Chapter 17

TURP in a Post Cardiac Transplant Patient

Dr. Vasanthi Vidyasagaran*

Department of Anaesthesiology, Kauvery Hospital, Chennai, Tamilnadu, India

*Correspondence: Vasanthi.vidyasagaran@gmail.com

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Anaemia-or-Hydrocele

A 65-year-old man was admitted for TURP. He had symptoms from chronic benign prostate hypertrophy. He reported to have undergone cardiac transplant 3 years ago for end stage ischemic heart disease and dilated cardiomyopathy. He was a known diabetic. He had been functioning well post- surgery on Diltiazem, Insulin and immunosuppressant drugs.

On examination, he was afebrile, pulse rate of 100/min, BP = 130/80, and chest was clear. Mild pedal oedema was present. No pacemaker fitted. A complete haemogram, coagulation profile and all biochemical parameters (including hepatic and renal functions, lipid profile, and electrolytes) were checked and found to be within normal limits. Echocardiogram showed left ventricular ejection fraction of 45% with mild diastolic dysfunction and mild tricuspid regurgitation. He was being regularly monitored and followed up by the cardiac team. He had been doing well with no signs of rejection.

It was decided to perform the procedure under general anaesthesia, due to concerns of denervated heart. On day of surgery, following premedication with Midazolam 1 mg IV, and antibiotic prophylaxis with Cefaperoxone-Sulbactam, patient was induced with Etomidate 100 mg, Atracurium 30 mg, and Fentanyl 100 mcg. Anaesthesia was maintained on Isoflurane/Oxygen/Air. Analgesia provided with IV Paracetamol and further 50 mcg Fentanyl.

Along with routine monitoring, Central venous line was placed, in case there was need for inotropic support. Adequate care was taken during patient positioning, haemodynamics was maintained, and pressure points were protected. Intra-arterial line was placed to measure continuous arterial blood pressure. TEE was used to closely monitor the cardiac function. Surgical team was ready with equipment to optimize surgical time. The height of the irrigation stand was kept at less than 60 cm. Patient’s temperature was checked and maintained with warming blanket. Close monitoring of blood loss was done. He received one litre of RL.

Surgery was uneventful, completed in 40 min, patient’s legs repositioned, and haemodynamics maintained. Mild drop in BP to 90/60 was observed, which picked up to 110/70, without any vasoactive drugs. Extubation was performed smoothly with patient awake and responsive and making good respiratory efforts. Prophylactic Frusemide 20 mg IV was given. Postoperatively the patient was sent to HDU for close monitoring of cardiac, respiratory and renal function, to watch for bleed and ensure complete asepsis.

Discussion

The anaesthetic implications in this group of patients include:

  1. Denervated heart is dependent on preload to function effectively.
  2. Adequate preoperative hydration is important, caution not to overload.
  3. Avoiding acute vasodilatation, hypotension and hypovolemia. Sole central neuraxial blockade preferably avoided, general anaesthesia may be method of choice.
  4. Respiratory and hemodynamic changes during and after lithotomy positioning are exacerbated in patient with denervated heart which can be irreversible. Hence GA preferred, where control of blood pressure can be better.
  5. Prevent hemodynamic response to direct laryngoscopy, and intubation.
  6. Post-transplant cardiac vasculopathy carries high risk of mortality.
  7. Atropine and Glycopyrrolate have no effect. Drugs with chronotropic effects (Isoprenaline, Ephedrine) and direct vasoactive effects (Adrenaline and Noradrenaline) should be made available.
  8. Caution should be exercised when reversing neuromuscular block with the anticholinesterase even when a muscarinic antagonist is co-administered. Reduction in heart rate should be anticipated. Wherever possible, neuromuscular block must be avoided. If anticholinesterase drugs are used, a muscarinic antagonist should always also be administered and potent β adrenergic agonists such as Isoproterenol or epinephrine should be readily available.
  9. The side-effects of immunosuppressant drugs that have a direct impact on anaesthetic and perioperative management are anaemia, leucopoenia, thrombocytopenia, hyperkalaemia, hypomagnesemia, hypertension, diabetes, neurotoxicity, renal insufficiency. Anaphylaxis and fever may also get precipitated.
  10. Appropriate perioperative antibiotic prophylaxis and sepsis prevention is essential.

TURP surgery has its own risk: It is particularly challenging and the procedure for benign prostatic hypertrophy cannot be deferred either. Intra-operative considerations are TURP syndrome, haemorrhage, bladder perforation, hypothermia and septicaemia. Tachycardia and hypertension may be only early signs of TURP syndrome in ventilated patient.

An understanding, efficient surgeon, and cooperation from the whole team is mandatory. It is essential to keep surgical time and quantity of irrigation fluid to a minimum., and it must be closely monitored.

Prophylactic frusemide in addition to transfusion of packed red cells as alternatives to loading with crystalloids may be considered in the event of significant blood loss. Intra operative cardiac output monitoring and trans-oesophageal echocardiogram may be advisable.

Newer surgical techniques like use of bipolar resectoscope, coagulating, intermittent cutting device, or robotic surgery which have minimal impact on the haemodynamics of the patient must be preferred.

References

  1. Blasco LM, Parameshwar J, Vuylsteke A. Anaesthesia for noncardiac surgery in the heart transplant recipient. Curr Opin Anaesthesiol. 2009;22:9-13.
  2. Backman SB, Fox GS, Stein RD, et al. Neostigmine decreases heart rate in heart transplant patients. Can J Anaesth. 1996;43:373-8.
  3. Sawasdiwipachai P, Laussen PC, McGowan FX, et al. Cardiac arrest after neuromuscular blockade reversal in a heart transplant infant. Anesthesiology 2007;107:663-5.
  4. Swami AC, Kumar A, Rupal S, et al. Anaesthesia for non-cardiac surgery in a cardiac transplant recipient. Indian J Anaesth. 2011;55:405-7.
  5. Blasco LM, Parameshwar J, Vuylsteke A. Anaesthesia for noncardiac surgery in the heart transplant recipient. Curr Opin Anaesthesiol. 2009,22:109-113.
  6. Hughes M, Hood. Anaesthesia for a patient with acardiac transplant. Brit J Anaesth. 2002;2(3).

 

Remember – team work – team work always works.

Chapter 18

Unplanned-Tonsillectomy

Unplanned Tonsillectomy in a Patient posted for Macroglossia

A 13-year-old boy weighing 70 kg, with ectodermal dysplasia, was posted for a partial glossectomy. He was a preterm infant on ventilatory support for a month after birth. His airway could not be assessed due to his low IQ. The Macroglossia was such that he was unable to close his mouth entirely. He was also edentulous. He had an underdeveloped nose with a left sided deviated nasal septum. The clinical presentation was clearly a case of anticipated difficult mask ventilation and difficult intubation.

His investigations were all within normal limits. X-ray neck was asked for to check the position of the trachea and larynx and it was normal.

As the boy was constantly drooling, adequate premedication with Glycopyrrolate 0.2 mg, Pentazocine 30 mg, Promethazine 25 mg, and aspiration prophylaxis (ranitidine and metoclopramide) were given 45 min before the procedure. An awake trial laryngoscopy could not be performed as he was anxious and un-cooperative.

Ensuring preoxygenation, Anaesthesia was induced with inj. Propofol 120 mg and a trial direct laryngoscopy was performed. Grade 3 view was seen. Succinylcholine 75 mg was used for intubation, as difficult mask ventilation was anticipated. An emergency airway tray including fibre optic intubating bronchoscope and tracheostomy were ready.

At this juncture, an unexpected difficulty was faced by the anaesthetist. The boy had an undiagnosed enlarged ‘kissing’ tonsils, and the tube had to be carefully manipulated using Magill’s forceps, making sure the tonsils were not traumatised. Trachea was intubated with a size 6 nasal RAE tube through the right nostril. A throat pack was also placed with moderate difficulty. General anaesthesia was maintained with Oxygen and Nitrous Oxide, 1 % isoflurane. His vitals were stable with pulse rate of 70-80 beats/min, and BP was around 120/70 mm Hg. IV Paracetamol 1g and Injection Fentanyl 50 µg were given for analgesia.

Surgical reduction of the tongue was done uneventfully, procedure lasting for about 2 h. The surgeons also noticed a mass on the mucosal aspect of his right cheek which was removed for biopsy.

After glossectomy, his upper airway looked completely obstructed as the enlarged tonsils seemed to have moved towards the midline, and it was suspected that it could cause post-operative respiratory distress in this child, who also had a low IQ. Hence, an unplanned tonsillectomy had to be done to ensure patent airway. The consent for this unplanned tonsillectomy was obtained from the parents.

Discussion

Anticipation of difficulty and precise execution of the right technique is the key to success. This was a child with hypo hidrotic ectodermal dysplasia, with a triad of hypohidrosis (reduced ability to sweat), hypotrichosis (reduced scalp and body hair), and hypodontia (absent and malformed teeth).

The particular anaesthetic concerns were overweight patient, edentulous, macroglossia, and reduced levels of mental capacity. Hence cooperation was an issue and a complete preoperative evaluation of the airway could not be performed.

Extubation in any airway procedure should be done only after the patient is completely awake and ensuring that the reflexes have returned. Extubation under deep plane of anaesthesia involves risk of upper airway obstruction in immediate recovery period, particularly in a case like this, and oxygenation in the immediate post-operative period will be extremely difficult. Tolerance to the presence of a tube will also be an issue in such patients. Hence smooth awake extubation is an art to learn to save lives.

A novel technique of “half extubation” to enable safe extubation in patients with difficult airways undergoing complex maxillo-facial surgery is being described here.

Over years of providing anaesthesia for such patient groups, this technique has been developed.

At the end of the procedure, throat pack is removed and airway is cleared using suction under vision. Anaesthesia is then switched off; reversal is given and the patient is allowed to wake up slowly. Once the patient is awake, and starts breathing and resisting the endotracheal tube, the cuff is deflated and the tube is slowly withdrawn. At one point, usually after 2-3 cm of tube withdrawal, patient stops bucking. The deflated endotracheal tube is now inside the trachea, just below the vocal cords, tolerated well by the patient.

This step allows the patient to tolerate the tube and breathe smoothly without reflex coughing on the tube. Usually about 5-10 min later, patient may be extubated safely. This ensures safe airway and good oxygenation at all times without having to hold a mask. This is particularly valuable in patients with difficult bag mask ventilation, where holding face mask and maintaining CPAP in immediate post extubation period would be difficult, such as morbidly obese patients, and those undergoing maxillo-facial surgery, rhinoplasty.

Extubation may be performed gently with an awake, comfortable patient. This does not cause any undue post-operative throat pain. (I have observed this in over 300 patients, out if which only about ten patients would not have tolerated the tube, and had to be extubated immediately.) It is worthwhile studying this on more number of patients.

During initial days of using this technique, the position of the tube was confirmed using a fibre optic scope. This procedure can be safely performed with oral or nasal endotracheal tubes. If a situation arises requiring re-intubation, due to surgical or anaesthetic reasons, this provides a great advantage to secure the airway without any lapse in time.

References

  1. Pinheiro MF-MN. Ectodermal dysplasias: a clinical classification and a causal review. Am J Med Genet. 1994;53:153-62.
  2. Irvine AD. Towards a unified classification of the ectodermal dysplasia: opportunities outweigh challenges. Am J Med Genet. 2009;149A:1970-2.

 

When there is a difficult intubation there might be a difficult extubation.

Never be in a hurry to extubate.

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