ANESTHETIC MANAGEMENT OF A CASE

WITH AORTIC REGURGITATION POSTED

FOR LAPROSCOPIC MESH REPAIR OF
UMBILICAL HERNIA.
DR. N.HANNAH MOUNIKA*, DR.GEETHA SOUNDARYA, DR. AROMAL.

ABSTRACT: Peri operative management of a case with congenital heart

disease is a challenging role for anesthesiologist. We present the
effective management f a case scheduled for laparoscopic mesh repair
for umbilical hernia recently diagnosed with aortic regurgitation.

KEYWORDS: aortic regurgitation, anesthesia ,laparoscopy, erector

spinae block, mesh repair.

INTRODUCTION: Valvular heart diseases have significant effect on

outcome of any kind of surgical procedures. Management of such cases
posted for non cardiac surgery involves the effects of drugs on cardiac
contractility, heart rate, preload, afterload , systemic vascular
resistance and pulmonary vasculature. Aortic regurgitation incidence is
in livebirths and accounts for % of patents.

CASE REPORT: a 57 year old, 68kgs scheduled for laproscopic mesh

repair of umbilical hernia. patient had complaints of palpitations
occasionally. He had no complaints of chest pain, syncope, tachycardia
etc. patient came under NYHA class II. He is average built, PR 80bpm,
BP 150/90 mmhg , 145/90mmhg in rt and left upperlimbs respectively
while 160/100mmhg and 150/95mmhg in right and left lower limbs
respectively. On auscultation, ejection systolic murmur heard at left 5 th
intercostal space. Routine blood and biochemical investigations were
done and were within normal limits.ECG shown left ventricular
hypertrophy and ECHO has shown normal left ventricular systolic
function with ejection fraction 50%, severe AR and progressive left
ventricular dilatation. Cardiologist opinion was obtained under high risk
for non cardiac surgery and was advised tab. amlodipine 5mg and
tab.atenolol 50mg BD. Patient was kept fast overnight, pre medicated
night before and morning of surgery. Anti hypertensives were advised
to be continued as per the usual routine. After shifting, non invasive
monitors were connected like capnograph, temperature probe, pulse
oximeter and Inj.midazolam 2mg IV was given. Right radial artery was
cannulated after local anesthetic application. Later under ultrasound
guidance, right internal jugular vein was cannulated.central venous
pressure (CVP) was started. epidural catheter was inserted after giving
local anesthetic and tip is fixed at T8-T9. Under Ultrasound guidance,
erector spinae block with 25ml of 0.25% bupivacaine was given on
bilateral sides in lateral decubitus position. Patient was then
preoxygented and induced with inj.etomidate IV and intubated with 8.0
size ETT and fixed at 20cm after checking bilateral air entry equal. After
5mins, skin incision was given and plane of anesthesia maintained with
oxygen and nitrous oxide 50%: 50% and sevoflurane with MAC 0.8.
after creation of pneumoperitoneum, blood pressure raise upto
180/90mmhg which was managed with inhalational anesthetic.
Pneumoperitoneum was maintained at 6-10mmhg and surgery was
performed in trendelenburg position and went for 100minutes. Patiend
was reversed with inj.glycopyrrolate and neostigmine IV .3mg
inj.morphine with 8ml Normal saline was given epidural route. Patient
was stable after extubation, was shifted to ICU for observation and
then shifted to ward after 2 hours. Intraoperative period was
uneventful.no events like arrhythmias, pulmonary edema were noted.
patient did not complain any pain thereafter, so No further post
operative analgesia was required.

DISCUSSION: anesthetic goals in managing a patient with aortic

regurgitation posted for non cardiac surgery are enlisted as below:
faster heart rate and avoid bradycardia which limits the diastolic time,
maintain sinus rhythm, decresed systemic vascular resistance, maintain
good contractility. Ionodilators like milrinone and dobutamine should
be kept ready along with angiotensin convertase enzyme inhibitors,
digitalis and diuretics which reduces afterload. Fluid management
should be monitored carefully in order to avoid volume
overload.monitors like transesophageal echocardiography can be
employed for the comprehensive evaluation of cardiac structure and
function which is above pulmonary artery catheterization. Capillary
blood glucose should be monitored periodically. Main concerns
regarding laparoscopy are insufflations of carbon dioxide, patient
positioning and increased intra abdominal pressure which should be
kept as low as possible just adequate to perform surgery without much
hemodynamic changes .pressure threshold must be maintained around
12mmhg.both intraoperative and Post operative analgesia can be
provided by epidural and erector spinae block which decreases
cardiovascular stress ,further release of catecholmines. This will avoid
delayed recovery .

SREE BALAJI MEDICAL COLLEGE AND HOSPITAL

CHROMEPET

CHENNAI-600077
CONFLICTS OF INTEREST : Nil

REFERENCES:
https://www.uptodate.com/contents/image/print?imageKey=ANEST%2
F108941&topicKey=CARD%2F8124&source=see_link

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3161478/

https://mail.google.com/mail/u/0?ui=2&ik=16b9d7c3ef&attid=0.1&per
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