1. HIGH CARDIAC RISK POLYMORBID PATIENT UNDERGOING NON-CARDIAC SURGERY
D. Smirnova1; R. Leibuss2
B. Vilīte2; I. Krustiņa2;
D.Bogdanovs1,2; E. Strīķe1,2
1 Rīga Stradiņš University, MD, Latvia
2 Pauls Stadiņš Clinical University Hospital, Cardiac Surgery Anesthesia and Intensive Care Unit, Latvia
Introduction
Aortic stenosis (AS) is the most common valvular lesion (2-9%) in individuals aged over 65 years [1;4] and it poses a considerable challenge to the anaesthesiologist, due to the significant risk of perioperative mortality (1,9-7,1%) [2].
General anaesthesia (GA) is traditionally advocated in this group of patients for its haemodynamically stable properties. However the patient’s individual characteristics may require a different anaesthetic management, especially according to GA association with an increased risk of post-operative cognitive dysfunction (POCD) for elderly individuals [3].
The patient remained clinically and haemodynamically stable (MAP 70±5; HR 60-70) and spontaneous respiratory compensated throughout the 115 minutes of surgery and unrequired any dose of vasoactive medication.
Data on haemodinamics are presented in Table 1.
Case report
An 81 year old polymorbid female (ASA IV) with a potentially difficult airway (Mallampati Score Class III) presented for an elective a.iliaca sinister reconstruction surgery.
Patient’s anamnesis included mild hypertension, first time diagnosed asymptomatic severe aortic stenosis (AVA 0,7 cm2; PGmean 40mmHg), dyslipidemia with cerebral ischemic stroke episode six years ago, diabetus mellitus type two, permanent tachysystolic atrial fibrillation and adiposity (BMI 39,1, Obesity Class II).
After reviewing risks and benefits, titratable continuous spinal anaesthesia (CSA) with isobaric 0,5% Bupivacaine was selected for anaesthetic management. The pencil point spinal needle and subsequent 27G catheter were inserted at the L5-S1 vertebral interspace into the subarachnoid space [Photo 1 and Photo 2]
Invasive arterial blood pressure measurement and arterial blood gases analyses was selected to guide haemodinamic parameters.
Table 1
Total fluid volume of 1000 ml of Ringer’s solution was infused, guided by haemodinamic parameters. Estimated blood loss was 200ml.
After surgery, the spinal catheter was removed and the patient was transferred to the vascular surgery department awake, alert and comfortable.
MOCA (Montreal Cognitive assessment) before and seven days after surgery was 27 and 26 points respectively and MMS (Mini mental status exam) 28 and 26 points respectively.
Discussion
Haemodynamic instability could be fatal for high cardiac risk patients undergoing surgery, so general anaesthesia and epidural block is traditionally recommended.
However CSA could be a valid alternative because of some preference: an adequate anaesthetic level and duration, post-operative pain control, using smaller doses of local anaesthetic, leading to maintenance of haemodynamic stability and probably lower risk of post-operative cognitive dysfunction.
Photo 1
Photo 2
Conclusion
The use of central regional anaesthesia is traditionally regarded as contrindicated in patients with severe aortic stenosis due to its sympatholytic effect, potentially causing loss of vascular tone and ultimately diminished cardiac output.
Our presented case report illustrates the successful use of continuous spinal anaesthesia as a valid alternative to other type of anaesthesia for high cardiac risk patient undergoing non-cardiac surgery.
Surgery was performed successfully after a Th8-sensory level of anaesthesia was achieved with initial bolus dose of 5mg 0,5% Bupivacaine and two consecutive 2,5mg Bupivacaine bolus doses every forty minutes.
Faggiano P, Antonini-Canterin F, Baldessin F, Lorusso R, D'Aloia A, Cas LD. Epidemiology and cardiovascular risk factors of aortic stenosis. Cardiovasc Ultrasound. 2006; 4:27. Published 2006 Jul 1. doi: /
S. Ghosh, L. Bogar, A. Sabry, Anaesthetic Considerations for Patients with Severe Aortic Stenosis. Department of Anaesthesiology and Intensive Care, University of Pecs, Pecs, Hungary. Sept 2011
Khalil S, Roussel J, Schubert A, Emory L (2015) Postoperative Cognitive Dysfunction: An Updated Review . J Neurol Neurophysiol 6:290. doi: /
Central regional anaesthesia in patients with aortic stenosis - a systematic review. Sofia Johansson & Morten Nikolaj Lind. Danish Medical Journal/64/9. September 2017