Case Report

A 68-year-old man sustained fracture of the neck of femur and was

scheduled for surgery. His previous medical records revealed that he had

dilated cardiomyopathy. He was previously admitted to the Coronary

Care Unit for episodes of congestive cardiac failure. He had no past

history of alcohol abuse or the use of

The heart rate was 74 min and regular. The systolic and diastolic

blood pressures were 96 mmHg and 60 mmHg respectively. The

respiratory rate was 16/min. There were no ronchi or rales on

auscultation. Heart sounds were normal.

Preoperative 12 lead EKG showed LBBB, rsR pattern in

v4 and poor progression of R wave in leads V1-V5. X-ray chest (Figure

2) revealed cardiomegaly. The lung fields were clear.

-adrenergic agonists.

Echocardiography reports demonstrated, global hypokinesia of left

ventricle, poor systolic function, ejection fraction of 25%; mitral

regurgitation, tricuspid regurgitation and left ventricular end diastolic

dilatation.

His symptoms were well controlled with Tab Lisinopril (zestril) 2-5

mg od, Lasix 40 mg od, digoxin 0.125 mg od, and spironolactone 25 mg

od for the last 4 years, No abnormalities were noted in the laboratory

investigations. Preoperative hemoglobin level was 11.1 gm%.

A high-risk consent was obtained. Regional (epidural) anesthesia

technique and the reason for its selection was explained to the patient and

his co-operation requested.

 

No premedication was advised. Intravenous access was established

with a 18 G cannula and lactated ringer solution administered at the rate

of 1.5ml /kg/hr.

Non-invasive blood pressure (NIBP) (every 5 min), arterial oxygen

saturation (SpO

throughout the surgery. CVP line was inserted peripherally through the

basilic vein.

After taking all aseptic and antiseptic precautions, an 18 G epidural

catheter was introduced at L3-4 space. 2% xylocaine plain (without

adrenaline) was injected slowly to attain a sensory and motor block up to

T10 level. BP of 70 mmHg systolic was observed after 10 min. This was

treated with intermittent bolus of ephedrine in doses of 2.5 to 5 mg. The

2) and lead II of the electrocardiogram were monitored

aim was to maintain the systolic BP of 90 mmHg. or more. Ventricular

premature beats seen on the EKG were not persistent enough to warrant

treatment.

Central venous pressure ranged between 8-9 cmH

Intraoperative blood loss was about 300-350 ml as judged by the

collection in suction bottle and the soaked gauze pieces. Surgery lasted

for 90 min.

Postoperatively, there was a drop in the blood pressure to 76/40

mmHg, CVP was 3 cm H

sweating or difficulty in breathing. Fluid administration continued at the

rate of 75ml/hr. Dobutamine infusion was started at the rate of 7.5

ug/kg/min,to maintain the systolic blood pressure to 90 mmHg. After 1

hour, ventricular bigemini rhythm was seen on the monitor, which

was successfully treated by administering amiodarone. Repeat Hb value

was 7.3 gm%.

1 unit of fresh blood was transfused.

2O.2O. Patient had no complaints of chest pain,

The subsequent postoperative course was uneventful. The patient is

doing fine and visits the OPD for regular follow up.