Oman Medical Journal 2010, Volume 25, Issue 1, January 2010
Perioperative Anesthetic Management of a Case with Severe
Mohamed A. Daabiss, Adel Hasanin
Dilated cardiomyopathy (DCM) is characterized by dilatation
and impaired systolic function of one or both ventricles. Five to
eight people per 100,000 develop this disorder each year. It is more
common in men. Malignant arrhythmias are the most common
cause of death in DCM1. Around 50% of cases of nonischaemic
dilated cardiomyopathy are idiopathic. Other causes are familial,
infectious, infiltrative and connective tissue diseases. This is a
report of successful anesthetic management of a patient with
severe DCM undergoing a surgical procedure using combined
thoracic epidural analgesia (TEA) and general anesthesia (GA).
From the Department of Anesthesia, Riyadh Military Hospital, Saudi Arabia
Received: 03 Oct 2009
Accepted: 05 Dec 2009
Address correspondence and reprint request to: Dr. Mohamed Daabiss, Department of
Anesthesia, Riyadh Military Hospital, P.O.Box 7897- D186, Riyadh 11159, Kingdom
of Saudi Arabia
Dilated cardiomyopathy (DCM) is characterized by
dilatation and impaired systolic function of one or both ventricles.
Each year, this disorder affects approximately five to eight people
per 100,000.1 It most commonly affects males than females.
Malignant arrhythmias are the most common cause of death
in DCM.1 Approximately 50% of cases of nonischaemic dilated
cardiomyopathy are idiopathic. This is a report of successful
anesthetic management of a patient with severe DCM undergoing
a long surgical procedure using combined thoracic epidural
analgesia (TEA) and general anesthesia (GA).
A 68 yr old male patient of 161 cm height and weighing 60 kg,
who was a known case of idiopathic DCM (American Society of
Anesthesia (ASA) class IV), having malignant tumor in the left
kidney was scheduled for nephroureterctomy. Two weeks prior
to surgery, the patient had an attack of palpitation followed by
loss of consciousness which was diagnosed as congestive heart
failure. 12 lead ECG and 24 hours Holters’ monitoring showed
significant ventricular ectopic activities. Chest radiography
showed cardiomegaly and pulmonary congestion, (Fig. 1).
Echocardiography showed a severely dilated left ventricle with
global hypokinesia and severe reduction of left ventricular systolic
function, Ejection Fraction (EF) 20% with mitral and tricuspid
regurgitation. The cardiologist treated him with carvedilol,
amiodarone, captopril and spironolactone. Anticoagulant
medications were not administered preoperatively.
Preoperatively, the patient was reviewed again by a cardiologist
and echocardiography was repeated. The patient’s cardiac
Figure 1: Chest radiography showed cardiomegaly and pulmonary
condition was optimized, and the patient was not in distress or
afebrile. Captopril and spirinolactone were omitted on the day
of surgery. All laboratory results were within normal values. The
surgical plan was to proceed into two stages at the same sitting,
endoscopic laser ureteric orifice avulsion followed by laparoscopic
nephrectomy. The expected operative time for both procedures
was 8-9 hours. Based on the patient’s critical cardiac condition,
open rather than laparoscopic nephrectomy was preferred. The
patient was premedicated with lorazepam 1 mg orally 2 hours
preoperative. Upon arrival into the operating theatre, the patient’s
blood pressure was 120/70 mmHg, heart rate (HR) was 66/min
and oxygen saturation (SaO2) was 99% on oxygen face mask 5L/
min. A 14G intravenous (IV) cannula, a 20G radial artery cannula
and a triple lumen catheter in the right internal jugular vein were
established under local anesthetic infiltration. After positioning
the patient on his right lateral side, a thoracic epidural catheter was
Daabiss MA, et al. OMJ. 25 (2010); doi:10.5001/omj.2010.20
Oman Medical Journal 2010, Volume 25, Issue 1, January 2010
inserted at D10-11. Bupivacaine 0.25% 10 ml with 50 μg fentanyl
were titrated over 2-3 minutes through the epidural catheter. The
patient was kept supine, head and shoulder up 30° with O2 face
mask 5L/min. Sensory loss was at T10 dermatome. Dopamine
infusion was started of 3-5μ/kg/min through the central venous
line. Intraoperatively, the mean arterial blood pressure (MAP) was
85-105mmHg, HR was 57-66 beats/min, central venous pressure
(CVP) was 10-17 cmH2O and SaO2 was 99-100%. Sedation was
achieved with IV midazolam 1mg. An epidural top up of 5 ml
bupivacaine 0.25% with 25μg fentanyl was titrated to maintain the
level of sensory loss. Several arterial blood samples were analyzed
for blood gases (ABG) and electrolytes, which were within normal
values. Total fluids received were 1200 ml of crystalloids in addition
to about 500 ml of absorbed irrigation crystalloid fluid used in 4
hours endoscopic ureteric procedure. Preparing for the second
stage of surgery, 6 ml bupivacaine 0.5% added to 50 μg of fentanyl
were titrated through the epidural catheter to reach analgesic level
to T8. After that, general anesthesia (GA) was induced using
IV injection of etomidate 10 mg and fentanyl 50 μg. Vecronium
bromide 6 mg was given to facilitate the insertion of a cuffed
endotracheal tube. Anesthesia was maintained with isoflurane (0.5-
1 MAC) O2/Air and intermittent vecuronium bromide. Dopamine
infusion was used to maintain adequate MAP. The patient was
positioned in lateral loin position for nephrectomy. This stage
lasted 3 hours during which MAP was 80-95 mmHg, HR was
60-71 beats/min, SaO2 was 99-100%, CVP was 9-15 cmH2O, end
tidal carbon dioxide was 33-37 mmHg and airway pressure was
15-18 cmH2O. ABG and electrolytes were within normal levels.
ECG tracing was normal sinus rhythm with infrequent PVCs (<6
/min) without any ischemic changes. Total urine output was 500
ml. At the end of the surgery, the residual muscle relaxant effect
was reversed and patient was extubated smoothly. Overall, the
anesthetic management was uneventful. In the PACU, the patient
was fully awake and on epidural infusion of bupivacaine 0.03%
with fentanyl 4 μg/ml, 3-5 ml/hour for postoperative pain control.
After an hour, the patient was transferred to High Dependency
Care Unit with stable vital signs. The following day, the patient
was discharged to the surgical ward with stable hemodynamics.
The present case had two major problems, DCM with severe
cardiac dysfunction (EF 20%) and prolonged surgical procedure
(7 hours) with the associated hemodynamic and intravascular
volume changes. The goals for anesthetic management were
avoidance of drug induced myocardial depression, maintenance
of normovolemia, and prevention of increased ventricular
afterload. GA solely may increase the risk of CHF, myocardial
ischemia or intraoperative arrhythmias.3 El-Dawlatly et al.
reported uneventful anesthetic management of a patient with
DCM who underwent laparoscopic cholecystectomy (LC) under
TEA.3 Aono et al. compared three anesthetic techniques: GA,
epidural analgesia (EA) and GA combined with EA for LC. They
reported that, GA with sevoflurane/N2O could not suppress
stress response of both hypothalamus-pituitary-adrenocortical
axis and sympathoadrenal system while EA suppressed only the
symathoadrenal responses.4 They concluded that TEA may be of
advantage in patients with limited cardiac function undergoing
abdominal surgery. Gramatica et al. used EA as a sole technique
for LC and recommended it for patients who are not good
candidates for GA due to cardiorespiratory problems.5 The choice
for anesthetic management in this case was fentanyl based EA with
low concentration local anesthetic agent. This technique offers
satisfactory analgesia with a relatively slow sympathetic blockade
as well as decreased peripheral vascular resistance. In addition,
induced reduction in afterload and preload benefits cardiac
function.6 Hashimoto et al. reported that high dose epidural
fentanyl anesthesia is an anesthetic method of choice for patients
with DCM.7 The small dose of dopamine used in this case was
to support the circulation if hypotension occurred in light of the
cardiac compromised status of the patient. Changing the surgical
plan to open laparotomy reduced the risk of pnuemoperitonieum
e.g. hypercarbia and cardio-pulmonary compromise.8 In the second
stage of surgery, the patient was positioned in lateral loin position
with the added risk of pleural injury during dissection due to
tumor infiltration. Therefore, EA would not be satisfactory unless
combined with relatively light GA to offer good analgesia with
hemodynamic stability. Monitoring of CVP with the other vital
signs was used to optimize the preload. CVP was kept between 12-
16 cmH2O and MAP 80-95mmHg. Although cardiac output was
not measured intraoperatively, it was believed that the circulatory
effects of epidural block contributed to a relatively stable operative
and postoperative course. Swan Ganz catheter was not used as the
patient position (lateral loin) might have disrupted the tracing of
pulmonary capillary wedge pressure (PCWP) as well as cardiac
output figures, and therefore eliminates the advantage of its use in
addition to its coexisting complications. This is in agreement with
Amaranath et al. and Kanu.6,9 Although using Transesophageal
Echocardiography (TEE) could be useful, it was not used due to
limited expertise with TEE. To the best of our knowledge, this may
have been one of the longest cases reported on the use of TEA with
GA in patient with severe cardiomyopathy. Such patients could be
well managed with preoperative optimized medical condition and
well-planned anesthetic management.
Perioperative Anesthetic Management... Daabiss et al.
Oman Medical Journal 2010, Volume 25, Issue 1, January 2010 Download full-text
In conclusion, TEA with relatively light GA offers good analgesia
with hemodynamic stability for major abdominal surgery in
patients with critical cardiac condition.
The authors reported no conflict of interest and no funding was
received on this work.
1. Dec GW, Fuster V. Idiopathic Dilated Cardiomyopathy. N Engl J Med,
2. Stoelting RK, Dierdorf SF. Cardiomyopathy, In: Stoelting RK (ed).
Anesthesia and Coexisting Disease (3rd ed). New York: Churchill Livingstone
3. El-Dawlatly A, Al-Dohayan A, Fadin A. Epidural Anesthesia For
Laparoscopic Cholecystectomy In A Patient With Dilated Cardiomyopathy:
Case Report And Review Of Literature. Internet J Anesthesiol. 2007; 13(1).
4. Aono H, Takeda A, Tarver SD, Goto H. Stress responses in three different
anesthetic techniques for carbon dioxide laparoscopic cholecystectomy. J Clin
Anesth 1998; 10:546-550.
5. Gramatica L, Brasesco OE, Mercado LA, Martinessi V, Panebianco G,
Labaque F, et al. Laparoscopic cholecystectomy performed under regional
anesthesia in patients with chronic obstructive pulmonary disease. Surg
Endosc 2002; 16:472-475.
6. Amaranath L, Shahpour E, Lockrem J, Rollins M. Epidural analgesia for
total hip replacement in a patient with dilated cardiomyopathy. Can Anaesth
Soc J 1986; 33(1):84-88.
7. Hashimoto K, Ooka T, Kosaka Y. Epidural anesthesia with high dose fentanyl
for a patient with dilated cardiomyopathy. Masui. 1994 ; 43(12):1881-1884.
8. Jansen F W, Kapiteyn K, Trimbos-Kemper T, Hermans, J Trimbos, JB.
Complications of laparoscopy: a prospective multicentre observational study.
Br J Obstet Gynecol,1997; 104:595-600.
9. Kanu C. The Swan-Ganz Catheters: Past, Present, and Future, A Viewpoint.
Circulation, 2009; 119:147-152.
Perioperative Anesthetic Management... Daabiss et al.