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.

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
1

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.
2

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.
3

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
4

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.
5

6. Antipsychotic
treatment
6

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.
7

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.
8

9. Prescriptions by
Physician
9

10. Follow up
echo
10

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%.
11

12. Lab Investigations
▪ Hb- 12.3gm/dl
▪ WBC- 10,900
▪ PCV- 34.7%
▪ Platelet count – 2.99
▪ BSL- 117mg %
▪ Creatinine-0.7mg/dl
▪ Na - 138/ K - 3.7/Cl – 98, Ca -9.0 / Mg - 1.6
▪ CXR- Mild Cardiomegaly/prominent BVM
▪ 12 lead ECG- normal sinus rhythm.
12

13. Resting
ECG
13

14. Goals of Anaesthesia
▪ The primary objective of anesthesia was to avoid
▪ Negative inotropism,
▪ Tachycardia
▪ A sudden increase in after load.
14

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
15

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.
16

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.
17

18. Heart Rate BP Sevoflurane % 02 lit/min N20 lit/min
Preoperative 72 127/76 0 0.35 0
Induction 78 123/84 4 2 0
Intubation 76 136/80 2 2 0
Post-intubation 78 106/70 1.5 2 2
30-minutes 74 112/60 1.5 0.35 0.35
60-minutes 72 116/70 1.5 0.35 0.35
75-minutes 70 128/66 1.2 0.35 0.35
90-minutes
extubation
78 118/60 2 2 0
18

19. 19
ANESTHESIA GAS MONITORING CHART

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
20
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.
21

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.
22

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.
23

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.
24

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.
25

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.
26

27. THE ONLY DIFFERENCE BETWEEN TRY ...
AND TRIMPH ...IS A LITTLE ...UMPH...
27