Hypotension need not necessarily be due to Spinal Anaesthesia

Dr. Vasanthi Vidyasagaran*

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

 

*Correspondence: [email protected]

Dr. Vasanthy Vidyasagaran Muralidharan

POST-OPERATIVE  – Chapter 13

Post inguinal-hernia repair

A 30-year-old male patient with ASA1 physical status was taken up for inguinal hernia repair under spinal anaesthesia. 2.5 ml 0.5% heavy Bupivacaine with 25 mcg Fentanyl was administered in the intrathecal space at L3-L4 level. Surgery lasted one hour. The patient remained hemodynamically stable throughout. There were no undue fluctuations in blood pressure. Patient was comfortable. He was shifted to recovery, with a blood pressure of 120/70.

In the recovery room, after about ten minutes, blood pressure recorded was 90/60 and heart rate 110/min. Patient had no complaints. Intravenous fluid bolus of 500 ml Normal Saline was administered. Ephedrine 3mg bolus was given as BP began to drop with systolic <85 mm Hg. Transient response to vasopressor drugs and fluids was observed, however the patient remained hypotensive. The senior anaesthesiologist was involved at this stage who examined the surgical site, only to find that there was a huge hematoma. Pressure was applied at the site and patient was wheeled into operating theatre immediately.

As the spinal anaesthesia was still working, exploration of the haematoma could be done immediately, drugs for general anaesthesia were ready, if required. Colloids were administered cautiously as at this point, it was apparent that this was a case of femoral artery injury and increases in blood pressure had to be avoided. Femoral artery was repaired and patient made an uneventful recovery. Once the bleeding was arrested two units of packed red blood cells were administered.

Discussion:

When there is an untoward event such as unexpected hypotension, tachycardia, sudden desaturation, or change in vital signs, all causative factors must be ruled out. Single track thought process may be detrimental. In this scenario, initially the anaesthetist dealing with a hypotensive patient assumed it to be spinal hypotension. Examination of the whole patient including the surgical site and drains if any, is essential to understand what’s happening to the patient.

Large vessel injuries must be attended to immediately.

Small injuries to vessels may heal by themselves, but precipitate local hematoma and fibrotic reaction with ischemic problems later on.

References:

[1].  JR DeBord Vascular Injuries from Hernia Surgery- Abdominal Wall Hernias, 2001 – Springer

[2].  Agarwal BB, Gupta MK, Agarwal S, and Mahajan KC: Spontaneous rupture of iatrogenic (post inguinal herniorrhaphy) venovenous malformation managed endoscopically. J Laparoendosc Adv Surg Tech A. 2008, 18: 80-83.

[3].  Teodorescu VJ, Reiter BP: Common iliac artery pseudo aneurysm following inguinal hernia repair–a case report and literature review. Vasc Surg. 2001, 35: 239-244.

 

POST-OPERATIVE – Chapter 14

Myocardial Infarction following Lap Cholecystectomy

A 45-year-old man with acute cholecystitis was posted for an emergency laparoscopic cholecystectomy. He was obese weighing 95 kg. Airway examination was normal, lungs were clear, and all investigations including chest x-ray, ECG, and echo were within normal limits. His triglycerides were increased to 500mg/dl.

Patient was induced with Propofol 180 mg and intubated with Succinylcholine 100 mg. 35–65 Oxygen: Nitrous Oxide mixture along with Isoflurane 1% was used for maintenance. Vecuronium was used for muscle relaxation. Intraoperatively after CO2 insufflation, a significant ST elevation was noticed. This persisted for about half an hour. The patient was hemodynamically stable with BP 130/90, heart rate around 85-90/min, and saturation 98%.

An NTG 10 mg patch was placed. The procedure was over in 60 minutes. Surgery and anaesthesia were uneventful; patient recovered smoothly and was extubated. The immediate postoperative ECG was normal. The cardiologist was involved due to the intraoperative ECG changes, but since the patient was very comfortable, he did not recommend any active management or any other tests. He was observed in the ICU for a day, and monitoring did not reveal any untoward event.

He was shifted to the ward on POD 2. On the eve of discharge, he complained of difficulty in breathing, had a bout of cough and developed frank pulmonary oedema. He was immediately shifted to the ICU and the ECG showed extensive anterior wall MI. He was taken up for an emergency angioplasty. He was discharged after 3 days.

Discussion

The cardiovascular system is subjected to stress during any surgical procedure, the magnitude of which cannot be precisely predicted. A previously healthy individual may develop significant post-operative morbidity and mortality due to a cardiac event. During general anaesthesia, the heart responds in several ways such as a fall in BP, increase in heart rate, decrease in cardiac output, and increase in myocardial irritability. These can lead to post-operative myocardial ischemia. In addition, procedures like laparoscopy can precipitate an impending infarction.

Diagnosis of an acute infarction in the immediate postoperative period poses some special problems specially if it is an upper abdominal surgery. The pain is not typical and can be misleading.

There have been several case reports of thrombolysis in the immediate post-operative period. It has been suggested that it can be used in procedures where no massive bleeding is expected, not in major procedures like craniotomy. Use of a NTG patch for prevention of myocardial ischemia is questionable. Enzyme studies were not done because his stable clinical status misled the whole team.

Cardiac complications occur in up to 5 per cent of patients at 45 years or older undergoing non-cardiac surgery, of these perioperative M I is the most common. Troponin levels are useful provided we have a preoperative value to compare. Just an elevated level done in the postoperative period is not a confirmatory test for diagnosis of M I. Twelve lead ECG must be done and they should be started on aspirin and statin.

References

  • Landesberg G, Beattie WS, Mosseri M, et al. Perioperative myocardial infarction. Circulation 2009; 119:2936.
  • Mahmoud KD, Sanon S, Habermann EB, et al. Perioperative Cardiovascular Risk of Prior Coronary Stent Implantation Among Patients Undergoing Noncardiac Surgery. J Am Coll Cardiol 2016; 67:1038.
  • Kavsak PA, Walsh M, Srinathan S, et al. High sensitivity troponin T concentrations in patients undergoing noncardiac surgery: a prospective cohort study. Clin Biochem 2011; 44:1021.

Everything is easy when you are busy, but nothing is easy when you are lazy.

                                                                                                – Swamy Vivekananda

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