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
Gaurab Maitra1, Palas Kumar2, Saikat Sengupta3, A Rudra1,
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
63 B, Chakraberia Road(North) Kolkata-700020
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.
|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;51:234-236
|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 Aug 22 ];51:234-236
Available from: http://www.ijaweb.org/text.asp?2007/51/3/234/61150
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.
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 .
Restrictive cardiomyopathy may be idiopathic, which is sometimes familial and appears to be associated with distal skeletal myopathy , or due to amyloidosis, where normal myocardial contractile elements are replaced by infiltrative interstitial deposits, or endomyocardial fibrosis and Loeffler's endocarditis, both of which are associated with eosinophilia .
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 . Doppler echocardiography shows an increased ratio of early diastolic filling to atrial filling velocity (>2) . 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 .
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 .
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.
Cardiac output in restrictive cardiomyopathy is usually low and barely maintained by increased filling pressures and tachycardia . 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  .
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 and in the other case, for a mitral valve replacement in a 48 yr old female. 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 . 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 .
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.
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