|Year : 2016 | Volume
| Issue : 1 | Page : 136-138
Anesthetic management of ischemic heart disease with ejection fraction of 35% in a patient of fracture neck femur
S Jawe Nilesh MBBS, MD , Naik Sanyogita, Jadhav Rahul, Kurhekar Vikas
Department of Anaesthesia, Government Medical College, Miraj, Maharashtra, India
|Date of Submission||05-Sep-2014|
|Date of Acceptance||21-Sep-2014|
|Date of Web Publication||17-Mar-2016|
S Jawe Nilesh
IHR Hostel Room No 50, PVPGHS, Sangli, Maharashtra
Source of Support: None, Conflict of Interest: None
Anesthetic management of cardiac patients coming for noncardiac surgery has always been challenging. Goal of anesthesia management is to keep myocardial oxygen supply greater than demand to avoid ischemia. In this case report, anesthetic implications included assessment of cardiovascular status of the patient preoperatively with selection of epidural anesthesia (EA) and analgesia technique. Incremental doses of local anesthetic were given to maintain myocardial oxygen demand. To the best of our knowledge, there have been only few case reports on EA for ischemic heart disease patient coming for noncardiac surgery. Hence, we report a successful anesthetic management of a patient with ischemic heart disease posted for fracture neck of femur under EA and analgesia.
Keywords: ejection fraction, epidural anesthesia, ischemic heart disease, local anesthetic
|How to cite this article:|
Nilesh S J, Sanyogita N, Rahul J, Vikas K. Anesthetic management of ischemic heart disease with ejection fraction of 35% in a patient of fracture neck femur. Ain-Shams J Anaesthesiol 2016;9:136-8
|How to cite this URL:|
Nilesh S J, Sanyogita N, Rahul J, Vikas K. Anesthetic management of ischemic heart disease with ejection fraction of 35% in a patient of fracture neck femur. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2020 Feb 17];9:136-8. Available from: http://www.asja.eg.net/text.asp?2016/9/1/136/178894
| Introduction|| |
Ischemic heart disease (IHD) is a leading cause of morbidity and mortality in the world and of perioperative complications in cardiac patients  . Patients with IHD require identification of risk factors, preoperative evaluation and optimization, medical therapy, monitoring, and appropriate anesthetic technique and drugs. Risk factors influencing perioperative cardiac morbidity are recent myocardial infarction (MI), congestive cardiac failure, peripheral vascular disease, angina pectoris, diabetes mellitus (DM), hypertension, hypercholesterolemia, dysrhythmias, age, renal dysfunction, obesity, sedentary life style, and smoking.
General anesthesia (GA) has been preferred by achieving the goal to keep myocardial oxygen supply greater than demand, achieved by preventing tachycardia and extremes of blood pressure, otherwise seen during laryngoscopy and intubation, which can lead to ischemia  . Epidural anesthesia (EA) can decrease cardiac morbidity and mortality in IHD patients posted for noncardiac surgery  . There have been only few case reports on EA for IHD patient coming for noncardiac surgery. Here, we report a successful anesthetic management of a patient with anterolateral IHD with ejection fraction of 35%, posted for neck femur fixation with Austin Moore's prosthesis under EA and analgesia.
| Case report|| |
A 64-year-old woman with known history of IHD, hypertension, and DM for the last 4 years diagnosed to have fracture neck of femur was posted for Austin Moore's prosthesis. Patient had undergone angioplasty 3 years back and was on metoprolol (25 mg) once daily, nitroglycerine (2.6 mg) twice daily, metformin (500 mg) once daily, aspirin (75 mg) once daily, and clopidogrel (75 mg) once daily. Of these, aspirin was continued and clopidogrel was discontinued since 3 days and metformin was discontinued since 2 days. Patient was started on insulin 2 days before surgery. On examination, patient was moderately built, well nourished, with pulse rate 70/min and blood pressure 120/70 mmHg. She was edentulous with adequate mouth opening and had normal neck and temporomandibular joint movements. Spine examination was normal.
Laboratory investigations (routine hematological, liver, and kidney function, serum electrolytes, coagulation, blood sugar level) were normal. Chest radiography showed cardiomegaly, whereas ECG showed anterolateral wall ischemic changes. Echo findings showed severe hypokinesia of septum and anterior wall with compromised left ventricular systolic function, IHD, mild mitral regurgitation (MR), mild tricuspid regurgitation (TR), and ejection fraction (35%). Cardiologist's opinion was obtained (class III cardiac risk index)  .
Preoperative counseling was performed and informed consent was obtained with ASA grade IV. On the day of surgery, antihypertensive medications and β blocker were continued and fasting blood sugar level was 107 mg%. After intravenous access, ranitidine (50 mg), ondansetron (4 mg), and midazolam (0.5 mg) were administered. Monitors included pulse oximetry (SpO 2 ), ECG, and noninvasive blood pressure. Patient was kept on maintained intravenous fluid of normal saline. Oxygen through ventimask was given.
EA was performed under strict aseptic precaution, in sitting position; skin was infiltrated with 2% plain xylocaine, and 18-G Tuohy needle was introduced at L2-L3 intervertebral space. Epidural space was confirmed by loss of resistance technique; 18-G epidural catheter was threaded up to T10-T11 level and fixed to skin. Test dose was given with 3 ml of 2% xylocaine after negative aspiration for cerebrospinal fluid and blood in sitting position. Total of 2 ml 2% plain xylocaine + 4 ml of 0.5% plain bupivacaine+tramadol (50 mg) was given by epidural catheter incrementally. Total blockade was obtained up to T12 level. Duration of surgery was 90 min epidural topped up with 2 ml of 0.5% of plain bupivacaine after 40 min of initial dose. Total intravenous fluid given intraoperatively was 500 ml of crystalloids (normal saline), urine output was 200 ml, and estimated blood loss was 100 ml. Intraoperative systolic blood pressure was maintained between 110 and 130 mmHg, diastolic blood pressure between 70 and 80 mmHg, and heart rate between 60 and 80/min.
Postoperatively, SpO 2 , noninvasive blood pressure, and ECG with O 2 supplementation by ventimask were performed in the recovery room. For postoperative analgesia, four epidural top up doses were given with 4 ml of 0.125% of plain bupivacaine up to 48 h after surgery. On third postoperative day, epidural catheter was removed and diclofenac 75 mg intramuscularly twice daily was started.
| Discussion|| |
Anesthetic goals for patient with IHD are stable hemodynamics, to prevent MI by optimizing myocardial oxygen supply and reducing oxygen demand, monitor for ischemia, to treat ischemia or infarction if it develops, normothermia, and avoidance of significant blood loss  .
For elective surgery, perioperative management depends upon various clinical risk factors and surgery-specific risk factors. In this case report, patient had mild angina pectoris, previous MI history, and known case of DM (intermediate clinical predictor), intermediate risk surgery with cardiac risk of more than 5%  . Premedication with benzodiazepine and opioid to allay anxiety and maintain hemodynamic can otherwise lead to ischemia. All anesthetic techniques must aim to keep myocardial oxygen supply greater than demand to avoid ischemia. Goal of GA for IHD is avoiding tachycardia and extremes of blood pressure  . GA is associated with hypotension due to intravenous induction agents, tachycardia, and hypertension due to pressor response during direct laryngoscopy and tracheal intubation, leading to cardiac morbidity  , which can be prevented with EA.
The potential and well-known advantage of regional anesthesia over GA should be an asset in cardiac patients. Disadvantages of regional anesthesia include hypotension from uncontrolled sympathetic blockade and need for volume loading, which can result in ischemia. Larger doses of local anesthetic (LA) can cause myocardial toxicity and myocardial depression  . Hence, in this case, LA was given at incremental dose slowly by monitoring hemodynamic parameters.
Epidural LAs or opioids as compared with systemic opioids are better for postoperative analgesia, suppressing the stress response to surgery and reducing MI and dysrhythmias  . Yeager et al.  and concluded that patients in the epidural analgesia group had less incidence of postoperative myocardial morbidity compared with the GA group patient's scheduled for high-risk surgery. Stress response may enhance perioperative hypercoagulable state and the release of cytokines and neuroendocrine hormones, leading to vascular thrombosis and cardiac morbidity through reduction in myocardial oxygen supply or increase in demand, which are prevented by epidural LA  .
Beattie et al.  in meta-analysis on epidural analgesia concluded that reduction in cardiac events with postoperative epidural analgesia is important, as it also reduces post MI. Rivers et al.  compared EA versus GA for infrainguinal arterial reconstruction and concluded that both regional and GA techniques remain equally acceptable.
| Conclusion|| |
EA can equally be an alternative for GA for anesthetic management in cardiac patient's coming for noncardiac surgery, as they reduce preload and after load, stress response, coagulation responses, coronary vasodilatation, postoperative analgesia, incidence of perioperative and postoperative MI, maintain myocardial oxygen supply, and reduce oxygen demand and harmful effects of GA, such as hypotension due to intravenous induction agents, tachycardia, and hypertension due to pressor response during direct laryngoscopy and tracheal intubation.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hall MJ, Owings MF. 2000 National Hospital Discharge Survey. Advance Data from Vital and Health Statistics
. Hyattsville, MD: Department of Health and Human Services; 2002.
Akthar SRL Hines, KE Marschall, eds. Ischemic heart diseaseStoelting's anesthesia and co-existing disease
. 5th ed. Philadelphia: Churchill-Livingstone; 2008. 17.
Ashburn MA, Streisand J, Zhang J, Love G, Rowin M, Niu S, et al.
. The iontophoresis of fentanyl citrate in humans. Anesthesiology 1995; 82:1146-1153.
Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, et al
. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977; 297:845-850.
Kaul TK, G Tayal. Anaesthetic considerations in cardiac patient undergoing non cardial surgery. Indian J Anaesth 2007; 51:280-286.
Yeager MP, Glass DD, Neff RK, Brinck-Johnsen T. Epidural anesthesia and analgesia in high-risk surgical patients. Anesthesiology 1987; 66: 729-736.
Matot I, Oppenheim-Eden A, Ratrot R, Baranova J, Davidson E, Eylon S, et al.
Preoperative cardiac events in elderly patients with hip fracture randomized to epidural or conventional analgesia. Anesthesiology 2003; 98:156-163.
Beattie WS, Badner NH, Choi P. Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis. Anesth Analg 2001; 93:853-858.
Rivers SP, Scher LA, Sheehan E, Veith FJ. Epidural versus general anesthesia for infrainguinal arterial reconstruction. J Vasc Surg 1991; 14:764-768. discussion 768-770.
Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et al.
ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 2007; 116:418-499.