Use of peripheral nerve blocks in perioperative management of cases with hypertrophic cardiomyopathy undergoing lower limb orthopedic surgeries

Abstract

Hypertrophic obstructive cardiomyopathy is a type of hypertrophic cardiomyopathy (HCM) that involves the left ventricular outflow tract obstruction. Most important parameters are preload, afterload, and ventricular contractility that are prone to fluctuations in HOCM patients in the perioperative period due to the surgical procedure, anesthetic agents and changes in intravascular volume. These lead to increased chances of arrhythmias and myocardial ischemia and can pose significant morbidity and mortality in HCM patients perioperatively. Here, we report three challenging cases of HCM with comorbidities who underwent successful operative management of lower limb fractures using regional nerve blocks. Although general anaesthesia is usually preferred in cases of HCM, this was not the preferred choice in these cases due to the asthmatic status, extremes of age, and also associated comorbidities such as chronic kidney disease Stage IV on maintenance hemodialysis. We selected Ultrasonography and peripheral nerve stimulator (PNS) guided regional nerve blocks including lumbar plexus and parasacral approach of sciatic nerve block in the first two patients and fascia iliaca compartment block with parasacral sciatic nerve block in the third case to successfully manage the patients perioperatively. Postoperative pain management was satisfactory. All the patients were discharged in a hemodynamically stable condition with advice for follow-up.

Regional Anesthesia for Arthroscopic Knee Repair in a Patient With Hypertrophic Obstructive Cardiomyopathy (HOCM) Under Monitored Anesthesia Care With Dexmedetomidine Infusion

“…Developing anesthetic plans for patients with HOCM requires attention to the patient's disease state, comorbidities, and the proposed operation [ 4 ]. Hemodynamic goals in HOCM include encouraging preload by increasing intravascular volume, maintaining afterload by increasing systemic vascular resistance to avoid wide LVOT gradients, maintaining a low-normal heart rate, and avoiding increased contractility by blunting the sympathetic response to stimulation and avoiding inotropic pharmacologic medications [ 1 ].…”

“…For patients with HOCM undergoing orthopedic surgery, techniques such as neuraxial anesthesia and peripheral nerve blockade have been demonstrated to be safe and efficacious [ 4 , 14 ]. Neuraxial anesthesia like epidural or spinal anesthesia was avoided in this case to avoid the risk of a sudden decrease in systemic vascular resistance.…”

“…Perioperative goals include maintaining adequate volume status, systemic vascular resistance, avoiding tachycardia, reducing contractility, and selecting agents that have minimal or reduced sympathetic effects. While general anesthesia is common, neuraxial and regional anesthesia can also be used cautiously [ 2 - 4 ].…”

“…Perioperative goals include maintaining adequate volume status, systemic vascular resistance, avoiding tachycardia, reducing contractility, and selecting agents that have minimal or reduced sympathetic effects. While general anesthesia is common, neuraxial and regional anesthesia can also be used cautiously [2][3][4]. Dexmedetomidine (DEX), a highly selective alpha-2 adrenergic agonist, offers unique direct and indirect cardioprotective stabilization, minimal respiratory depression, anxiolysis, sedation, and analgesia [5,6].…”