Anesthetic Management of Patient with Global Left Ventricular Systolic Dysfunction Posted for Transurethral Resection of Prostrate and Bilateral Hernioplasty

INTRODUCTION

Left ventricular (LV) dysfunction is an entity that refers to defective functioning of the heart. It can be either systolic or diastolic. It is a serious complication that can lead to postoperative myocardial infarction and cardiac failure.¹ LV systolic dysfunction can be graded from 0 to 4 (normal to severe) based on left ventricular ejection fraction (LVEF): mild (LVEF 41–45%), moderate (LVEF 36–40%), or severe (LVEF less than 35%). LVEF refers to the amount of blood pumped out at each heartbeat, normally it ranges from 55 to 70%. When the ejection fraction (EF) percentage reduces to less than 35%, it indicates the presence of severe systolic dysfunction. The most common postoperative cardiac events induced mortality in these patients is heart failure, especially in the elderly age-group.² The advantage of neuraxial blockade when compared to general anesthesia, is that it produces a better perioperative outcome in cardiac illness patients undergoing noncardiac illness.³

CASE REPORT

A 70-year-old male, with a history of completely recovered cardio vascular accident (CVA) 8 years back, currently was not on any medication, came with the complaints of lower urinary tract symptoms gradually worsening and more for the past 20 days with the development of urinary retention for 4 days, was diagnosed with benign prostatic hypertrophy posted for transurethral resection of prostrate (TURP) and bilateral hernioplasty procedure. The patient had a chronic history of smoking and alcohol intake for the past 40 years. No history of any symptoms pertaining to cardiac abnormalities such as palpitation, breathlessness, or chest pain, although the patient gives a history suggestive of poor effort intolerance (METS < 4). On examination, the patient was conscious, oriented, and moderately built and nourished. Preoperatively the pulse rate was 94 beats/minute, blood pressure 130/70 mm Hg, room air saturation is 96%, and cardiovascular and respiratory system examination showed no abnormalities. An airway examination was done. Blood investigations were within normal limits. ECG showed sinus rhythm with T wave inversion in lead I, II, aVL. Chest X-ray showed cardiomegaly. Echo showed global hypokinesia of LV dysfunction, severe LV dysfunction, dilated LV, moderate mitral regurgitation (MR) (Figs 1 and 2). Cardiologist and nephrologist opinions were sought regarding ECG and echo changes; patient was started on T. Carvedilol 3.125 mg BD and T. Lasix 20 mg BD.

On the day of surgery, the OT was made ready with the availability of emergency cardiac drugs, warm fluids, and warmers. Anesthetic management of choice for this patient was regional technique, under aseptic precautions, patient in sitting position epidural anesthesia performed at L2–L3 space and placement of catheter and fixation at 10 cm after confirming the space with loss of resistance (LOR) technique (Fig. 3). Followed by subarachnoid block at the level of L3–L4 space with 25G spinal needle—1.2 mL of 0.5% bupivacaine with 25 µg of fentanyl was given, an adequate level of sensory blockade was attained till the level of T12. After the anesthetic procedure, the patient was placed in a lithotomy position, the patient was monitored for any hypotension or cardiac events, and the patient was hemodynamically stable. Adequate fluid (less than 1.5 L/day) was given as per cardiologist and nephrologist orders. Postoperatively continuous monitoring of vitals and intravenous fluid administration was done. A cardiologist review was sought and cardiac drugs such as diuretics, beta-blockers, and angiotensin receptor neprilysin inhibitor (ARNI) were continued postoperatively.

DISCUSSION

CONCLUSION

Thus in patients with moderate risk cardiac illness, who are posted for noncardiac surgeries, the more preferable and safer alternative is regional anesthesia as it reduces the sympathetic stress response which is present while performing general anesthesia (during intubation and extubation). In this case, the patient was having moderate LV dysfunction posted for noncardiac surgery (TURP and bilateral hernioplasty), the most preferred safe choice of anesthesia is subarachnoid block combined with epidural anesthesia which is also helpful in the management of postoperative analgesia.

ORCID

Dilip K Govindan https://orcid.org/0000-0003-2597-1922
Krishna Prasad T https://orcid.org/0000-0002-7833-9982

REFERENCES

1. Kaul TK, Tayal G. Anaesthetic considerations in cardiac patients undergoing non cardiac surgery. Indian J Anaesth 2007;51(4):280–286.

2. Maile MD, Engoren MC, Tremper KK, Elizabeth Jewell E, Kheterpal S. Worsening preoperative heart failure is associated with mortality and noncardiac complications, but not myocardial infarction after noncardiac surgery: a retrospective cohort study. Anesth Analg 2014;119(3):522–532. DOI: 10.1213/ANE.0000000000000116.

3. Authors/Task Force Members, Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, Hert SD, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014;35(35):2383–2431. DOI: 10.1093/eurheartj/ehu282.