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 Table of Contents    
CASE REPORT
Year : 2007  |  Volume : 51  |  Issue : 3  |  Page : 234-236  

Combined sciatic femoral nerve block in a case of restrictive cardiomyopathy for arthroscopy and anterior cruciate ligament (ACL) reconstruction


1 MD, Consultant, Department of Anaesthesiology, Perioperative Medicine & Pain, Apollo Gleneagles Hospitals, Kolkata, WB, India
2 MD, Registrar, Department of Anaesthesiology, Perioperative Medicine & Pain, Apollo Gleneagles Hospitals, Kolkata, WB, India
3 MD, DNB, Consultant, Department of Anaesthesiology, Perioperative Medicine & Pain, Apollo Gleneagles Hospitals, Kolkata, WB, India

Date of Acceptance21-Mar-2007
Date of Web Publication20-Mar-2010

Correspondence Address:
Gaurab Maitra
63 B, Chakraberia Road(North) Kolkata-700020
India
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Source of Support: None, Conflict of Interest: None


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Restrictive cardiomyopathy is a rare heart muscle disease resulting in impaired ventricular filling, low cardiac output and a propensity for development of heart failure with minimal fluid overload. Here, we present the management of a case of restrictive cardiomyopathy undergoing arthroscopy and anterior cruciate liga­ment (ACL) reconstruction.

Keywords: Restrictive cardiomyopathy; Sciatic femoral block; Arthroscopy.


How to cite this article:
Maitra G, Kumar P, Sengupta S, Rudra A. Combined sciatic femoral nerve block in a case of restrictive cardiomyopathy for arthroscopy and anterior cruciate ligament (ACL) reconstruction. Indian J Anaesth 2007;51:234-6

How to cite this URL:
Maitra G, Kumar P, Sengupta S, Rudra A. Combined sciatic femoral nerve block in a case of restrictive cardiomyopathy for arthroscopy and anterior cruciate ligament (ACL) reconstruction. Indian J Anaesth [serial online] 2007 [cited 2019 Nov 21];51:234-6. Available from: http://www.ijaweb.org/text.asp?2007/51/3/234/61150


   Introduction Top


Restrictive cardiomyopathy is a rare heart muscle disease that results in impaired ventricular filling, with nor­mal or decreased diastolic volume of either or both ven­tricles[1].

The condition usually results from increased stiffness of the myocardium that causes pressure within the ven­tricles to rise precipitously with only small increases in vol­ume. The diagnosis of restrictive cardiomyopathy should be considered in patients presenting with left or right sided heart failure but with no evidence of cardiomegaly or sys­tolic dysfunction [2].

Restrictive cardiomyopathy may be idiopathic, which is sometimes familial and appears to be associated with distal skeletal myopathy [3], or due to amyloidosis, where normal myocardial contractile elements are replaced by infiltrative interstitial deposits[4], or endomyocardial fibrosis and Loeffler's endocarditis, both of which are associated with eosinophilia [5].

Chest X-ray is not diagnostic as cardiac size is usu­ally normal. Electrocardiogram shows nonspecific ST-T wave abnormalities, ventricular hypertrophy, bundle-branch or atrio-ventricular block [6]. Doppler echocardiography shows an increased ratio of early diastolic filling to atrial filling velocity (>2) [7]. Cardiac catheterization shows the so called dip and plateau or square root sign which is mani­fested in the atrial pressure tracing as a prominent y de­cent followed by a rapid rise to a plateau. Endomyocardial biopsy should be considered for patients in whom diagno­sis is not clear by other methods of evaluation [8].

The sciatic-femoral nerve blocks are typically used together for procedures on lower extremities and very useful in numerous procedures involving thigh, knee, particularly knee arthroscopy, patellar surgery, total knee arthroplasty, and even procedures distal to knee. An interesting com­mon practice is the insertion of an indwelling femoral cath­eter for continuous perineural infusion for postoperative analgesia in knee surgeries [9].


   Case report Top


A middle aged man, diagnosed with restrictive cardi­omyopathy six years ago was admitted for arthroscopy and anterior cruciate ligament (ACL) reconstruction of the left knee. He was hospitalized twice for chest pain and breathlessness, and was on treatment with diuretics. His chest was clear on auscultation, and his vital signs were stable. Hematologic, biochemical and coagulation param­eters were normal. Chest x-ray showed a normal sized heart but the electrocardiogram showed evidence of left ventricular hypertrophy and global ST-T changes.

Echocardiography showed impaired diastolic filling (ratio of early diastolic filling to atrial filling velocity 2.3) but with a normal ejection fraction, normal valves and peri­cardium.

After routine premedication the patient was taken to the operating room and ECG, NIBP, and pulse oximetry monitoring were started .The sciatic and femoral nerve blocks were performed with the aid of a nerve stimulator (Stimuplex® DigRc) using nerve stimulating needles (StimuplexA®, B Braun) with a total dose of 30ml of 0.5% bupivacaine. The sciatic nerve was blocked first in the posterior approach with 15ml of the local anaesthetic solu­tion. A catheter (Contiplex®) was introduced while per­forming the femoral nerve block in the supine position and the remaining 15ml of anaesthetic solution was used for the femoral block.

The patient was pain free and comfortable during the procedure. The monitored parameters were stable throughout the procedure. 1.5L of Ringer lactate was in­fused. Following the procedure the patient was shifted to the intensive care area for monitoring. Bupivacaine 0.125% infusion was started through the femoral catheter for post­operative pain relief for the next 48hrs.


   Discussion Top


Cardiac output in restrictive cardiomyopathy is usu­ally low and barely maintained by increased filling pres­sures and tachycardia [10]. Consequently, the anaesthetic plan should not include drugs and techniques that cause de­creased venous return, bradycardia, or decreased contrac­tility. Invasive monitoring is helpful because biventricular failure is common and small volume shifts may greatly af­fect cardiac output. Inotropic support is beneficial to main­tain stable haemodynamics in these patients because of the risk of death from low cardiac output [11] .

There are very few literature regarding anaesthesia in restrictive cardiomyopathy as it is a very rare clinical entity. There are only two reported cases of an­aesthetic management of restrictive cardiomyopathy as per a Pubmed search from 1990 to 2006.

In one case, general anaesthesia was administered for a subtotal gastrectomy in a 52 yr old man[12] and in the other case, for a mitral valve replacement in a 48 yr old female[13]. Both the cases were managed with invasive monitoring and inotropic support, but in both the cases improvements in car­diac output occurred with the administration of PGE1 by reducing the left ventricular afterload.

Regional anaesthesia is a widely accepted technique for knee arthroscopic procedures and the combined sciatic-femoral nerve block has been described with successful results [14]. Subarachnoid or epidural block is better avoided in restrictive cardiomyopathy because the decreased venous return resulting from sympathetic block may cause deterioration of cardiac output. Sciatic-femoral nerve block is safe and effective, providing excellent intra and postoperative analgesia as well as minimizing postoperative complications in knee arthroscopy [15].

Therefore we conclude that lower limb procedures particularly thigh and knee, can be safely and effectively managed with combined sciatic-femoral nerve block in patients with restrictive cardiomyopathy without invasive monitoring.

 
   References Top

1.Richardson P, McKenna W, Bristow M, et al. Report of the 1995 World Health Organization /International Society and Federation of Cardiology Task Force on the Definition and Classification of cardiomyopathies. Circulation 1996; 93: 841 - 2.  Back to cited text no. 1
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2.Schoenfeld MH, Supple EW, Dec GW Jr, Fallon JT, Palacios IF. Restrictive cardiomyopathy versus constrictive pericarditis: role of endomyocardial biopsy in avoiding unnecessary thoracotomy Circulation 1987; 75: 1012 - 7.  Back to cited text no. 2
    
3.Fitzpatrick AP, Shapiro LM, Rickards AF, Poole-Wilson PA. Familial restrictive cardiomyopathy with atrioventricular block and skeletal myopathy. Br Heart J 1990; 63: 114- 8  Back to cited text no. 3
    
4.Smith TJ, Kyle RA, Lie JT. Clinical significance of histopatho­logic patterns of cardiac amyloidosis. Mayo Clin Proc 1984; 59: 547 - 55.  Back to cited text no. 4
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5.Fauci AS, Harley JB, Roberts WC, Ferrans VJ, Gralnick HR, Bjornson BH. NIH conference. The idiopathic hypereosinophilic patterns of cardiac amyloidosis. Ann Intern Med 1982; 97: 78 - 92  Back to cited text no. 5
    
6.Hesse A, Altland K, Linke RP, Almeida MR, Saraiva MJ, Steinmetz A, Maisch B. Cardiac amyloidosis: a review and re­port of a new transthyretin (prealbumin) variant. Br Heart J 1993; 70; 111 - 5.  Back to cited text no. 6
    
7.Appleton CP, Hatle LK, Popp RL. Demonstration of restrictive ventricular physiology by Doppler echocardiography. J Am Coll Cardiol 1988; 11: 757 - 68.  Back to cited text no. 7
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8.Mason JW, O'Connell JB. Clinical merit of endomyocardial bi­opsy. Circulation 1989; 79: 971 - 9.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Morgan GE, Mikhail MS, Murray MJ. Peripheral nerve blocks. In: Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiol­ogy. New York 2006; 344 - 45.  Back to cited text no. 9
    
10.Wilmshurst PT, Katritsis D. Restrictive Cardiomyopathy. Br Heart J 1990; 63; 323 - 4.  Back to cited text no. 10
    
11.Oliver WC, Nuttal GA. Uncommon cardiac diseases. In: Kaplan J, Reich D, Lake C, Konstadt SN. Kaplan's Cardiac Anesthesia. Philadelphia: Saunders 2006; 783 - 84.  Back to cited text no. 11
    
12.Nishida T, Taniguchi A, Tanigami H, Hagihira S, Yoshiya I. An­esthetic management of a patient complicated with restrictive cardiomyopathy for gastrectomy. Masui 1996; 45 : 1265-8.  Back to cited text no. 12
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13.Nonaka A, Suzuki S, Imamura M, Kumazawa T. Anesthetic management for mitral valve replacement in a patient with idio­pathic hypereosinophilic syndrome. Masui 2001; 50: 34-6.  Back to cited text no. 13
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14.Patel NJ, Flashburg MH, Paskin S, Grossman R. A regional anesthetic technique compared to general anesthesia for outpa­tient knee arthroscopy. Anesth Analg 1986; 65: 185 - 7.  Back to cited text no. 14
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15.Cappellino A, Jokl P, Ruwe PA. Regional anesthesia in knee arthroscopy: a new technique involving femoral and sciatic nerve blocks in knee arthroscopy. Arthroscopy 1996; 12: 120-3.  Back to cited text no. 15
    




 

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