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CASE REPORT
Year : 2008  |  Volume : 52  |  Issue : 1  |  Page : 77 Table of Contents     

Lumbar Discectomy of a Patient of Mitral Stenosis with Chronic Atrial Fibrillation Under Epidural Anaesthesia


1 Lecturer, Department of Anaesthesiology, B.J.Medical College,Pune,Maharashtra, India
2 Associate Professor, Department of Anaesthesiology, B.J.Medical College,Pune,Maharashtra, India
3 Chief Resident, Department of Anaesthesiology, B.J.Medical College,Pune,Maharashtra., India

Date of Acceptance18-Dec-2007
Date of Web Publication19-Mar-2010

Correspondence Address:
Vinaya R Kulkarni
Flat A- 202, Nakshtra Apartment,Erandavane, Pune, 411004
India
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Source of Support: None, Conflict of Interest: None


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A 60-year-old female patient posted for discectomy of lumbar region L 3 -L 4 was accidently diagnosed to have chronic atrial fibrillation of rheumatic aetiology.This is a case report of this patient of critical mitral stenosis with mild mitral regurgitation with chronic atrial fibrillation managed successfully under lower thoracic epidural anaesthesia,in prone position without any compli­cation.

Keywords: Discectomy, Prone position


How to cite this article:
Kulkarni VR, Jamkar MA, Dhole A, Junghare S. Lumbar Discectomy of a Patient of Mitral Stenosis with Chronic Atrial Fibrillation Under Epidural Anaesthesia. Indian J Anaesth 2008;52:77

How to cite this URL:
Kulkarni VR, Jamkar MA, Dhole A, Junghare S. Lumbar Discectomy of a Patient of Mitral Stenosis with Chronic Atrial Fibrillation Under Epidural Anaesthesia. Indian J Anaesth [serial online] 2008 [cited 2019 Mar 19];52:77. Available from: http://www.ijaweb.org/text.asp?2008/52/1/77/60602


   Introduction Top


Mitral stenosis(MS) is almost always rheumatic in origin. Pure MS occurs in 25% of patients who develop long term rheumatic sequelae. [1] The remaining patients have either combined lesions in one valve or combined valvular disease. Infrequent causes include congenital defects seen in infancy and childhood,malignant carcinoid,rheumatic arthritis and prolapse of left atrial myxomas into the mitral valve opening. [1] MS exhibits a 2:1 female preponderance. [1] Prevalence is 0.4% and it increases with age. [2]

Atrial fibrillation is a known complication of mitral valve disease. Non cardiac surgery of patients with val­vular heart lesions especially mitral stenosis carries many risks for anaesthesia.There is no universal recommended ideal anaesthesia technique for such patients.The deci­sion has to be individualized as per the patient's general and cardiac condition and the type of non cardiac sur­gery.


   Case report Top


A 60-year-old lady weighting 50kg with chief com­plaints of tingling and numbness of both lower limbs since three months and difficulty while walking came to or­thopaedic OPD for treatment. She was diagnosed to have prolapsed interverteral disc L 3 -L 4 for which she was posted for discectomy and referred for pre anaesthetic evaluation. There was no history of any surgery or any other major illness in the past.

On examination, her general condition was normal except irregularity of pulse rate was noticed. There was mid-diastolic murmur in cardiovascular system.

Her haemogram, urine examination, bleeding and clotting time were normal. Blood sugar was 102 mg.dL­-1, blood urea was 40 mg.dL -1 , and serum electrolytes Na+/K+ were 132/4.2 mEq.L -1 . Her ECG showed irregu­larly irregular rhythm with absent P waves. X ray chest showed moderate cardiomegaly. She was advised 2D echo which showed critical mitral stenosis (MS) with valve area of 1 cm 2 with mild mitral regurgitation (MR). There were no clots in left atrium. Ejection fraction was 50%. Physician diagnosed her to have critical MS and MR with chronic atrial fibrillation (AF) and advised to start digoxin and anticoagulation therapy postoperatively.


   Anaesthetic management Top


The urgency and the need of the surgery and role of conservative management was discussed with ortho­paedic surgeons considering various risk factors for ana­esthesia. Surgeons denied role of conservative manage­ment and went ahead with definitive surgery and insisted on regional anaesthesia. Merits and demerits of general anaesthesia were compared against regional anaesthe­sia. Though general anaesthesia would have been a bet­ter choice for this patient, it was decided to perform this surgery under epidural anaesthesia as patient was clini­cally asymptomatic. This was a unanimous decision by surgeons and anaesthesiologists. We are practicing epidural anaesthesia for almost all patients posted for discectomies of ASA I & II in our institute.

She was advised infective endocarditis prophylaxis and anxiolytic oral diazepam 10 mg a night prior to sur­gery. 500 ml of whole blood was kept ready. On the day of surgery, her pulse rate was 80/min, irregularly irregu­lar, BP- 110/80 mm Hg and irregularly irregular rhythm of atrial fibrillation on ECG, there were no crepts or rhon­chi. High risk consent in view of cardiac pathology was taken. Cardiac drugs were kept ready and her urinary bladder was catheterised. Her preoperative urine output was 200 ml. Intravenous access was taken with 18 G intracath. CVP line was put through internal jugular vein. CVP was 8 cm of water. Ranitidine 1mg.kg -1 and ondansetron 0.1 mg.kg -1 were given intravenously. She was preloaded with 500 ml of Ringer lactate. ECG monitor and pulse oximeter were attached and defibrillator was kept ready.

Epidural catheter,numbered 16, was put at T11 - T12 space with all aseptic precautions. Test dose of 2% lidocaine with adrenaline was given. Later a total dose of 8 ml lidocaine without adrenaline was required for adequate action. The catheter was fixed.

She was given prone position with due precautions. Oxygen was given by ventimask. Her vital parameters, ECG and oxygen saturation were monitored throughout the procedure. The patient was given 1000ml of crystal­loids intraoperatively in the form of Ringer's lactate and 0.9% dextrose normal saline. The surgery was unevent­ful and over within 45 minutes. There was approximately 30 ml of blood loss. The urine output of the patient was 25 ml at the end of the surgery. Her postoperative pe­riod was uneventful. The postoperative analgesia was provided with 0.125% bupivacaine through the epidural catheter which was removed 24 hours later.


   Discussion Top


Modern lumbar spinal surgery ranges from disc ex­cision through tiny incisions to extensive instrumentation. [1] The anaesthetic techniques must be adapted to the particular type of surgery. These cases traditionally have been performed with general anaes­thesia. Spinal or epidural anaesthesia is more commonly preferred for simple disc excision. [1] Lumbar spinal fu­sion can be performed with low thoracic epidural anaes­thesia. [1] The virtues of epidural anaesthesia are less bleed­ing and improved postoperative epidural analgesia. [1] Safe application of regional anaesthesia requires care, skill and discretion by both surgeon and anaesthesiologist. [3]

General anaesthesia is often preferred over cen­tral neuraxial blockade for anaesthetic management of patients with mitral stenosis. General anaesthesia is pre­ferred because of greater patient acceptance and ability to perform operations of long duration in the prone posi­tion with a secured airway. [4] This choice is made often because peripheral sympathetic nervous system block­ade produced by regional anaesthesia can lead to unde­sirable decrease in systemic vascular resistance. Indeed, when regional anaesthesia is selected, epidural is often recommended due to gradual onset of peripheral sym­pathetic nervous system blockade. [4]

Regional anaesthesia decreases blood loss and improves operating conditions by decreasing peripheral venous pressure which reduces venous blood loss in the operative field. Awake patient can self position to avoid nerve injury to brachial plexus and pressure necrosis to face which may occur in the malpositioned patient un­der general anaesthesia. Less bleeding would facilitate dissection and removal of disc in less time as less time is needed to achieve haemostasis. Pulmonary complica­tions are more common with general anaesthesia.

Hypotension in spine surgery is related to the posi­tion rather than to anaesthetic technique. [4] The outcome of discectomy and laminectomy patients under spinal and general anaesthesia has been compared. [4]

Our patient had critical MS with trivial MR. Al­though the interval between rheumatic fever and devel­opment of MS is at least 2 years, patients are usually asymptomatic for 2 decades and symptoms generally develop in the 3 rd and 4 th decades of life. In this case, this patient was totally asymptomatic for 6 decades and diagnosed only when she was posted for discectomy. There was no history of decompensation during deliver­ies. She had two children with history of full term nor­mal vaginal deliveries.

This patient also had chronic atrial fibrillation. Perioperative treatment goals of AF are restoration and maintenance of sinus rhythm, control of ventricular rate and prevention of thromboembolic complications. [5],[6] Im­mediate synchronized electrical cardioversion is required when AF is associated with rapid ventricular rate, haemodynamic compromise, worsening of left ventricu­lar function or evidence of myocardial ischaemia. Digoxin has a limited role in intraoperative setting because of its slow onset of action.

Amiodarone is studied extensively and is found effective for perioperative management of these cases. [5],[6] Amiodarone is referred by American Heart Association's Guidelines 2002 as the drug of choice for pharmacologic conversion of AF [6] . Amiodarone and defibrillator were kept ready for this case but fortunately not required as there was no further rhythm disturbances observed in­traoperatively.

The patient was not receiving any anticoagulant preoperatively which eased our choice of regional ana­esthesia. Though there are studies [7],[8] in literature where spinal and epidural anaesthesia was successfully used in patients receiving anticoagulants.

In this patient, it was chronic AF and patient was clinically asymptomatic. The surgeon and his team were very fast and insisted for regional anaesthesia for better field and as it was a single disc. Hence, keeping in mind the precautions and risks involved under regional anaes­thesia and problems of prone position, we still decided to give epidural anaesthesia for this case.

Continuous monitoring of intra-arterial blood pres­sure and arterial filling pressures is useful when a major surgery is planned in patients of cardiac diseases who are symptomatic at rest. [8]

However, as this was a single discectomy without any major fluid shifts, hence we used noninvasive blood pressure monitoring. Intraoperative fluid management must be carefully titrated as these patients are suscep­tible to volume overload and to the development of pul­monary oedema. We used CVP line and gave titrated fluids initially before prone position was given. Pulmo­nary artery catheter (PAC) would have been ideal in such cases as it was an afterthought for us. But this procedure is not without risks, there can be precipitation of arrhythmias. [8] Our patient did not have any docu­mented left ventricular dysfunction and due to the presence of MS and mild MR, the wedge pressure would not reliably reflect end diastolic pressure. [8] We did not think that cardiac output or CVP measurements would have altered our management as it was a short duration surgery. Hence we suggest that use of PAC in cases of valvular heart diseases should be assessed on a case to case basis and to be used if it can provide reliable infor­mation by Helder et al in his study where he used com­bined spinal epidural anaesthesia for labour and unex­pected caesarian section in a patient with mitral and aortic stenosis and insufficiency. [9]

There are case reports where epidural anaesthe­sia was used in patients with aortic stenosis. [9],[10],[11] These case reports boosted our decision to use epidural anaes­thesia in this case.

Prone position for spine surgeries poses many prob­lems for anaesthesiologists. Hypotension, chest compres­sion, pressure necrosis are some of the important com­plications of prone position. [12] The risk increases in pa­tients with valvular heart diseases. [9] But precautions if taken like adequate leg stockings and prior preloading can avoid the known complications of prone position which we followed in this case and managed without any complication. Another important complication is venous air embolism which is rare. [12],[13]

In conclusion, a patient of rheumatic mitral steno­sis with chronic atrial fibrillation poses many risks for anaesthesiologist. Spine surgery of such patients in prone position increases the risk even more. This case, how­ever, was managed successfully under epidural anaes­thesia without any complications, with proper perioperative precautions. As it was a short duration surgery, hence it offered advantage for our management. We suggest that the alternative of epidural anaesthesia for such patients may be helpful only for short duration surgeries without major fluid shifts.

 
   References Top

1.Sharrock N E. Savarese J J. Anaesthesia for orthopedic surgery Miller's Anaesthesia Volume 2; Edition 4: 2125-2140.   Back to cited text no. 1      
2.2.Garwoo S. Atrial fibrillation. Anaesthesia Clinics Miller 2006;24:509-522.  Back to cited text no. 2      
3.Murphy F L. Anaesthesia for orthopaedic surgery Wyllie and Churchill - Davidson's A practice of Anaesthesia,sixth Edi­tion:1251-1260  Back to cited text no. 3      
4.Scott,W. Thalji J.Z, A prospective randomized study compar­ing short and intermediate term perioperative outcome vari­ables after spinal or general anaesthesia for lumbar disc and laminectomy surgery. Anesth Analg 1996; 83: 559-564  Back to cited text no. 4      
5.Sahoo M. Perioperative atrial fibrillation. 9th IACTA Confer­ence; Pune 2005: 60-62.  Back to cited text no. 5      
6.Guarnieri T, Nolan S. Intravenous amiodarone for prevention of atrial fibrillation after open heart surgery:The amiodarone reduction in coronary heart (ARCH) trial J Am Coll Cardiol 1997; 34: 343-347.  Back to cited text no. 6      
7.Odoom J A., Sih I L.Epidural analgesia and oral anticoagulant therapy. Experience with 1000 cases of continuous epidurals. Anaesthesia 1983; 38: 254 -259.  Back to cited text no. 7      
8.Horlekar, et al Does preoperative antiplatelet therapy increase the risk of haemorrhagic complications associated with re­gional anaesthesia. Anesth Analg 1990; 70: 630-634  Back to cited text no. 8      
9.Helder T V, Samsted K G. Combined spinal epidural anaesthe­sia in a primigravida with valvular heart disease Canadian Jour­nal of Anesthesia 1998;45: 488-490.  Back to cited text no. 9      
10.Collard C D,. Eappen S, et al Continuous spinal anaesthesia with invasive haemodynamic monitoring for surgical repair of hip in two patients with severe aortic stenosis Anesth Analg 1995; 81: 195-198  Back to cited text no. 10      
11.Coldough G. Epidural anaesthesia for caesarian delivery in a parturient with aortic stenosis. Reg Anaesth 1990; 158: 273-­274.  Back to cited text no. 11      
12.Cucchiara R F, Faust R J. Patient positioning. Miller's Anes­thesia, 4th edition ; 30: 1057- 1074  Back to cited text no. 12      
13.Alin M S, Ritter R R. Venous air embolism during lumbar laminectomy in prone position: Report of three cases. Anesth Analg 1991; 73: 346-349.  Back to cited text no. 13      




 

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