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LETTERS TO EDITOR
Year : 2020  |  Volume : 64  |  Issue : 6  |  Page : 534-536  

Chronic bifascicular block in a geriatric patient presenting for elective surgery. How prepared can we be?


Department of Anaesthesiology and Critical Care, Indira Gandhi Medical College and Research Institute, Kathirkamam, Puducherry, India

Date of Submission02-Feb-2020
Date of Decision05-Apr-2020
Date of Acceptance03-May-2020
Date of Web Publication01-Jun-2020

Correspondence Address:
Dr. Savitri Velayudhan
Department of Anaesthesiology and Critical Care, Indira Gandhi Medical College and Research Institute, Kathirkamam, Puducherry - 605 009
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_111_20

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How to cite this article:
Velayudhan S, Natrajan P, Bhat R. Chronic bifascicular block in a geriatric patient presenting for elective surgery. How prepared can we be?. Indian J Anaesth 2020;64:534-6

How to cite this URL:
Velayudhan S, Natrajan P, Bhat R. Chronic bifascicular block in a geriatric patient presenting for elective surgery. How prepared can we be?. Indian J Anaesth [serial online] 2020 [cited 2020 Jul 7];64:534-6. Available from: http://www.ijaweb.org/text.asp?2020/64/6/534/285524



Sir,

With increase in the geriatric population, anaesthesiologists face the challenge of anaesthetising older patients with rare conditions.[1] The incidence of bifascicular block is almost 17% in patients of age more than 80 years and is diagnosed by the presence of complete right bundle branch block along with left anterior or posterior hemifascicular block or complete left branch block alone.[2] The risk of progression to complete heart block (CHB) is remote and hence insertion of temporary pacing is not warranted in these asymptomatic patients. However, there is a dilemma whether to initiate temporary pacing in patients who present with syncope. Recently we had an 85-yr-old patient who presented with doubtful history of syncope following, which she sustained right inter-trochantric fracture. Her pre-operative work up revealed a bifascicular block in the electrocardiogram [Figure 1]. Albeit the history of syncope, cardiologists deferred temporary pacing and suggested pharmacologic methods for intraoperative episodes of bradycardia.
Figure 1: ECG showing bifascicular block

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She was posted for proximal femoral nailing under spinal anaesthesia with bupivacaine and fentanyl combination to reduce the level of sympathetic blockade. Bupivacaine itself has arrhythmia inducing potential, predominant changes include prolonged QRS duration and lengthening of PR interval. It is especially significant in patients who have conduction defects.[3] In addition to the usual operating room preparation, (which includes preparing the defibrillator), we also placed stick on paddles to facilitate transcutaneous pacing should the need arise. Also other emergency drugs like adrenaline, atropine, isoprenaline, dopamine, dobutamine and milrinone were kept ready. She remained stable through the surgery and post-operative period. By maintaining a sensory level below T10, we ensured that there were minimal haemodynamic disturbances intra-operatively.

Though our patient had an uneventful intra-operative course, there are incidences of progression to complete heart block in these patients with chronic bifascicular block especially those patients who present with syncope. Martí-Almor et al.[4] studied 263 patients with chronic bifascicular block. They analysed clinical, electrocardiographic and electrophysiologic variables to identify predictors for progression of bifascicular block to significant atrioventricular block. They identified presence of syncope, structural heart disease and renal disease as predictors of progression to atrioventricular block. Block progression to CHB though rare cannot be totally ruled out. CHB if it does occur could be quite disastrous and initiating temporary venous pacing would be very difficult in the situation. The availability of external non-invasive pacing (transcutaneous and transoesophageal) may preclude the need for transvenous pacing, which itself might have adverse consequences in these elderly patients.[5] Transcutaneous pacing is one of the techniques of external non-invasive pacing and is an important alternative when emergency transvenous pacing is immediately not available. We had placed stick on paddles to enable cutaneous pacing had the patient progressed to CHB or severe bradycardia. It should be remembered that patient might need deep sedation and analgesia to tolerate transcutaneous pacing and the necessary drugs and equipments should be available.

To conclude, bifascicular block in elderly patients can be common and the incidence of progression to CHB though rare is not impossible. Meticulous pre-operative work up and intra-operative preparedness to monitor and manage any adverse events will ensure a safe peri-operative period for these patients. More emphasis cannot be made on preparedness and vigilant monitoring.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Srilata M, Durga P, Ramachandran G. Influence of changing trends in anaesthetic practice on morbidity and mortality in elderly patients undergoing lower limb surgery. Indian J Anaesth 2014;58:132-7.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: The Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J 2013;34:2281-329.  Back to cited text no. 2
    
3.
Bourne E, Wright C, Royse C.A review of local anesthetic cardiotoxicity and treatment with lipid emulsion. Local RegAnesth 2010;3:11-9.  Back to cited text no. 3
    
4.
Martí-Almor J, Cladellas M, Bazán V, Delclós J, Altaba C, Guijo MA. Novel predictors of progression of atrioventricular block in patients with chronic bifascicular block. Rev EspCardiol 2010;63:400-8.  Back to cited text no. 4
    
5.
Maddali MM. Cardiac pacing in left bundle branch/bifascicularblock patients. Ann Card Anaesth 2010;13:7-15.  Back to cited text no. 5
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