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CASE REPORT
Year : 2018  |  Volume : 11  |  Issue : 6  |  Page : 559-561  

Child with dilated cardiomyopathy for colostomy closure: Anesthesia considerations


Department of Anaesthesia, BJMC and SGH, Pune, Maharashtra, India

Date of Submission03-Mar-2018
Date of Acceptance04-Jul-2018
Date of Web Publication15-Nov-2018

Correspondence Address:
Sunita M Khedkar
Department of Anaesthesia, BJMC and SGH, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_40_18

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  Abstract 


Perioperative management of a patient with dilated cardiomyopathy (DCM) is challenging for an anesthetist in view of depressed function of myocardium, ventricular enlargement, risk of perioperative arrhythmia, and sudden cardiac death. Preoperative assessment, optimization of medical condition with drug therapy, and appropriate anesthesia management help in better perioperative outcome. Here, we discuss successful perioperative management of DCM in a child scheduled for colostomy closure under general and epidural anesthesia.

Keywords: dilated cardiomyopathy, epidural anesthesia, general anesthesia, pediatric patients


How to cite this article:
Tandale SR, Khedkar SM, Kelkar KV, Kumar R. Child with dilated cardiomyopathy for colostomy closure: Anesthesia considerations. Med J DY Patil Vidyapeeth 2018;11:559-61

How to cite this URL:
Tandale SR, Khedkar SM, Kelkar KV, Kumar R. Child with dilated cardiomyopathy for colostomy closure: Anesthesia considerations. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2018 Dec 19];11:559-61. Available from: http://www.mjdrdypv.org/text.asp?2018/11/6/559/245426




  Introduction Top


Pediatric cardiomyopathy is a rare but carries significant perioperative risk. Incidence is 1.3/100,000 children under 10 years.[1] Of all the types, dilated cardiomyopathy (DCM) is the most common type.[2] Anesthetic management in such patient is challenging in view of poor ventricular performance and perioperative risk of arrhythmia and sudden cardiac death. We report the anesthetic management of a patient with DCM scheduled for colostomy closure under general and epidural analgesia.


  Case Report Top


A 7-year-old male child weighing 16 kg with stoma prolapse was scheduled for colostomy closure on semi-emergency basis. The child underwent colostomy 2 years ago in view of enterocutaneous fistula secondary to trauma at perineal region. He presented at our institute with complaints of stoma prolapse of about 20 cm with the presence of slough on exposed bowel end. The child was also diagnosed to have DCM 1 year ago when he underwent evaluation for difficulty in breathing, decreased effort tolerance, and failure to thrive. The child was managed conservatively with oral furosemide, propranolol, and carnitine with advice to continue the same medication. On preanesthetic examination, the child was afebrile, heart rate was 70 bpm and regular, blood pressure was 96/56 mmHg, and respiratory rate was 16/min. There were no rales or ronchi on auscultation, and heart sounds were normal. Hepatomegaly and pedal edema was not seen. Pallor was present. Preoperative complete blood cell count was normal, except for low hemoglobin (9 g%). Biochemical investigations were within normal limit. Preoperative electrocardiogram revealed right bundle branch block with occasional ventricular premature ectopics. X-ray chest revealed cardiomegaly with clear lung fields. Recent echocardiograph reports revealed global hypokinesia and dilation of left ventricle with ejection fraction of 15%–20%. The patient received packed cell transfusion followed by diuretic on night before surgery. The child was asked to continue propranolol and furosemide till day of surgery. After obtaining high-risk consent, the child was shifted to operation theater without any sedative premedication. He was monitored with electrocardiogram, noninvasive blood pressure monitor, pulse oximetry, temperature, and respiratory agent monitor. The child was preloaded with 75 cc of Ringer lactate followed by intravenous (IV) midazolam 0.5 mg, fentanyl 20 mcg and was anesthetized with gradually increasing concentration of sevoflurane with 100% oxygen. Orotracheal intubation was done with size 5 cuffed tube and was secured. Anesthesia was maintained with oxygen: nitrous oxide (40:60) and sevoflurane via closed circle absorber. Intermittent IV atracurium was given for muscle relaxation. Analgesia was maintained with intermittent bolus of bupivacaine 0.1% via low thoracic epidural and IV paracetamol 220 mg at the end of procedure. Intraoperative hemodynamic remained stable except for occasional ventricular premature complex and transient hypotension which responded to IV mephentermine 3 mg bolus twice. Procedure lasted for 1 h with blood loss of 150 ml. 180 ml of Ringer lactate was used as intraoperative fluid for replacement. Blood loss was replaced with packed cell volume of 100 ml. The patient was extubated on table after achieving adequate neuromuscular recovery and was shifted to critical care unit for monitoring. Analgesia was continued with intermittent boluses of 0.1% bupivacaine 5 cc and tramadol 16 mg through epidural catheter twice a day for 3 days postoperatively. The patient was discharged home on the 12th postoperative day.


  Discussion Top


DCM is a primary myocardial disease of varied etiology. Important causes are idiopathic, familial, genetic, secondary to viral infection, toxic, secondary to endocrine disease, or malnutrition.[3] It is characterized by left ventricular or biventricular dilatation and impaired ventricular contractility.[2] It mainly manifests as a reduced ejection fraction and cardiac output. The decrease in forward blood flow leads to increase in end diastolic left ventricular volume, ventricular filling pressure, and subsequently ventricular enlargement to maintain cardiac output.[4] There are few clinical signs until DCM is severe; patients usually presents with history of cough, easy fatigability, difficulty in breathing, decreased effort tolerance, poor feeding, failure to thrive, and syncopal episode.[2] Children with DCM remains at significant perioperative risk of arrhythmia, cardiac failure, cardiac arrest, embolism, and death.[5] Ejection fraction < 25%, left ventricular dilatation, and hypokinetic left ventricle are the predictors of poor prognosis which were noted in index case.[6] Preoperative echocardiography is essential to determine ventricular function and presence of thrombus. Serum potassium levels should be assessed as these patients may be receiving diuretics and digoxin, and hypokalemia if present should be treated. Injection dobutamine infusion was kept ready to manage persistent intraoperative hypotension.

The goals for anesthetic management consist of avoidance of drug-induced myocardial depression, maintenance of normovolemia, prevention of increased ventricular afterload, and adequate perioperative analgesia. Sevoflurane is useful anesthetic agent as it provides good intubating condition and better hemodynamic stability and hence was preferred in our case for induction as well as maintenance of anesthesia over the conventional anesthetic agent. Adequacy of fluid volume can be assessed by central venous pressure, hemodynamics, and urine output. As the procedure concerned was not associated with greater fluid shifts, we avoided the central venous cannulation and meticulous fluid replacement for evaporative loss and packed cell volume replacement in titration to hemodynamic was done. Epidural analgesia was preferred over subarachnoid block in view of less hypotension, less postdural puncture headache, and ability to extend analgesia in the postoperative period. Epidural analgesia is of particular benefit as it avoids the increase in afterload and helps maintain forward flow from left ventricle.[7] Incremental and titrated bolus of local anesthetic through epidural catheter gives better hemodynamic stability. IV mephentermine was used to treat hypotension as it increases blood pressure by restoring cardiac output and peripheral vascular résistance. Failing ventricle will not maintain cardiac output in the presence of high systemic vascular resistance; hence, if inotropic support is required dilating agent such as milrinone, dobutamine should be used and titrated to clinical effect.[2] The main determinants of oxygen carrying capacity are cardiac output and hemoglobin. Hence, hemoglobin should be maintained at higher level (>12 g%) in the perioperative period.[8] This necessitates the preoperative improvement in hemoglobin and replacement of intraoperative blood loss with blood transfusion for immediate effect.


  Conclusion Top


Preoperative assessment, plan of anesthesia keeping in mind depressed cardiac status, epidural analgesia, and maintenance of normovolemia result in better perioperative outcome.

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.
Nugent AW, Daubeney PE, Chondros P, Carlin JB, Cheung M, Wilkinson LC, et al. The epidemiology of childhood cardiomyopathy in Australia. N Engl J Med 2003;348:1639-46.  Back to cited text no. 1
    
2.
Ing RJ, Ames WA, Chambers NA. Paediatric cardiomyopathy and anaesthesia. Br J Anaesth 2012;108:4-12.  Back to cited text no. 2
    
3.
Kumar N. Sevoflurane in an infant with dilated cardiomyopathy due to myocarditis and hypocalcaemia. Indian J Anaesth 2016;60:73-4.  Back to cited text no. 3
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4.
Chen CQ, Wang X, Zhang J, Zhu SM. Anesthetic management of patients with dilated cardiomyopathy for noncardiac surgery. Eur Rev Med Pharmacol Sci 2017;21:627-34.  Back to cited text no. 4
    
5.
Stoelting RK, Dierdorf SF. Cardiomyopathy. In: Stoelting RK, editor. Anaesthesia and Coexisting Disease. 3rd ed. New York: Churchill Livingstone; 1993. p. 97-102.  Back to cited text no. 5
    
6.
Dec GW, Fuster V. Idiopathic dilated cardiomyopathy. N Engl J Med 1994;331:1564-75.  Back to cited text no. 6
    
7.
Srivastava D, Tiwari T, Sahu S, Chandra A, Dhiraaj S. Anaesthetic management of renal transplant surgery in patients of dilated cardiomyopathy with ejection fraction less than 40%. Anesthesiol Res Pract 2014;2014:525969.  Back to cited text no. 7
    
8.
Kaur H, Khetarpal R, Aggarwal S. Dilated cardiomyopathy: An anaesthetic challenge. J Clin Diagn Res 2013;7:1174-6.  Back to cited text no. 8
    




 

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   Abstract
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  Case Report
  Discussion
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