old man with low ejection fraction secondary to dilated cardiomyopathy scheduled for Transurethral Resection of the Prostate Gland (TURP).
Method: Combined low dose spinal (2 ml of 0.5% of heavy Bupivacaine) and epidural anaesthesia was used in this patient to avoid drug induced myocardial depression of general anaesthesia. Patient had a bout of hypotension which was treated with 3mg of Ephedrine otherwise intraoperative and postoperative period were uneventful.
Conclusion: Anaesthesia for a patient with low ejection fraction secondary to dilated ardiomyopathy required that the patient should have a meticulous perioperative management to achieve a good outcome.
Most patients scheduled for Transurethral Resection of the Prostate Gland (TURP) are elderly and are usually present with cardiovascular, endocrine, renal, cerebral or respiratory diseases thereby increasing their risk for surgery and anaesthesia. Patients presenting with low ejection fraction secondary to Dilated Cardiomyopathy (DCM) present a challenge to the anaesthetist. They have poor prognosis and are at increased risk of congestive cardiac failure, arrhythmias and sudden death [1].
Ejection Fraction (EF) is an important measurement in determining how well the heart is pumping out blood, in diagnosing, as well as tracking heart failure. The normal EF is between 55% and 70% and EF of 40% to 55% indicates damage from previous heart disease [2].
EF 117% excluding any known cause of myocardial disease1. Familiar dilated cardiomyopathy accounts for 20-48% of all DCM1. Patients with low EF may present at any time for anaesthesia. It is essential that the anaesthetist understands the underlying pathology to better manage these patients. We present a case with low ejection fraction of 42% secondary to DCM who underwent TURP under combined low dose spinal epidural anaesthesia.
A 66 year old man with symptomatic benign prostate hypertrophy was scheduled for TURP. The patient was a known case of dilated cardiomyopathy for 3 years and the cause of the cardiomyopathy could not be established by the cardiologist. He had a history of orthopnea and exertional dyspnea. No history of alcohol intake or smoking. He was not a known hypertensive, diabetic or asthmatic patient. He had a previous history of cataract extraction under local anaesthesia prior to presentation to the urologist, surgery and anaesthesia were uneventful.
No known drug allergy. His symptom was well controlled on Moduretic one tablet daily and Digoxin 0.125 mg daily. On pre-anaesthetic examination he was not pale, anicteric, acyanosed, no pedal oedema. Cardiovascular examination revealed a pulse rate of 67 beats per minute, blood pressure of 110/70mmHg, Jugular Venous Pressure (JVP) was not raised, heart sounds 1 and 2 were heard no murmur. Respiratory rate was 16 per minute, vesicular breath sounds heard without any added sounds. There were no signs of heart failure like raised JVP, ankle oedema or hepatomegally.
His investigations were as follows; packed cell volume 48%, electrolytes; sodium 140meq/L, potassium 3.8 meq/L, chloride 107 mg/dl, creatinine 106 mg/dl and urea 10mg/dl. Chest radiograph revealed cardiomegally with no signs of pulmonary congestion. Pre operative 12 lead electrocardiographs showed left bundle branch block. Echocardiograph showed global hypokinesia of the left ventricle, poor systolic function, dilated cardiac chambers with bilateral ventricular dysfunction, mild tricuspid regurgitation, no intracardiac clot and ejection fraction was 42%. The international normalizing ratio was 1.0. Patient was classified as American Society of Anaesthesiologist classification physical status of 3.
High risk informed consent and written consent was obtained in view of the cardiac disease and poor ejection fraction. We decided to go with regional anaesthesia (combined spinal epidural anaesthesia) technique reason for the selection was explained to the patient. Patient continued with his cardiac medication and diazepam 5mg a night before and on the morning of surgery.
On arrival in the operating room, peripheral venous cannulation was established with 18 G Intravenous cannula and 0.9% Normal saline infusion was administered at 250ml per hour. Non invasive blood pressure, pulse oximeter and electrocardiograph were attached for continuous monitoring. Base line vital signs were pulse 72/ minute, blood pressure 120 /80 mmHg, oxygen saturation was 99%. Emergency drugs like adrenaline, inotropes and amiodarone were kept ready.
In the sitting position, epidural needle was inserted at L1/2 under aseptic technique and epidural catheter was inserted after a test dose of 3 ml of lidocaine with adrenaline to eliminate intravascular or intrathecal injection. Spinal anaesthesia was instituted at L3/4 space and 2ml of 0.5% of heavy Bupivacaine was injected into the subarachnoid space after a free flow of cerebrospinal fluid. The sensory level was up to T10.
Oxygen was given via nasal prong at the rate of 2l/minute. After 10 minutes of spinal anaesthesia, the blood pressure dropped to 90/50 mmHg, intravenous ephedrine 3 mg was given and the blood pressure increased to 110/65mmHg. There was no episode of arrhythmia. Total fluid infused was one litre of 0.9% normal saline and surgery lasted one hour. Throughout the surgery the patient was pain free, conscious and comfortable.
At the end of the surgery patient was transferred to the high dependency unit postoperative vital signs were pulse 95 /minute, blood pressure115/ 80mmHg , and oxygen saturation 100% in room air. After 2 hours of surgery a bolus of 5 ml of plain Bupivacaine of 0.125% was given by epidural catheter and the catheter was removed 12 hours postoperatively. Postoperative period was uneventful.
Increasing aging of the population leads to high prevalence of comorbidities including heart failure in the elderly. Normal ejection fraction is between 55%-70% and EF of 40% to 55% indicates damage from previous heart disease [2]. EF <35% is considered to be an optimal predictor of postoperative cardiac event [3]. However, patients having low ejection fraction secondary to dilated cardiomyopathy are prone to increased risk of congestive cardiac failure and sudden death from ventricular arrhythmias [1].
Preoperative preparation is an important part of the management in this patient; it must be meticulous as the patient has minimal cardiac reserve. The patient was managed medically in conjunction with the cardiologist for proper optimization [3].
Our patient was placed on digoxin, an inotrope to improve his cardiac contractility and cardiac output before surgery. He was on diuretic because of dyspnea and orthopnea. He was not on any antiarrythmitic drugs. Preoperative electrolytes should be measured and corrected preoperatively as a decrease in potassium can lead to arrhythmias as patient on diuretic has a risk factor for low potassium although our patients’ electrolytes were normal.
Packed cell volume should be maintained above 30% in elective cases to increase the oxygen carrying capacity of the blood. The anaesthetic management goals in patients with cardiomyopathy and low EF include avoidance of drug - induced myocardial depression, maintenance of normovolemia, avoidance of fluid overload, avoidance of sudden hypotension, prevention of increased ventricular afterload and maintenance of stable condition in the postoperative period [6].
With these factors in mind we opted for combined low dose Spinal Epidural Anaesthesia (CSEA) as opposed to general anaesthesia. Regional anaesthesia has advantage of attenuating the neurohumoral stress response to surgery, produces vasodilatation thereby reducing after load, reducing the incidence of thromboembolic phenomenon, avoid polypharmacy and enhance early ambulation [7].
Early recognition of cardiac, cerebral changes and TURP syndrome were other benefits of regional anaesthesia during a TURP. General anaesthesia is not desirable in this patient due to myocardial depressant effect of intravenous and inhalational anaesthestic agents and the stress of larngoscopy [6]. The TURP in this patient was performed under CSEA, spinal anaesthesia is the anaesthetic technique of choice for TURP in our centre and is usually enough for the procedure, however, patient with low ejection fraction may not tolerate high dose of bupivacaine hence low dose spinal block and extension with epidural catheter may be reasonable in the management of this patient.
Patients with low ejection fraction undergoing caesarean section and TURP have previously been done successfully under CSEA [8-10]. Indira et al. in a case report employed CSEA during caesarean section in a patient with ejection fraction less than 25%, similarly Osinaike and Ogar in our institution used CSEA in a patient with peripartum dilated cardiomyopathy with ejection fraction of 39% scheduled for caesarean section also CSEA was used also in a patient for transurethral resection of prostrate [8,9]. CSEA has the advantages of both spinal and epidural anesthesia.
Spinal anaesthesia component offers the rapid onset and reliability of spinal block with low drug dosage and the duration of anaesthesia can be extended with epidural catheter [8,9]. Epidural catheter is also used to provide the postoperative pain relief. Low-dose local anaesthetic is commonly administered to limit the level of block in order to minimize the haemodynamic changes [7,10].
However, CSEA has its disadvantages, including that higher level of neuronal blockade causing rapid precipitous reduction in the systolic blood pressure resulting in severe reduction in venous return and cardiac output [11]. However, this can be countered by administering vasopressors with mixed alpha and beta adrenergic properties e.g. ephedrine [11].
Fluid management is an important part in this management of this patient. To reduce fluid overload, one litre of normal saline was given throughout the period of the surgery to decrease the risk of congestive cardiac failure. Patient had a bout of hypotension following sympathetic blockade, this was corrected with ephedrine rather than fluid.
Monitoring is an important part of management in this patient, several authors have used invasive monitoring to manage more symptomatic cases [12], others have used non –invasive monitoring technique for asymptomatic and haemodynamically stable patients [8,9]. Elective use of invasive monitoring (arterial and central venous) is justified in symptomatic patient with an elevated JVP, third and fourth heart sound and clinical evidence of low cardiac output or echocardiographic evidence of significant myocardial depression [12].
Although this patient had low ejection fraction and dilated cardiomyopathy, he did not have any form of invasive monitoring such as invasive blood pressure, central venous pressure, cardiac output monitoring and myocardial performance by trans-oesophageal echocardiography during the anaesthesia due to high cost in a low resource centre like Nigeria but non - invasive blood pressure monitoring was at frequent intervals (2 minutes) with continuous ECG and pulse oximetry were used successfully in the management of this patient. Supplemental oxygen was administered to ensure that the oxygen saturation remained between 98%-100%.
Combined spinal low dose and epidural anaesthesia is a safe and feasible technique of anesthesia in low ejection fraction undergoing TURP.
5. Sanderson JE. Heart failure with a normal ejection fraction. Heart. 2007; 93: 155-158.
9. Osinaike B, Ogar J. Anaesthesia for Caesarean section in a patient with pericardium cardiomyopathy. Cardiovascular Journal of Africa. 2011; 22: 152-154.
Adigun TA and Sotunmbi PT. Combined Spinal Epidural Anaesthesia for TURP in a Nigerian Geriatric Patient with Low Ejection Fraction- Case Report. SM J Clin Med. 2017; 3(3): 1027.
The purpose of this statement is none other than to highlight the importance of ethical standards and quality required in basic and applied research currently being done so we can subsequently inform health care professionals of new developments that are taking place in this area.
Ma. Esperanza Rodríguez-van Lier*
Chemotherapy is commonly used in cancer treatment. So far, chemotherapy agents can be categorized into three types: classical chemotherapeutic drugs, molecular target agents and cellular machineries target drugs.
Ziyou Wang1,2 and Zunnan Huang1,2*
Blood transfusion can cause some transfusion adverse reactions. In order to understand the incidence of adverse transfusion reactions, we performed a meta-analysis in Chinese hospitals. Of 809 literatures, seven studies involving a total of 211, 050 patients with blood transfusion treatment were included in this meta-analysis. Meta-analysis showed that the total incidence of adverse reactions was 0.4% [95% CI (0.2, 0.9), P < 0.0001]. Further subgroup analysis showed that the incidence of febrile and allergic reactions was 0.2% [95% CI (0.1, 0.5), P < 0.0001] and 0.2% [95% CI (0.1, 0.3), P < 0.0001], respectively. The common blood components caused adverse reactions were red blood cell, plasama, and platelet in clinical practice.
Yulu Gao1 , Qinyun Li2 , Zongshuai Gao2 , Yunxia Zhu4 , Yanqiu Liao5 , Changtai Zhu2 *# , Yongning Sun3 *#
Background: CT scanning remains one of the most routinely used diagnostic tools in a setting of Interstitial Lung Disease (ILD). New and improved technologies, such as High Resolution Computer Tomography (HRCT) have revolutionized the quality of imaging, leading to a prominent increase in number of incidental findings that may or may not be of any clinical significance. The aim of this study was to evaluate the prevalence of incidental findings on thoracic CT and their clinical significance.
Methods: Retrospective analysis was conducted on a cohort of 84 patients referred to our academic center as cases of ILD. Patients were referred for further evaluation between January 2000 and January 2014 and were followed over the disease course. CT scans were done annually as part of clinical management and patients were screened for any incidental findings. All incidental findings were reviewed, recorded in a clinical database and followed up on subsequent visits.
Results: 25 (30%) patients were found to have incidental findings. Liver abnormalities were found in 12 (14.29 %) patients. 11(13.10 %) patients were reported to have coronary artery calcifications. 5 (5.95 %) and 3 (3.57%) patients had thyroid abnormalities and renal cysts, respectively. A malignant lesion was found in 1 patient each in liver and thyroid abnormality subgroup.
Conclusion: Incidental findings are common on thoracic CT scans providing valuable and unexpected findings which warrant investigation by health care providers to exclude malignant processes.
Sonu Sahni1,2*, Sameer Verma1,2, Reeju S Thomas1 , Barbara Capozzi3 and Arunabh Talwar1,2
Hepatitis C Virus infection (HCV) is an increasing public health concern with an estimated 184 million people infected worldwide and approximately 350.000 yearly deaths from HCV-related complications.
Nesrine Gamal and Pietro Andreone*
We report a case of large cell undifferentiated lung carcinoma in a middle aged patient with previously treated tuberculosis and scarring. 20 pack years of smoking history was noted. He presented with metastasis at multiple sites including trochanter, liver and acute bilateral lateral rectus palsy. Chest radiography showed fibrosis of right upper zone with homogenous opacity. Sputum examination for AFB was negative. Computerized tomography of the thorax showed an irregular heterogeneously enhancing mass involving right upper lobe with cavitation, necrosis along with lymph node involvement and the erosion of the 4th rib with liver metastasis. Radiography of hip joint was suggestive of lesser trochanteric metastasis. MRI brain was suggestive of mass at base of brain in parasellar area. Fine needle aspiration cytology and CT guided biopsy confirmed undifferentiated large cell carcinoma of lung. Tuberculosis and smoking may increase the risk of lung scarring and malignancy and pulmonary scarring may be associated with increased lung carcinoma in ipsilateral lung. Clinician needs to be more sensitive to look for malignancy association particularly in patient with or previously treated for tuberculosis and even more emphasis to be laid if scarring of lung is observed.
Sreenivasa Rao Sudulagunta1 *, Shyamala Krishnaswamy Kothandapani2 , Mahesh Babu Sodalagunta3 , Hadi Khorram2 , Mona Sepehrar4 and Zahra Noroozpour1
Systemic Sclerosis (SSc) is a connective tissue disease characterized by fibrosis of the skin and internal organs, pronounced alterations in the microvasculature and frequent cellular and humoral immunity abnormalities. The rheumatic involvement of SSc is polymorphic and can reveal the disease or may appear during the course of its progression. Musculoskeletal involvement is dominated by non specific arthralgia, polyarthritis, and bony resorption especially acro-osteolysis. The diagnosis of these rheumatic manifestations is generally based on x rays examination. Musculoskeletal involvement in SSc is generally relieved with Non Steroidal Anti-Inflammatory Drugs (NSAID) or low dose of corticotherapy. The immunosuppressive therapy is used in corticoid-resistant or corticoid-dependent forms such us méthotrexate. The aim of our review is to presents an overview of the different osteoarticular and muscular involvement in SSc, their diagnosis and management.
Nessrine Akasbi*, Fatima Ezzahra Abourazzak and Taoufik Harzy
Sedigheh Mirhashemi1 , Mohammad Hosein Kalantar Motamedi1 *, Amir Hossein Mirhashemi2 and Hamid Reza Rasouli1
We encountered two autopsy cases of huge cardiomegaly with over 1000g in weight. Histochemical characteristics were examined using conventional staining including HE and Azan stains and immunohistochemical staining using antibodies against Complement Component 9 (CC9), RNA Binding Protein Motif 3(RBM3), Endothelial Type NO Synthase (eNOS) and Hypoxic Inducible Factor1α (HIF1). The reactive area with anti CC9 antibody, which presumed to be a marker of hypoxic change of myocardium, overlapped with eosinophilic area by HE and basophilic one by Azan. Although the reactive area with anti CC9 antibody showed relatively weak in the cytoplasm by anti eNOS antibody and no in the nucleus of cardiocytes with anti RBM3 antibody, outside of the reactive area with anti CC9 antibody there were intensive reactivity with anti eNOS antibody in cytoplasm and in a nucleus with anti RBM3 antibody. Anti HIF1 antibody showed weak reactivity with cytoplasm of endocardial cardiocytes and no with cytoplasm of cardiocytes in another area. The results obtained from the present cases revealed that the hypoxic change was equivalent even though the cause of cardiomegaly was deferred between two cases, and conventional staining such as HE and Azan utilized to detect hypoxic change in the heart and immunohistochemical studies seemed to be a useful tool for clarifying the cascade of hypoxic changes in the myocardium.
Satoshi Furukawa1,2*, Mayumi Kataoka1 , Satomu Morita1,2, Akari Uno2 , Masahito Hitosugi2 , Hiroshi Matsumoto1,3 and Katsuji Nishi1,2
A 45-year-old woman with multiple sclerosis was admitted to our hospital after out of hospital cardio-pulmonary resuscitation. The first ECG showed ventricular fibrillation. Following direct current defibrillation and mechanical reanimation, spontaneous circulation was restored and the ECG unremarkable without any signs of ischemia. Coronary angiography showed unobstructed coronary arteries Figure 1, (Panel A). Left ventriculography revealed apical wall obstruction, suggestive of apical aneurysm (Panel B, supplementary videos). Transthoracic echocardiography and Cardiac Magnetic Resonance Imaging (CMR) eventually lead to the diagnosis of a rare case of Apical Hypertrophic Cardiomyopathy (AHC) with ace of spades-form (Panel C,D). The patient underwent Cardioverter-Defibrillator Implantation (ICD) and amiodarone medical therapy for secondary prophylaxis. Patient’s family history and screening for HCM were unsuspicious.
Wiedemann S# *, Heidrich FM# , Speiser U and Strasser RH