dcm case presntatn vkas
TRANSCRIPT
Case presentation
Moderator : Dr Sushila Tabdar
2014/09/24 (071/06/07)
• 53/F, 52 kgs
• Admitted by orthopaedics dept.
• h/o RTA (fall from bike) 5 days back
• # Lt distal radius
• No other associated injuries xcept for minor scratches (lt knee,ext surface lt forearm,rthand)
• No LOC, Vomitting
• h/o dyspnea (NYHA II) since 2 yrs
• Dizziness Off and on
• No orthopnea or PND
Past History
• ICU adm. 5 mnths back (4 days) due to increased dyspnea severity
• Discharged onT. Spironolactone 25 mg ODT. Lasix 40 mg ODT. Ecosprin 75 mg ODT. Losartan 50 mg ODT. Isosorbide Dinitrate 20 mgT. Atorvastatin 10 mg OD’
• Taking Till date
• No h/o any previous surgery or anesthetic exposure
Personal history
• Non-Smoker
• Non-drinker
• Normal bowel/bladder habits
• No known allergies
General examination
• Gen. Condition - fair
• PILCCOD – NIL
Airway
• Normal Dentition/ Patent nares
• Mouth opening – 3 fingers breadth
• TMD – >6 cm
• TMJ – free/mobile
• Neck mobility – free
• MP – grade I
Systemic examination
• CVS Examination :
– Pulse: 80,regular
– BP: 100/70 mm Hg (left sitting)
– S1 + S2 + M0
• Respiratory Examination:
– RR: 16/min
– Air entry B/L on bases, otherwise NVB
• Abdomensoft, non-distendedno organomegaly,
Investigations
• Hb:13.2 gm%
• TC: 10,300/mm3
• P72, L22, E06• PT: 15 secs
• INR: 1.1
• Platelets: 2,25,000/mm3
• Blood group: 0 +ve
• SpO2 @ room air- 94%
• Na: 146 meq/l• K: 4.7 meq/l• Urea: 26 mg/dl• Creatinine: 0.9
mg/dl• RBS: 134 mg/dl• ABG: N/A• Trop I – Neg• CK MB- 17 U/L
Echo report
• Dilated LV (6.18cm)
• Global hypokinesia of LV
• LVEF 27%
• LV diastolic dysfunction (E<A)
• DCM
Anesthetic plan
Regional
• USG + PNS guided supraclavicular block
• 20 ml 0.25 % plain Bupivacaine + 5 ml plain Lidocaine 2%
• Supine, Nasal prongs (3l/min)>> SpO2 98%
• Inj fentanyl 25 mcg to facilitate block
• Minimal IV fluid- 400 ml R/L in total
• BP ˷ 90/60 (mean 65-70 mm Hg)
• DOS – 45 mins
• Uneventful
DISCUSSION
DCM
• Most common cardiomyopathy
• Progressive disease with ventricular enlargement & contractile dysfunction but NORMAL LV thickness
• Rt ventricle can be involved
• Amongst common causes of heart failure
• Cause unknown
• May be genetic or a/w Coxsackie B infection
• Secondary cardiomyopathies might have features of DCMAlcohol/Cocaine abusePeripartum CMHIVPheochromocytomaHyperthyroidismCAD,IHD
SYMPTOMS
• Fatigue
• Dyspnea on exertion, SOB
• Orthopnea, PND
• Peripheral edema
SIGNS
• Tachypnea
• Tachycardia
• Hypertension/hypotension
• Signs of pulmonary and systemic vascular congestion
• Valvular regurgitation (due to AV ring dilation)
Diagnostic Studies
CXR -enlarged cardiac silhouette,
vascular redistribution interstitial edema,
pleural effusions
ECG –normal
tachycardia, atrial and ventricular
enlargement, LBBB, RBBB, Q-waves
Echocardiography
LV size, wall thickness
valve function, pressures
Cardiac catheterization
PCWP, CO
Endomyocardial Biopsy
Anesthetic concerns
• Decompensationcardiodepressioninc afterload
• Arrhythmias
• Electrolyte anomalies (diuretics)
• Thromboembolism (cardiac thrombus)
Preparation/Optimization
• Determining optimal time for elective surgery
• Grading the severity
• Heart failure control at least >1 week
• Treatment of arrhythmias if any
• Correction of electrolyte anomalies
Overall aim
• avoid tachycardia;
• avoid/minimize the effects of negative inotropic agents, in particular anesthetic drugs;
• prevent increases in afterload;
• maintain adequate preload in the presence of elevated LVEDP.
• Treatment be considered if a >10% decrease in systolic pressures occurs.
Poor Prognosis
• EF < 25 %
• PCWP > 20 mm Hg
• Systemic hypotension
• Pulm. HTN
• Inc. CVP
• Cardiac index < 2.5 L/min/M2
Brachial plexus block
Brachial Plexus Sheath
• A sheath surrounds the brachial plexus, from the transverse processes all the way down into the axilla.
Relations
• Brachial plexus is contained within a fascial sheath.
• Subclavian artery lies medial to plexus as they cross the 1st rib together.
Supraclavicular Imaging:• Start parallel and adjacent to clavicle.
• May have to rotate probe slightly to get a good cross section.
MedialLateral
Here is a nice example of the brachial plexus to the left of the subclavian artery.
Look for subclavian artery, with plexus sheath on lateral aspect.
MedialLateral
MedialLateral
Supraclavicular Approach:
Use in-plane approach only – so position of
needle relative to lung is always known.
• http://www.omjournal.org/casereports/pdf/201001/perioperative.pdf
• www.medscape.com
• http://ceaccp.oxfordjournals.org/content/9/6/189.full