Case presentation

Moderator : Dr Sushila Tabdar

2014/09/24 (071/06/07)

• 53/F, 52 kgs

• Admitted by orthopaedics dept.

• h/o RTA (fall from bike) 5 days back

• # Lt distal radius

• No other associated injuries xcept for minor scratches (lt knee,ext surface lt forearm,rthand)

• No LOC, Vomitting

• h/o dyspnea (NYHA II) since 2 yrs

• Dizziness Off and on

• No orthopnea or PND

Past History

• ICU adm. 5 mnths back (4 days) due to increased dyspnea severity

• Discharged onT. Spironolactone 25 mg ODT. Lasix 40 mg ODT. Ecosprin 75 mg ODT. Losartan 50 mg ODT. Isosorbide Dinitrate 20 mgT. Atorvastatin 10 mg OD’

• Taking Till date

• No h/o any previous surgery or anesthetic exposure

Personal history

• Non-Smoker

• Non-drinker

• Normal bowel/bladder habits

• No known allergies

General examination

• Gen. Condition - fair

• PILCCOD – NIL

Airway

• Normal Dentition/ Patent nares

• Mouth opening – 3 fingers breadth

• TMD – >6 cm

• TMJ – free/mobile

• Neck mobility – free

• MP – grade I

Systemic examination

• CVS Examination :

– Pulse: 80,regular

– BP: 100/70 mm Hg (left sitting)

– S1 + S2 + M0

• Respiratory Examination:

– RR: 16/min

– Air entry B/L on bases, otherwise NVB

• Abdomensoft, non-distendedno organomegaly,

Investigations

• Hb:13.2 gm%

• TC: 10,300/mm3

• P72, L22, E06• PT: 15 secs

• INR: 1.1

• Platelets: 2,25,000/mm3

• Blood group: 0 +ve

• SpO2 @ room air- 94%

• Na: 146 meq/l• K: 4.7 meq/l• Urea: 26 mg/dl• Creatinine: 0.9

mg/dl• RBS: 134 mg/dl• ABG: N/A• Trop I – Neg• CK MB- 17 U/L

Echo report

• Dilated LV (6.18cm)

• Global hypokinesia of LV

• LVEF 27%

• LV diastolic dysfunction (E<A)

• DCM

Anesthetic plan

Regional

• USG + PNS guided supraclavicular block

• 20 ml 0.25 % plain Bupivacaine + 5 ml plain Lidocaine 2%

• Supine, Nasal prongs (3l/min)>> SpO2 98%

• Inj fentanyl 25 mcg to facilitate block

• Minimal IV fluid- 400 ml R/L in total

• BP ˷ 90/60 (mean 65-70 mm Hg)

• DOS – 45 mins

• Uneventful

DISCUSSION

DCM

• Most common cardiomyopathy

• Progressive disease with ventricular enlargement & contractile dysfunction but NORMAL LV thickness

• Rt ventricle can be involved

• Amongst common causes of heart failure

• Cause unknown

• May be genetic or a/w Coxsackie B infection

• Secondary cardiomyopathies might have features of DCMAlcohol/Cocaine abusePeripartum CMHIVPheochromocytomaHyperthyroidismCAD,IHD

SYMPTOMS

• Fatigue

• Dyspnea on exertion, SOB

• Orthopnea, PND

• Peripheral edema

SIGNS

• Tachypnea

• Tachycardia

• Hypertension/hypotension

• Signs of pulmonary and systemic vascular congestion

• Valvular regurgitation (due to AV ring dilation)

Diagnostic Studies

CXR -enlarged cardiac silhouette,

vascular redistribution interstitial edema,

pleural effusions

ECG –normal

tachycardia, atrial and ventricular

enlargement, LBBB, RBBB, Q-waves

Echocardiography

LV size, wall thickness

valve function, pressures

Cardiac catheterization

PCWP, CO

Endomyocardial Biopsy

Anesthetic concerns

• Decompensationcardiodepressioninc afterload

• Arrhythmias

• Electrolyte anomalies (diuretics)

• Thromboembolism (cardiac thrombus)

Preparation/Optimization

• Determining optimal time for elective surgery

• Grading the severity

• Heart failure control at least >1 week

• Treatment of arrhythmias if any

• Correction of electrolyte anomalies

Overall aim

• avoid tachycardia;

• avoid/minimize the effects of negative inotropic agents, in particular anesthetic drugs;

• prevent increases in afterload;

• maintain adequate preload in the presence of elevated LVEDP.

• Treatment be considered if a >10% decrease in systolic pressures occurs.

Poor Prognosis

• EF < 25 %

• PCWP > 20 mm Hg

• Systemic hypotension

• Pulm. HTN

• Inc. CVP

• Cardiac index < 2.5 L/min/M2

Brachial plexus block

Brachial Plexus Sheath

• A sheath surrounds the brachial plexus, from the transverse processes all the way down into the axilla.

Relations

• Brachial plexus is contained within a fascial sheath.

• Subclavian artery lies medial to plexus as they cross the 1st rib together.

Supraclavicular Imaging:• Start parallel and adjacent to clavicle.

• May have to rotate probe slightly to get a good cross section.

MedialLateral

Here is a nice example of the brachial plexus to the left of the subclavian artery.

Look for subclavian artery, with plexus sheath on lateral aspect.

MedialLateral

MedialLateral

Supraclavicular Approach:

Use in-plane approach only – so position of

needle relative to lung is always known.

• http://www.omjournal.org/casereports/pdf/201001/perioperative.pdf

• www.medscape.com

• http://ceaccp.oxfordjournals.org/content/9/6/189.full