Anaesthesia in patients with dilated cardiomyopathy and low ejection fraction has always been a challenge because these patients are extremely susceptible to cardiodepressive action of anaesthetics resulting in perioperative inotropic support dependence. We report the first case of xenon anaesthesia in a patient with dilated cardiomyopathy and ejection fraction less than 30% suffering from rapidly progressing spinal cord tumour. With exclusive haemodynamic stability and fully controllable reversibility enabling anaesthesia without inotropic support and fast track recovery, xenon seems to open new horizons for non-cardiac surgery in patients with severe cardiac dysfunction.
A 22-year-old man (1.7 m, 72.5 kg) presented with intramedullary tumour at C4-Th1 level with syringomyelytic cysts above it resulting in tetraparesis and loss of sensation. The patient suffered from dilated cardiomyopathy and was treated with furosemide, spironolactone, metoprolol; 3 days before surgery digoxin was added to the therapy. Preoperative echocardiography showed left ventricular hypokinesis with the ejection fraction 21%, troponin I (cTnI) level was normal and brain natriuretic peptide (BNP) level was 294 pg ml−1.
In the operating room the radial artery was cannulated, anaesthesia depth monitoring with BIS XP A-2000 monitor (Aspect Medical Systems, Norwood, Massachusetts, USA) was started, and induction with midazolam 0.06 mg kg−1, fentanyl 4 μg kg−1and pipecuronium 0.03 mg kg−1 was performed. Ventilation was started in controlled mechanical ventilation mode adjusted to normoventilation (tidal volume 650 ml, frequency 10 min−1, inspiratory to expiratory time ratio (I: E) 1: 2, no positive end expiratory pressure) with TAEMA Felix Dual anaesthesia machine (ALMS, France) designed for anaesthesia with xenon. After Swan–Ganz catheterisation, the patient was turned into the prone position. Then a 10 min denitrogenation was performed, and the machine was switched into the xenon mode with FiO2 of 30% and a xenon concentration of 54–65%; and the operation began.
The 8 h anaesthesia was maintained with xenon inhalation, sufficient to keep bispectral index (BIS) values of 35–60; total xenon consumption was 46 l. Midazolam 3 mg in total, fentanyl 0.5 mg in total and propofol 50 mg in total were added when needed. Blood gases were normal. The anaesthesia was marked by stable haemodynamics with arterial blood pressure (ABP) 80–150/50–80 mmHg and heart rate 90–140 min−1 (Fig. 1), cardiac index (CI) higher than 2.5 l min−1 m−2 and diuresis of 2200 ml (under 1850 ml of crystalloids infused and 300 ml of blood loss), thus no inotropic support was needed. Cardiac output was measured during denitrogenation under propofol anaesthesia (baseline measurement) and under xenon anaesthesia at high-risk stages of the surgery and at the end of the surgery. Throughout the anaesthesia the CI and systemic vascular resistance index (SVRI) were within normal range, with the lowest CI (2.74 l min−1 m−2) and the highest SVRI (2419 dynes s cm−5 m−2) registered at the baseline measurement.
At 4.5 h of the surgery at a stable surgical anaesthesia depth (BIS 45–50) there was an increase in ABP to 150/80 mmHg with narrow complex tachycardia 140 beats min−1. It was accompanied by an increase in SVRI from 1204 to 1858 dynes s cm−5 m−2, a decrease in CI from 4.18 to 3.14 l min−1 m−2, and an increase in pulmonary artery wedge pressure from 14 to 21 mmHg. It was considered to be a reaction at tumour removal from the anterior spinal artery. Fentanyl 0.2 mg was given that decreased ABP to 100/60 mmHg and restored sinus rhythm with the frequency of 110–130 beats min−1.
The patient was extubated 5 min after the end of the surgery. Lornoxicam 8 mg and perfalgan 1 g were given for postoperative analgesia. In the ICU, he was given lornoxicam and tramadol according to our protocol for this type of surgery. The next day, the ejection fraction was 29%, cTnI level was normal, and BNP was 286 pg ml−1. Recovery was uncomplicated and 10 days later, the patient was discharged from the hospital with a good neurologic outcome.
Dilated cardiomyopathy is characterised by severe systolic and diastolic dysfunction and high incidence of potentially lethal arrhythmias. So the anaesthetic concerns are to maintain cardiac contractility, to avoid increase in afterload and to prevent arrhythmia. In our case additional difficulties were raised by surgery duration and prone position. For non-cardiac surgery different anaesthetic methods have been described, but whatever anaesthetic agent was used, authors reported the need for inotropic support1–4 that for certain prolongs and complicates recovery and imposes risks per se.
Xenon is a sole anaesthetic agent that does not metabolise, does not cumulate, and provides anaesthesia with ultrarapid recovery. Uncontestable advantage is the capability to preserve cardiac contractility, arterial pressure and vascular resistance,5,6 giving a chance to pass without inotropic or vasopressor support in patients who have not needed it before operation. In these patients, this can be the key to successful and rapid recovery. In 2001 Hofland et al.7 described the first case of xenon anaesthesia for laparoscopic cholecystectomy in a patient with Eisenmenger's syndrome recommending xenon when cardiovascular stability is needed. Up to the present, high cost and the need for specially designed closed circuit machines have partially prevented xenon propagation. However, with xenon being licensed in most European countries we hope that clinical research with this promising anaesthetic for patients with severe cardiac compromise will continue to grow.
The authors are grateful to Professor I.A. Kozlov for useful remarks on the case.
There are no conflicts of interest.
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