This document describes the anesthetic management of a 52-year-old female patient with dilated cardiomyopathy who was undergoing breast surgery. Key aspects included:
1. The patient had a left ventricular ejection fraction of 20% and was on various heart failure medications.
2. Careful preoperative evaluation and planning was done including stress testing which showed no perfusion defects.
3. A supraglottic airway device was used along with local anesthesia to avoid cardiovascular stress.
4. Close monitoring was maintained and the patient had an uneventful postoperative recovery without complications.
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Anaesthetic Management Of Dilated Cardiomyopathy For Breast Surgery
1. Anaesthetic Management Of A Case
Of Dilated Cardiomyopathy For
Breast Surgery With SupraGlottic
Airway Device (SGAD)
Dr. Nayana Kulkarni
Head of Department- Anesthesia
HCG Manavata Cancer Centre
Nasik, Maharashtra
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2. What is Dilated Cardiomyopathy?
Dilated cardiomyopathy (DCM) is defined as a myocardial disease
characterised by left ventricle (LV) or biventricular dilatation, normal LV
wall thickness, and systolic dysfunction. DCM is defined by two key
factors:
(a) Left ventricular ejection fraction (LVEF) less than 45% and/or
fractional myocardial shortening less than 25%
(b) Left Ventricular End Diastolic Diameter (LVEDD) greater than 117%
by excluding presence or known cause of myocardial disease.
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3. Background
▪ DCM is considered as the most common form of non-ischemic
cardiomyopathy.
▪ It is also the third common cause of heart failure.
▪ An EF of 20% and severe ventricular dysfunction is a predictor of
sudden death in such patients.
▪ There are very few cases of perioperative management of patients
with DCM.
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4. Incidence
▪ The annual incidence varies between five to eight cases per 100,000
individuals.
▪ Patients with DCM are always a challenge to the anesthesiologist as
they are high-risk patients with several complications including
progressive cardiac failure
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5. Case Report
▪ Age-52 yr/ wt- 62 kg / height-158 cm , BMI 24.8
▪ Diagnosis- Benign Breast Disease. & C/O watery discharge from the nipple.
▪ Treatment- plan for lumpectomy/ frozen section under GA.
▪ Medical history-Diagnosed Dilated-CMP on
▪ digoxin,torsemide, spironolactone,carvedilol,rosuvastatin/aspirin (10/75 mg)
for four years.
▪ Assessment- (METS) <4
▪ Fairly healthy,performed daily activities without any assistance,LIMITED
TOLERANCE.
▪ antipsychotic medications, i.e. sodium valproate, olanzapine, and
ziprasidone for 17 years.
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7. Clinical Assessment
▪ Heart Rate -Regular (72/min)
▪ No arrhythmias/APD
▪ Pulse Rate- Steady/ Normal Volume.
▪ Blood pressue -117/75 mmHg.
▪ RR- 16 breaths per minute.
▪ Respiratory system was clear on auscultation Breath Holding Time (BHT) of 20
seconds
▪ JVP - normal.
▪ No hepatomegaly was noted.
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8. Previous 2-D Echo
▪ Intact septae
▪ Dilated Left Ventricle
▪ Generalised Hypokinesia of All the Walls
▪ The left ventricular (LV) function was 20%
▪ An enlarged left atrium
▪ Mild mitral regurgitation
▪ No pericardial effusion was noted.
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11. Adenosine Scan with Mibi Tracer
● Resting HR -71 bpm
● BP -125/68 mmHg.
● Post injection-HR- 91/ BP- 112/60 mmHg.
● No Post-injection perfusion defect.
● The MIBI uptake observed in all segments without any perfusion
defect.(methoxyisobutylisonitrile)
● (LVEF) - 44%.
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14. Goals of Anaesthesia
▪ The primary objective of anesthesia was to avoid
▪ Negative inotropism,
▪ Tachycardia
▪ A sudden increase in after load.
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15. Preparation
▪ A high-risk informed consent.
▪ Plan - General Anesthesia with Local Infiltration.
▪ Premedication - Nebulization budecort.
▪ HR - 72 bpm, BP -127/75 mmHg, SpO2 - 96%.
▪ Considering the patient’s EF was 44% with no perfusion defects,
▪ Non invasive standard monitoring used, ECG, Spo2,Temp,BP, End-
tidal carbon dioxide.
▪ All invasive monitoring equipment were kept at standby along with a
defibrillator.
▪ Iv glycopyrolate 0.2 mg, midazolam 1 mg, fentanyl 50 microgram, and
ondansetron 4mg
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16. Anesthesia Plan- Post oxygenation
▪ Fentanyl 100 microgm+propofol 20 mg & sevoflurane 4% (MAC 4)
▪ I-gel no.3 was introduced smoothly.
▪ Confirmation of proper placement with the help of ETCO2 readings.
▪ NDMR-rocuronium 30 mg titrated doses + (IPPV) using oxygen (50%) nitrous oxide
(50%) Sevoflurane mixture at 1.5% (IAA)
▪ Intercostal blocks were administered atT3 to T7 mid axillary line using mixture of 1.5
% lignocaine (10ml) with bupivacaine 0.125% (12ml).
▪ A total of 3 ml per segment/local incisional infiltration (7 ml) was used.
▪ BIS monitoring for adequate depth of anesthesia (55-60)
▪ There was no hypotension or arrhythmias intra-operatively.
▪ At the end reversed with myopyrolate and extubated uneventfully.
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17. Post-operative Progress
▪ The patient was awake and fully conscious.
▪ Her score as per the visual analogue scale (VAS) was 1, heart rate -76/minute, and blood
pressure - 118/70 mm Hg
▪ SpO2 -98% on O2 4 lit/min.
▪ The patient was shifted to the post-operative surgical ICU ward.
▪ The patient did not require any ionotrope, vasopressor, or ionodilator support.
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20. Post-operative (hours) VAS HR BP
1 1 76 116/70
2 1 73 118/68
3 1 72 128/66
4 2 78 126/72
5 3 78 128/84
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POST OPERATIVE MONITORING
21. Discussion▪ Common perioperative issues:
▪ Arrhythmias,
▪ Precipitation of CCF
▪ Systemic embolism from pre-existing mural thrombi. Mural thrombi may
also be present in the LV apex.
▪ In our case, the patient was treated with digoxin with METS less than or
almost 4.
▪ The patient had no recent history of Congestive Cardiac Failure (CCF).
▪ As per the adenosine stress scan, she did not show stress-induced
ischemia,while she had normal hemodynamics without any perfusion
defect.
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22. Discussion
▪ Midazolam was administered to the patient as premedication in the
operating room.
▪ It provided good anxiolysis.
▪ The use of supraglottic airway device (SGAD), as I-Gel has been associated with
efficient airway control while delivering an anesthetic agent.
▪ It helps in delivering optimal concentrations of both, anesthetic agent and gas.
The use of SGAD was associated with uneventful extubation with minimal stress
response.
▪ Analgesia was provided with the help of infiltration and intercostal blocks
T3-T7 in calculated dosages and fentanyl at induction.
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23. SGAD▪ In conventional approaches,i.e ETT such high-risk
patients have a high stress response including
arrhythmias which may require the use of beta
blockers or antiarrhythmic agents.
▪ The advent of SGAD has changed the overall
management of high-risk patients.
▪ The need for invasive monitoring is prevented using
(SGAD), I-Gel.
▪ The overall process also reduces overall hospital stay
and cost along with morbidity and stress of
hospitalisation.
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24. Conclusion
▪ DCM IS A BIG CHALLANGE!!
▪ Meticulous perioperative workup and planning with interdepartmental
discussion,(cardiologist,surgeon,intensivist) is required for favorable
outcome.
▪ The use of SGAD (I-GEL) for breast surgeries along with intercostal blocks
and local infiltration can be considered as an ideal choice to reduce overall
anesthetic complications.
▪ Nuclear scanning to assess the heart function is most recent addition and
needs to be considered.
▪ Invasive monitoring should be at hand and its requirement should be
assessed as per patients condition and type of surgery.
▪ If patient is on antipsychiatric medication,looking towards the drug induced
cardiomyopathy aspect is helpful.
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25. Take Home Message
▪ Clinical studies need to be conducted to ascertain the efficiency
of SGAD IN BREAST SURGERIES.
▪ NUCLEAR SCANNING SHOULD BE USED MORE OFTEN FOR
CARDIAC ASSESMENT.
▪ Clonazipine induced-DCM has been reported, However, we need
to investigate if olanzipine was the primary cause of DCM.
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26. Reference
▪ Kaur H, Khetarpal R, Aggarwal S. Dilated Cardiomyopathy: An Anaesthetic Challenge.
Journal of Clinical and Diagnostic Research : JCDR. 2013;7(6):1174-1176.
doi:10.7860/JCDR/2013/5390.3069.
▪ Kannaujia A, Srivastava U, Saraswat N, Mishra A, Kumar A, Saxena S. A Preliminary Study
of I-Gel: A New Supraglottic Airway Device. Indian Journal of Anaesthesia. 2009;53(1):52-56.
▪ Alawami M, Wasywich C, Cicovic A, Kenedi C. A systematic review of clozapine induced
cardiomyopathy. Int J Cardiol. 2014 Sep 20;176(2):315-20. doi: 10.1016/j.ijcard.2014.07.103.
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