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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 7  |  Issue : 2  |  Page : 321-322

Graded epidural anesthesia for fistulectomy with symptomatic obstructive hypertrophic cardiomyopathy


Department of Anesthesiology, Vinayaka Missions Kirupananda Variyar Medical College and Hospital, Salem, Tamil Nadu, India

Date of Submission09-Feb-2022
Date of Decision21-Feb-2022
Date of Acceptance14-Mar-2022
Date of Web Publication09-Sep-2022

Correspondence Address:
V Nivedha
Department of Anesthesiology, Vinayaka Missions Kirupananda Variyar Medical College and Hospital, Salem, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjhs.bjhs_27_22

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  Abstract 


Hemodynamic fluctuations can occur when fistulectomy is usually done under spinal anesthesia that can cause detrimental effects for a patient with obstructive cardiomyopathy. This is a case of 51-year-old male with fistula in ano sustaining obstructive hypertrophic cardiomyopathy as suggested by chest pain, palpitation, breathlessness on exertion was scheduled for fistulectomy. Electrocardiography (ECG) showed left ventricular hypertrophy with deep narrow Q waves in V1 to V6. Echo showed asymmetrical septal hypertrophy, grade 1 diastolic dysfunction, EF – 60%. Regional anesthesia technique such as graded epidural anesthesia can be safe and cost effective by prolonging the postoperative pain relief and thus also effective in blunting autonomic, somatic, and endocrine response triggered by surgical insult.

Keywords: Epidural anesthesia, fistulectomy, obstructive hypertrophic cardiomyopathy


How to cite this article:
Nivedha V, Brindha R, Vigneshwaran S. Graded epidural anesthesia for fistulectomy with symptomatic obstructive hypertrophic cardiomyopathy. BLDE Univ J Health Sci 2022;7:321-2

How to cite this URL:
Nivedha V, Brindha R, Vigneshwaran S. Graded epidural anesthesia for fistulectomy with symptomatic obstructive hypertrophic cardiomyopathy. BLDE Univ J Health Sci [serial online] 2022 [cited 2023 Feb 7];7:321-2. Available from: https://www.bldeujournalhs.in/text.asp?2022/7/2/321/355848



Fistulectomy is usually done under spinal anesthesia but they can cause hemodynamic fluctuations which will be detrimental for a patient with obstructive cardiomyopathy. In this case, graded epidural anesthesia provided optimal surgical condition with hemodynamic stability. We report successful management of this patient under graded epidural anesthesia.


  Case Report Top


A51-year-old male, a case of fistula in ano with obstructive hypertrophic cardiomyopathy as suggested by chest pain, palpitation, breathlessness on exertion was scheduled for fistulectomy. Electrocardiography (ECG) showed left ventricular hypertrophy with deep narrow Q waves in V1 to V6 [Figure 1]. Echo showed asymmetrical septal hypertrophy, grade 1 diastolic dysfunction, Ejection Fraction (EF) – 60%.
Figure 1: Electrocardiography showed left ventricular hypertrophy with deep narrow Q waves in V1 to V6

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On general physical examination, the patient was conscious, cooperative, oriented moderately built and nourished. There was no evidence of pallor, icterus, cyanosis, clubbing, lymphadenopathy edema with Metabolic equivalents (METS) ̴ 5, pulse - 98/min, regular rhythm, blood pressure (BP) -110/70 mm Hg, SpO2 – 98% RA, weight – 52 kg, height – 140 cm. Cardiovascular and respiratory system was normal with no added sounds.

On evaluating the airway, patient had modified Mallampatti score of class II, with missing tooth, adequate inter incisor and thyromental distance. Neck movements were normal. Spine was in midline. All investigations were within the normal limits. Computed tomography thorax for COVID screening was normal.

The patient was accepted for surgery under ASA –III, after getting an informed and written consent. The patient was shifted to OR and standard anesthetic monitoring was initiated which included noninvasive BP monitoring, pulse oximetry and ECG. Plan was to administer graded epidural anesthesia after securing the IV access with 18 G cannula [Figure 2]. RL solution was started and premedicated with IV ondansetron 4 mg. Under aseptic precautions, patient in sitting position, parts painted and draped. 18 G Tuohy needle was inserted in L4–L5 space with tip pointing downwards after infiltrating skin with LA. Epidural space was confirmed by loss of resistance technique to air and 20 G catheter was threaded in and fixed at 9 cm. Test dose was avoided. Epidural was activated with incremental doses of mixture of plain lignocaine 2%, 0.375% bupivacaine, 40 mcg fentanyl (5 mcg/ml) (3 ml + 3 ml + 2 ml). Proseal laryngeal masks of size 3 and 4 were kept as stand by incase of failed epidural or Patient discomfort. Blockade of L4–S5 dermatomes was achieved Level of analgesia was checked by needle prick, after confirming the adequacy and level, surgery was commenced. Surgery was done in one hour without patient discomfort and patient remained hemodynamically stable throughout the procedure and blood loss was minimal. Postoperative analgesia was maintained with intermittent boluses of 4 ml of 0.125% bupivacaine and 20 mcg of fentanyl. Postoperative course was uneventful.
Figure 2: Epidural anesthesia being administered

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  Discussion Top


The presence of any cardiovascular ailments in a patient scheduled for surgery introduces special consideration for preoperative evaluation and subsequent management of anesthesia to ensure patient safety and hemodynamic stability. Regional anesthesia technique such as graded epidural anesthesia can be safe and cost effective by prolonging the postoperative pain relief and thus also effective in blunting autonomic, somatic, and endocrine response triggered by surgical insult.[1],[2]

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.
Sivakumar RK, Panneerselvam S, Das S, Rudingwa P. Labour epidural analgesia in hypertrophic obstructive cardiomyopathy. Indian J Anaesth 2019;63:321-3.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Rigg JR, Jamrozik K, Myles PS, Silbert BS, Peyton PJ, Parsons RW, et al. MASTER anaethesia trial study group. Epidural anaesthesia and analgesia and outcome of major surgery: A randomised trial. Lancet 2002;359:1276-82.  Back to cited text no. 2
    


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