|Year : 2016 | Volume
| Issue : 2 | Page : 89-91
Anesthetic management of post-coronary artery bypass grafting patient posted for below-knee amputation
Kumari Priyanka Tallur, Chanabasavaraj S Sanikop, Mallikarjun G Dhorigol
Department of Anesthesia, KLE University, Belagavi, Karnataka, India
|Date of Web Publication||18-May-2016|
Kumari Priyanka Tallur
C/O GM Harakuni, H No. 1484, Kudasomannavar Galli, Bailhongal, Belgaum, Karnataka
Source of Support: None, Conflict of Interest: None
Unilateral spinal anesthesia is a promising alternative to traditional, widely used techniques of spinal anesthesia as it decreases the risk of adverse events and complications.
Keywords: Hemodynamic stability, post-coronary artery bypass grafting (CABG), unilateral spinal
|How to cite this article:|
Tallur KP, Sanikop CS, Dhorigol MG. Anesthetic management of post-coronary artery bypass grafting patient posted for below-knee amputation. J Sci Soc 2016;43:89-91
|How to cite this URL:|
Tallur KP, Sanikop CS, Dhorigol MG. Anesthetic management of post-coronary artery bypass grafting patient posted for below-knee amputation. J Sci Soc [serial online] 2016 [cited 2020 Aug 13];43:89-91. Available from: http://www.jscisociety.com/text.asp?2016/43/2/89/182606
| Introduction|| |
Unilateral spinal anesthesia has been used successfully in high-risk patients undergoing surgery involving one lower limb. It has many advantages over conventional spinal anesthesia such as lower incidence of hypotension, faster recovery, and increased patient satisfaction.  To achieve successful unilateral spinal anesthesia, several factors need to be considered including the site, speed of injection of anesthetic solution, volume, baricity, concentration of the anesthetic solution, type of needle, and bevel direction with degree of operating table inclination. It has been claimed by many as an alternative technique to restrict the undesired sympathetic block.  Unilateral spinal anesthesia is associated with hemodynamic stability, so there is a trivial use of vasoconstrictors for blood pressure maintenance.  It provides a more profound and longer lasting block. 
| Case report|| |
A 78-year-old male patient with ischemic heart disease (IHD) gave a history of post-coronary artery bypass grafting (CABG) 5 weeks back posted for a right below-knee amputation for squamous cell carcinoma. A thorough preanesthetic evaluation was done with following investigations. Complete blood count (CBC), renal function test (RFT), liver function test (LFT), and electrolytes were normal and there was electrocardiogram (ECG) T-wave inversion in V2-V6. Echocardiogram (ECHO) showed impaired left ventricular (LV) systolic function with left ventricular ejection fraction (LVEF) 45%, akinesia of the apical septum and apex with hypokinesia of the anterior wall, anterior part of the septum, mitral annular calcification with trivial mitral regurgitation (MR), aortic valve (AV) thickening, trivial tricuspid regurgitation with peak pressure gradient 30 mmHg, mild pulmonary hypertension (PAH), no clot, and no pericardial effusion after CABG. The patient was on the following medications: tablet Stromix A 150 mg once a day (OD), tablet Atorvastatin 10 mg OD, tablet Deriphyllin 300 mg two times a day (TID), tablet Dytor 10 mg OD, and tablet Nebicard 2.5 ug OD. The advice to withhold anticoagulation drugs for 3 days before surgery was given. The patient's preanesthetic evaluation was done keeping in mind the above investigation and instructions. The patient and patient's attenders were counseled. On the night prior to the surgery, tablet alprazolam 0.25 mg was advised. On the day of surgery, the patient was asked to continue all his medications with sips of water except for antiplatelet drug.
We decided to proceed with unilateral spinal anesthesia. On the day of surgery, the patient was shifted to the preoperative room and an 18G cannula (18G iv cannula) was inserted into a vein on the dorsum of the left hand. Intravenous (IV) infusion of 8 mL/kg Ringer lactate was infused over 30 min and baseline blood pressure (BP) was measured. To reduce the patient's anxiety injection midazolam 2 mg was given intravenously. The patient was shifted to the operation theater, standard monitors were connected [ECG, noninvasive blood pressure (NIBP), pulse oximetry], and baseline readings were recorded. The patient was put in the lateral decubitus position with the target limb in the lower position. Under strict aseptic precaution L3-L4 interspinous space was infiltrated with 2 mL of 2% lignocaine. Using a 23G Quienke's spinal needle, the L3-L4 interlaminar space was puncture to access the subarachanoid space demonstrated by free-flowing cerebrospinal fluid (CSF). 1.5 mL of 0.5% bupivacaine (H)+ 0.5 mL (25 ug) of fentanyl is injected with 23G Quincke needle after free clear flow of CSF. The patient was asked to lie in the lateral position for 15 min and then placed in a supine position for surgery [Figure 1]. Block was adequate (tested as per Bromage scale). There was no significant change in the vitals during the procedure. 1000 mL of Ringer lactate was given intraoperatively. Urine output was 300 mL at the end of the surgery. Total duration of surgery was around 60 min. The patient was shifted to the recovery unit. Vital signs, input, and output were monitored regularly during the postoperative period. The patient was shifted to the ward after 6 h and discharged after 5 days. He was advised to continue his medications after consultation with the physician.
|Figure 1: Unilateral spinal anesthesia is associated with less hemodynamic changes compared to spinal anesthesia|
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| Discussion|| |
Spinal anesthesia is one of the commonly used techniques in anesthesia and is a good choice in intermediate, low-risk surgeries and in procedures involving the extremities, perineum, and lower abdomen. It is most popular because of its profound analgesia and muscle relaxation.  A restricted sympathetic block during spinal anesthesia may minimize hemodynamic changes. Unilateral spinal anesthesia is most useful in high-risk patients because of less adverse events and complications.  Unilateral spinal anesthesia may show advantages for the short procedures involving only one lower limb as compared to conventional spinal anesthesia, which are: lower incidence of hypotension, fast recovery, and increased patient satisfaction. When unilateral spinal anesthesia was performed using a low-dose, low-volume, and low-flow injection technique, it provided adequate sensory-motor block and helped to achieve stable hemodynamic parameters [Figure 2].  Unilateral spinal anesthesia is used during most surgical procedures performed on the lower limbs. There are many benefits to this technique including fewer hemodynamic changes,  less urinary retention, better motility during recovery, and the restriction of selective nerve block to the relevant limb. 
|Figure 2: Unilateral spinal anesthesia is associated with more stable cardiovascular stability. There is no signifi cant variation in hemodynamic parameters following unilateral low dose spinal anesthesia|
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Kuusniemi et al. reported that hyperbaric bupivacaine was more effective in achieving unilateral spinal anesthesia than plain bupivacaine.  The anesthetic drug may migrate even when the patient was placed in the lateral position for 30-60 min. Conversely, if a low dose of anesthetic solution is used, putting the patient in the lateral position for 10-15 min may prevent migration of the anesthetic drug. Unilateral spinal anesthesia with a low dose and limited volume induces sufficient sensory and motor block with an appropriate level of analgesia. The technique is therefore, suitable for lower limb surgery. This technique achieves stable hemodynamics, particularly in the elderly and American Society of Anesthesiologists (ASA) class III/IV patients. It also results in rapid recovery and greater satisfaction among outpatients, in addition to preventing unnecessary nerve block in the contralateral limb.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]