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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 244-246

Subarachnoid block in transurethral surgery for bladder tumor in Eisenmenger’s syndrome

Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham, Kochi, Kerala, India

Date of Submission18-May-2019
Date of Acceptance26-Feb-2020
Date of Web Publication27-Jun-2020

Correspondence Address:
MD Kumar Lakshmi
Amrita Institute of Medical Sciences, Kochi 682041, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/roaic.roaic_44_19

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Uncorrected left to right intracardiac shunts can progress to a reversal of shunting in the fourth or fifth decade of life due to severe pulmonary artery hypertension. As the changes in the pulmonary vasculature are irreversible at this stage the condition can only be palliated by medication. Regional anaesthesia decreases the systemic vascular resistance and increases the right to left shunt but in optimal doses can minimize this shunting while protecting from other adverse effects of general anaesthesia. We highlight the anaesthetic management of a 53 year old male with Eisenmenger’s syndrome with atrial septal defect on anti failure medications successfully managed with a low dose subarachnoid blockade for transurethral surgery. We believe that this simplified management while providing a safe protocol for use.

Keywords: Eisenmenger’s syndrome, subarachnoid block, transurethral surgery

How to cite this article:
NK S, Lakshmi K, BK V, Rajan. Subarachnoid block in transurethral surgery for bladder tumor in Eisenmenger’s syndrome. Res Opin Anesth Intensive Care 2020;7:244-6

How to cite this URL:
NK S, Lakshmi K, BK V, Rajan. Subarachnoid block in transurethral surgery for bladder tumor in Eisenmenger’s syndrome. Res Opin Anesth Intensive Care [serial online] 2020 [cited 2020 Oct 28];7:244-6. Available from: http://www.roaic.eg.net/text.asp?2020/7/2/244/287992

  Background Top

Congenital heart disease rarely progresses to the fourth or fifth decade, manifesting as adult congenital heart disease. The fibrotic and permanent changes in the pulmonary vasculature pose challenges for anesthesia and surgery. General anesthesia has been accepted as a suitable choice in these patients, but regional anesthesia may have a role in select surgeries in this group of patients.

  Case report Top

A 53-year-old man with Eisenmenger’s syndrome following an atrial septal defect (ASD) was scheduled for a transurethral bladder tumor surgery. Reversal of flow in preexisting left to right shunts owing to the development of pulmonary hypertension is known as Eisenmenger’s syndrome. His medications included digitalis tablets 0.125 mg, furosemide tablets 40 mg, and sildenafil tablets 25 mg t.i.d. orally daily. Investigations revealed oxygen saturation of 86%, compensatory polycythemia (hemoglobin 17.3 g/dl, hematocrit 52%), right bundle branch block in electrocardiogram ([Figure 1]), and cardiomegaly with prominent pulmonary arteries (PAs) on the chest roentgenogram ([Figure 2]). Echocardiography revealed a 3.1 mm ostium secundum ASD and systolic PA pressures of 110 mmHg, with good biventricular function.
Figure 1 ECG showing right bundle branch block.

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Figure 2 Radiograph of chest showing cardiomegaly.

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The patient presented to us for treatment on August 2015. The surgery was planned under subarachnoid block (SAB), and invasive arterial and central lines were placed before surgery. SAB was performed at L3–4 space with 0.5% hyperbaric bupivacaine 1.5 ml (7.5 mg) with fentanyl 0.5 ml (25 mcg) with the patient in the left lateral position. Sensory block was obtained at the 10th thoracic dermatome, and hemodynamics were maintained with the infusion of 1.5 l crystalloids, and surgery completed uneventfully. Paracetamol 1 g intravenously every 8 h and intravenous tramadol 75 mg for breakthrough pain were prescribed. He was readmitted to the ICU 36 h later with breathlessness and desaturation (<65%) but the radiography and echocardiogram were similar to the preoperative state. He responded to oxygen, antibiotics, and furosemide 40 mg intravenously and was discharged in a stable state on the 10th postoperative day.

  Discussion Top

Pulmonary hypertension contributes to poorer outcomes after cardiac surgery [1]. We chose a SAB because we believed that the risks were lesser in comparison with a general anesthetic [2] and ease in detecting early symptoms of hyponatremia. The addition of opioid allowed the use of lower volumes of anesthetic. A fall in systemic vascular resistance (SVR) associated with a neuraxial block increases right-to-left shunting across the ASD, leading to an increase in arterial hypoxemia. Conversely, increased SVR will cause increased left to right shunting, with a further increase in PA pressure and right ventricular failure [3].

Although a segmental block with an epidural may have been an alternative, we believed that the same effects could be obtained with spinal. Moreover, an inadequate or patchy block could produce increases in PA resistance and SVR on account of the pain.

Despite successful use of GA in Eisenmenger’s for lower abdominal surgery [3],[4] GA could be a cause of myocardial depression, sudden decrease in SVR, heart rate changes, and volume overload. Combined GA and epidural anesthesia has been used for cesarean section in Eisenmenger’s syndrome [5],[6]. Sildenafil can potentiate hypotension, decrease tone of the lower esophageal sphincter, and rarely cause optic atrophy and blindness, and we were vigilant for signs and symptoms postoperatively.Occurrence of arrhythmias or cardiac failure in Eisenmenger’s portend a poor prognosis [7], and minor infection could have triggered the desaturation postoperatively. Limited reports are available on the use of SAB in surgery other than cesarean. We highlight the use of SAB as a simpler and effective alternative in select surgeries in patients with Eisenmenger’s syndrome.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Lai HC, Lai HC, Wang KY, Lee WL, Ting CT, Liu TJ. Severe pulmonary hypertension complicates postoperative outcome of non-cardiac surgery. Br J Anaesth 2007; 99:184–190.  Back to cited text no. 1
Martin JT, Tautz TJ, Antognini JF. Safety of regional anesthesia in Eisenmenger’s syndrome. Reg Anesth Pain Med 2002;27:509–513.  Back to cited text no. 2
Puri GD, Pradhan A, Kumar B, Hegde HV, Singh A, Prasad GRV. Anaesthetic management of a patient with Eisenmenger syndrome for lower abdominal surgery. Trends Anaesth Crit Care 2011; 1:51–53.  Back to cited text no. 3
Gupta N, Kaur S, Goila A, Pawar M. Anaesthetic management of a patient with Eisenmenger syndrome and β-thalassemia major for splenectomy. Indian J Anaesth 2011; 55:187–189.  Back to cited text no. 4
[PUBMED]  [Full text]  
Gurumurthy T, Hegde R, Mohandas BS. Anaesthesia for a patient with Eisenmenger’s syndrome undergoing caesarean section. Indian J Anaesth 2012; 56:291–294.  Back to cited text no. 5
[PUBMED]  [Full text]  
Mishra L, Pani N, Samantaray R, Nayak N. Eisenmenger’s syndrome in pregnancy: use of epidural anesthesia and analgesia for elective cesarean section. J Anaesthesiol Clin Pharmacol 2014; 30:425–426.  Back to cited text no. 6
Diller GP, Dimopoulos K, Broberg CS, Kaya MG, Naghotra US, Uebing A, Harries C et al. . Presentation, survival prospects, and predictors of death in Eisenmenger syndrome: a combined retrospective and case–control study. Eur Heart J 2006; 27:1737–1742.  Back to cited text no. 7


  [Figure 1], [Figure 2]


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