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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 14  |  Issue : 4  |  Page : 199-201

Thoracic paravertebral block as an alternative to general anaesthesia in patients with hypertrophic cardiomyopathy for elective breast surgeries: A case series study


1 Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Ophthalmology, Command Hospital, Pune, Maharashtra, India

Date of Submission17-Jul-2021
Date of Decision24-Aug-2021
Date of Acceptance07-Sep-2021
Date of Web Publication11-Jan-2022

Correspondence Address:
Shalendra Singh
Department of Anaestheiology and Critical Care, Armed Forces Medical College, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hmj.hmj_47_21

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  Abstract 


Introduction: Sympathetic stimulation during general anaesthesia (GA) in hypertrophic cardiomyopathy (HOCM) patients poses the risk of sudden intraoperative death. Regional anaesthesia using paravertebral block (PVB) provides an excellent alternative to GA in HOCM patients undergoing carcinoma breast surgery. Case Report: We hereby describe the perioperative management of three patients of HOCM, with PVB as the preferred anaesthetic modality. Conclusion: Thoracic PVB is a safe and efficacious technique which provides good intra-operative haemodynamic stability and a superior postoperative analgesia for breast surgery in HOCM patients.

Keywords: Breast surgeries, hypertrophic cardiomyopathy, paravertebral block


How to cite this article:
Singh S, Sharma R, Taank P, Ambooken GC. Thoracic paravertebral block as an alternative to general anaesthesia in patients with hypertrophic cardiomyopathy for elective breast surgeries: A case series study. Hamdan Med J 2021;14:199-201

How to cite this URL:
Singh S, Sharma R, Taank P, Ambooken GC. Thoracic paravertebral block as an alternative to general anaesthesia in patients with hypertrophic cardiomyopathy for elective breast surgeries: A case series study. Hamdan Med J [serial online] 2021 [cited 2022 Jan 20];14:199-201. Available from: http://www.hamdanjournal.org/text.asp?2021/14/4/199/335382




  Introduction Top


Hypertrophic cardiomyopathy (HOCM) is characterised by asymmetric hypertrophy of the intraventricular septum, which results in an intermittent obstruction to the outflow tract of the left ventricle. Sympathetic stimulation during general anaesthesia (GA) in HOCM patients may lead to a decrease in preload and afterload to the left ventricle, leading to angina pectoris, syncope, tachydysrhythmias, congestive heart failure and, at times, sudden death. Conventionally, breast surgeries are performed under GA and require endotracheal intubation or supraglottic airway. Regional anaesthesia using paravertebral block (PVB) is a substitute to GA for such surgery to avoid sympathetic stimulation.[1] Additional benefits of PVB comprise lessened post-operative nausea/vomiting, extended post-operative pain and elevated potential for early ambulatory performance.[2],[3] We hereby describe the perioperative management of three known patients of HOCM who underwent breast surgery under PVB which resulted in a better intraoperative condition with requisite post-operative analgesia and lesser haemodynamic alterations.


  Case Reports Top


Case 1

A 60-year-old hypertensive female suffering from invasive ductal carcinoma of the right breast was posted for breast conservation surgery. Her co-morbidities compromised of HOCM with severe left ventricular outflow tract (LVOT) with dyspnoea Grade II New York Heart Association Functional Classification associated with inferolateral wall ischaemia on electrocardiogram (ECG). Her two-dimensional (2D) echo disclosed left ventricular ejection fraction (LVEF) of 81% and LVOT gradient of 58 mmHg. The patient was on beta-blocker. She was accepted under the American Society of Anesthesiologists (ASA) III.

Case 2

An 81-year-old female, weight 45 kg, diagnosed as a case of carcinoma of left breast, was scheduled for modified radical mastectomy. During the pre-anaesthetic evaluation, pan systolic murmur at mitral, tricuspid and the aortic area was heard on auscultation. The ECG revealed atrial fibrillation with controlled ventricular rate, left ventricular hypertrophy (LVH) on voltage criteria and left bundle branch block. Bedside 2D echo by fast assessment diagnostic echocardiography protocol revealed concentric LVH with asymmetric septal hypertrophy, with LVEF of 70%, and turbulent flow across the atrioventricular valve. The case was evaluated by a cardiologist prior to surgery, diagnosed as HOCM and started on a beta-blocker. The patient was accepted in ASA III and was taken up for surgery.

Case 3

A 68-year-old female, weight 50 kg, diagnosed as carcinoma breast left was posted for lumpectomy with axillary dissection. She was a known case of chronic kidney disease and HOCM with mild mitral regurgitation. Her 2D echo revealed severe concentric LVH, presence of systolic anterior motion of anterior mitral leaflet, LVEF of 75%, interventricular septal/posterior wall thickness ratio of 1.2 and LVOT gradient of 80 mmHg. Owing to her high potassium level (6.6 mmol/L), the patient underwent urgent haemodialysis prior to surgery. The patient was accepted in ASA III with high risk.

Monitoring

Standard monitoring comprising ECG, pulse oximetry, non-invasive blood pressure (BP), end-tidal carbon dioxide, urine output and the temperature was ensued after confirming the patency of peripheral intravenous line and nil per oral status in all three patients. Invasive BP monitoring was also secured to ensure continuous, real-time cardiovascular monitoring.

Anaesthetic management

In view of cardiac status, the thoracic PVB block was planned for all three surgeries. IV access was established using 1 ml of local anaesthesia (LA), with 18G cannula, and all patients were attended in sitting position. With the patient in the sitting position, ultrasound-guided thoracic PVB was performed on the operative side at thoracic (T) levels T3 and T4 [Figure 1]. A 7.5–12-MHz transducer was used for all blocks. The PVB was administered with an 18G Tuohy needle, utilising an out-of-plane approach with the probe oriented longitudinally, parallel to the spinal cord at the level of the transverse process [Figure 2]. Once the transverse processes were identified, the needle was jabbed out-of-plane to touch the transverse process and was then walked off the transverse process in a caudocranial direction penetrating towards the parietal pleura. At each level, 15 ml of 0.25% bupivacaine was administered [Figure 3]. PVB catheter was also inserted to supplement the block intraoperatively and to ensure post-operative analgesia by bolus top-ups with 5 ml 0.125% bupivacaine with 2 mic/ml fentanyl 6 hourly. The efficacy of the block was examined by sensory loss in the surgical site to pinprick method and cold touch technique before the incision. The surgical incision was given after 20 min of completion of the block. Intraoperative sedation was provided with dexmedetomidine[4] 5 mcg/kg and fentanyl 1 mcg/kg. Patients were verbally responsive throughout the surgery. Oxygen was given by a face mask during the procedure.
Figure 1: Ultrasound scanning of the paravertebral space with a patient in sitting position, prior to giving the block

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Figure 2: Ultrasound scan of the thoracic paravertebral space at T4 level using parasagittal in-plane approach. The needle can be visualised proceeding towards the paravertebral space. (CTL: costotransverse ligament, TP: transverse process)

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Figure 3: Ultrasound scan of the thoracic paravertebral space at T4 level using parasagittal in-plane approach in which downward displacement of the pleura (depicted by arrows) can be seen after injecting local anaesthetic in paravertebral space. (CTL: costotransverse ligament, TP: transverse process, LA: local anaesthetic)

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All three surgeries lasted for 2–3 h and Visual Analogue Scale (VAS) scores were 0 and 2 at the end of surgery and after 3–4 h post-surgery, respectively. Haemodynamic parameters were maintained within 20% of the baseline throughout the surgery. Injection paracetamol infusion and PVB top-up were continued for post-operative analgesia.


  Discussion Top


Our patient being a case of HOCM with severe LVOT required a technique with the least haemodynamic perturbation and least use of polypharmacy. In light of the specific requirements of the case, thoracic PVB was preferred over GA because of its superior safety output and stable haemodynamics. Thoracic PVB is also favoured over epidural anaesthesia for patients with associated disease as it presents more effective anaesthesia and stable haemodynamic response, and comes up with quick recovery without nausea and vomiting, with preserved respiratory functions.[2],[3] PVB has been found to have a lower rate of side effects and complications, apart from reportedly reducing the time for tumour recurrence.[2] According to the recent meta-analysis, PVB is a safer and more effective technique and yields anaesthesia and post-operative analgesia during breast surgery, and it can be combined with a pectoral nerve block.[5] Thus taking note of the nature of the cardiac co-morbidities of our patients, our preference of thoracic PVB was ideally suited to the case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for 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.
Coveney E, Weltz CR, Greengrass R, Iglehart JD, Leight GS, Steele SM, et al. Use of paravertebral block anesthesia in the surgical management of breast cancer: Experience in 156 cases. Ann Surg 1998;227:496-501.  Back to cited text no. 1
    
2.
Syal K, Chandel A. Comparison of the post-operative analgesic effect of paravertebral block, pectoral nerve block and local infiltration in patients undergoing modified radical mastectomy: A randomised double-blind trial. Indian J Anaesth 2017;61:643-8.  Back to cited text no. 2
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3.
Singh S, Jacob M, Hasnain S, Krishnakumar M. Comparison between continuous thoracic epidural block and continuous thoracic paravertebral block in the management of thoracic trauma. Med J Armed Forces India 2017;73:146-51.  Back to cited text no. 3
    
4.
Singh S, Chouhan RS, Bindra A, Radhakrishna N. Comparison of effect of dexmedetomidine and lidocaine on intracranial and systemic hemodynamic response to chest physiotherapy and tracheal suctioning in patients with severe traumatic brain injury. J Anesth 2018;32:518-23.  Back to cited text no. 4
    
5.
Nikam S, Marghade P, Paliwal N, Lawhale S. Thoracic paravertebral block for breast surgery in a patient with ischemic heart disease. Anaesth Pain Intensive Care 2014;18:280-1.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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