1. Case presentation
Moderator : Dr Sushila Tabdar
2014/09/24 (071/06/07)

2. • 53/F, 52 kgs
• Admitted by orthopaedics dept.
• h/o RTA (fall from bike) 5 days back
• # Lt distal radius

3. • No other associated injuries xcept for minor
scratches (lt knee,ext surface lt forearm,rt
hand)
• No LOC, Vomitting

4. • h/o dyspnea (NYHA II) since 2 yrs
• Dizziness Off and on
• No orthopnea or PND

5. Past History
• ICU adm. 5 mnths back (4 days) due to increased
dyspnea severity
• Discharged on
T. Spironolactone 25 mg OD
T. Lasix 40 mg OD
T. Ecosprin 75 mg OD
T. Losartan 50 mg OD
T. Isosorbide Dinitrate 20 mg
T. Atorvastatin 10 mg OD’
• Taking Till date

6. • No h/o any previous surgery or anesthetic
exposure

7. Personal history
• Non-Smoker
• Non-drinker
• Normal bowel/bladder habits
• No known allergies

8. General examination
• Gen. Condition - fair
• PILCCOD – NIL

9. Airway
• Normal Dentition/ Patent nares
• Mouth opening – 3 fingers breadth
• TMD – >6 cm
• TMJ – free/mobile
• Neck mobility – free
• MP – grade I

10. Systemic examination
• CVS Examination :
– Pulse: 80,regular
– BP: 100/70 mm Hg (left sitting)
– S1 + S2 + M0
• Respiratory Examination:
– RR: 16/min
– Air entry B/L on bases, otherwise NVB

11. • Abdomen
soft, non-distended
no organomegaly,

12. Investigations
• Hb:13.2 gm%
• TC: 10,300/mm3
• P72, L22, E06
• PT: 15 secs
• INR: 1.1
• Platelets:
2,25,000/mm3
• Blood group: 0 +ve
• SpO2 @ room air- 94%
• Na: 146 meq/l
• K: 4.7 meq/l
• Urea: 26 mg/dl
• Creatinine: 0.9
mg/dl
• RBS: 134 mg/dl
• ABG: N/A
• Trop I – Neg
• CK MB- 17 U/L

15. Echo report
• Dilated LV (6.18cm)
• Global hypokinesia of LV
• LVEF 27%
• LV diastolic dysfunction (E<A)
• DCM

16. Anesthetic plan

17. Regional
• USG + PNS guided supraclavicular block
• 20 ml 0.25 % plain Bupivacaine + 5 ml plain
Lidocaine 2%
• Supine, Nasal prongs (3l/min)>> SpO2 98%
• Inj fentanyl 25 mcg to facilitate block

18. • Minimal IV fluid- 400 ml R/L in total
• BP ˷ 90/60 (mean 65-70 mm Hg)
• DOS – 45 mins
• Uneventful

19. DISCUSSION

20. DCM
• Most common cardiomyopathy
• Progressive disease with ventricular
enlargement & contractile dysfunction but
NORMAL LV thickness
• Rt ventricle can be involved
• Amongst common causes of heart failure

21. • Cause unknown
• May be genetic or a/w Coxsackie B infection
• Secondary cardiomyopathies might have features
of DCM
Alcohol/Cocaine abuse
Peripartum CM
HIV
Pheochromocytoma
Hyperthyroidism
CAD,IHD

22. SYMPTOMS
• Fatigue
• Dyspnea on exertion, SOB
• Orthopnea, PND
• Peripheral edema

23. SIGNS
• Tachypnea
• Tachycardia
• Hypertension/hypotension
• Signs of pulmonary and systemic vascular
congestion
• Valvular regurgitation (due to AV ring dilation)

25. Diagnostic Studies
CXR -enlarged cardiac silhouette,
vascular redistribution interstitial edema,
pleural effusions
ECG –normal
tachycardia, atrial and ventricular
enlargement, LBBB, RBBB, Q-waves
Echocardiography
LV size, wall thickness
valve function, pressures
Cardiac catheterization
PCWP, CO
Endomyocardial Biopsy

26. Anesthetic concerns
• Decompensation
cardiodepression
inc afterload
• Arrhythmias
• Electrolyte anomalies (diuretics)
• Thromboembolism (cardiac thrombus)

27. Preparation/Optimization
• Determining optimal time for elective surgery
• Grading the severity
• Heart failure control at least >1 week
• Treatment of arrhythmias if any
• Correction of electrolyte anomalies

28. Overall aim
• avoid tachycardia;
• avoid/minimize the effects of negative
inotropic agents, in particular anesthetic
drugs;
• prevent increases in afterload;
• maintain adequate preload in the presence of
elevated LVEDP.
• Treatment be considered if a >10% decrease
in systolic pressures occurs.

29. Poor Prognosis
• EF < 25 %
• PCWP > 20 mm Hg
• Systemic hypotension
• Pulm. HTN
• Inc. CVP
• Cardiac index < 2.5 L/min/M2

31. Brachial plexus block

32. Brachial Plexus
Sheath
• A sheath surrounds the
brachial plexus, from the
transverse processes all
the way down into the
axilla.

33. Relations
• Brachial plexus is
contained within a
fascial sheath.
• Subclavian artery lies
medial to plexus as they
cross the 1st rib
together.

35. Supraclavicular Imaging:
• Start parallel and adjacent to clavicle.
• May have to rotate probe slightly to get a good cross
section.

36. Medial
Lateral
Here is a nice example of the brachial plexus to the left of the subclavian artery.

37. Look for subclavian artery, with plexus sheath on lateral aspect.
Medial
Lateral

38. MedialLateral

39. Supraclavicular Approach:
 Use in-plane approach only – so position of
needle relative to lung is always known.

40. • http://www.omjournal.org/casereports/pdf/2
01001/perioperative.pdf
• www.medscape.com
• http://ceaccp.oxfordjournals.org/content/9/6/
189.full