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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.56 no.1 Campinas Jan./Feb. 2006
Hemodynamic repercussions of exaggerated lithotomy position for vaginal hysterectomy in cardiac patient. Case report*
Repercusiones hemodinámicas de la posición de litotomía exagerada para histerectomía vaginal en una paciente con cardiopatía. Relato del caso
Roberto Cardoso Bessa Junior, TSAI; Agnaldo L Silva FilhoII; Plínio V. MaiaIII; Lúcio O QuitesIV; Sérgio A TriginelliV
IEspecialista em Medicina Intensiva.
Anestesiologista do HC/UFMG e Hospital Lifecenter
IIEspecialista em Cirurgia Geral, Ginecologia e Obstetrícia. Doutor em Ginecologia pela UNESP
IIIME3 do CET do Hospital das Clínicas da UFMG
IVEspecialista em Anestesiologia. Professor Assistente da Faculdade de Medicina da UFMG
VEspecialista em Ginecologia e Obstetrícia. Professor Adjunto da Faculdade de Medicina da UFMG
BACKGROUND AND OBJECTIVES:
Vaginal hysterectomy shortens surgery duration and may be performed with neuraxial
block, which promotes better postoperative analgesia and lower systemic response
to surgical procedure. This report aimed at describing hemodynamic changes promoted
by exaggerated lithotomy position in cardiac patient.
CASE REPORT: Female patient, 33 years old, with history of abnormal uterine bleeding and anemia. Ultrasound revealed myomas of approximately 420 cm3. Patient had thrombophilia and dilated cardiomyopathy, with history of two ischemic strokes and two acute myocardial infarction. Monitoring consisted of invasive blood pressure and pulmonary artery catheter for continuous cardiac output measurement. Spinal anesthesia was performed with hyperbaric bupivacaine and morphine. Patient was placed in exaggerated lithotomy position being total hysterectomy performed by the Heaney technique and bilateral salpingectomy. Intraoperative intercurrences were post-positioning decreased cardiac output and increased right chambers pressure requiring dobutamine.
CONCLUSIONS: Exaggerated lithotomy position may promote hemodynamic changes which should be considered when choosing the surgical technique.
Key Words: ANESTHETIC TECHNIQUES, Regional: spinal block; DISEASES, Cardiac; POSITION: exaggerated lithotomy; SURGERY, Gynecological, vaginal hysterectomy
JUSTIFICATIVA Y OBJETIVOS:
La técnica de histerectomía vaginal permite menor tiempo operatorio
y el uso de bloqueo espinal, con los beneficios en la analgesia post-operatoria
y en la menor respuesta sistémica frente al procedimiento quirúrgico.
El objetivo de este relato es describir las alteraciones hemodinámicas
secundarias al posicionamiento en litotomía exagerada en una paciente con
RELATO DEL CASO: Paciente de 33 años, G0P0A0, con historia de sangrado uterino anormal y anemia. La ultra-sonografía evidenciaba útero miomatoso con volumen estimado de 420 cm3. Portadora de miocardiopatía dilatada, refería dos accidentes vasculares isquémicos y dos infartos agudos de miocardio en el pasado. Fue monitorizada con presión arterial invasiva y catéter en la arteria pulmonar para medir el gasto cardíaco en forma continua. Fue realizada raquianestesia con bupivacaína hiperbárica y morfina. La paciente fue posicionada en litotomía exagerada para realizar histerectomía total con la técnica de Heaney y salpingectomía bilateral. Durante el intra-operatorio, luego del posicionamiento, presentó disminución del índice cardíaco y aumento de presión en las cámaras derechas, que requirió tratamiento con dobutamina.
CONCLUSIONES: La posición de litotomía exagerada puede ser causa de alteraciones hemodinámicas que deben ser consideradas al seleccionar la técnica quirúrgica.
Cardiovascular diseases are the most frequent clinical changes in the anesthetic practice and are major perioperative morbidity/mortality factors1. Anesthetic/surgical procedure repercussions imply additional cardiovascular overload, requiring increased cardiac demand which may be easily tolerated by normal patients, but which result in significant complications for cardiac patients2. Adrenergic response to surgical stimulation, associated to circulatory effects of anesthetic agents, of tracheal intubation, of positive pressure ventilation, of blood losses, of fluid displacement, of surgical positioning and of postoperative pain, is one of those factors. Postoperative death-related events include acute myocardial infarction (AMI), arrhythmias and multiple organs failure secondary to low cardiac output2.
Vaginal hysterectomy, described by Heaney in 1934, has some advantages over the abdominal procedure. Intestinal loops are less manipulated and there is less postoperative pain, in addition to shorter hospitalization and recovery period3-6. However, this procedure requires patients positioning in exaggerated lithotomy, which may be related to significant hemodynamic changes7. This report aimed at describing the case of a patient with dilated cardiomyopathy submitted to vaginal hysterectomy associated to invasive hemodynamic monitoring and neuraxial block.
Black, obese patient (BMI: 32), 33 years old, with history of abnormal uterine bleeding affecting hemoglobin level (hemoglobin: 5.7 g/dL), not improving with clinical treatment. Pelvic evaluation showed good vaginal amplitude and increased uterus with preserved mobility. Ultrasound evidenced myomas of approximately 420 cm3.
Patient had unexplained thrombophilia with history of two strokes without sequelae and one extensive AMI eight years ago evolving to cardiogenic shock, and one AMI without upper unlevelling of ST segment one year ago. Echocardiogram showed increased left atrium (50 mm) and ventricle (67 mm), increased right chambers, posterior and inferior septal wall and apex akinesia, marked anterior and lateral walls hypokinesia, with estimated ejection fraction of 0.28. Cineangiocoronariography showed coronary circulation with right dominance, coronary arteries without significant injuries and severe diffuse left ventricle hypokinesia.
Due to lack of atherosclerosis, coronary syndrome was attributed to thrombotic phenomena secondary to thrombophilia. Patient was under enalapril (5 mg every 12 hours), spironolactone (25 mg/day), furosemide (40 mg/day), carvedilol (25 mg every 12 hours) and warfarin (7 mg/day).
Warfarin was withdrawn four days before surgery and 80 mg enoxaparin were administered every 12 hours. Last enoxaparin dose was administered 24 hours before surgery, with RNI and APTT within reference values the day before surgery. Enoxaparin was reintroduced 12 hours after surgery and warfarin the day after. Chronic medications were maintained. Patient was premedicated with 2 mg lorazepam at 10 p.m. the day before surgery and at 6 a.m. of surgery day with fast as from midnight.
Patient was noninvasively monitored in the operating room and, after sedation, left radial artery catheter was inserted and pulmonary artery catheter (PAC) was inserted through the right subclavian vein with continuous cardiac output monitoring (Baxter-Edwards®). Baseline hemodynamic parameters were measured after monitoring. Then, spinal anesthesia was performed with 15 mg of 0.5% hyperbaric bupivacaine and 200 µg morphine. Approximately 15 minutes after lumbar puncture with sensory level in T8, patient was placed in exaggerated lithotomy position for vaginal hysterectomy by the Heaney technique with bilateral salpingectomy. During surgery, 4 mg ondansetron and 8 mg dexametasone were administered to prevent postoperative nausea and vomiting, in addition to 1200 mL of 0.9% saline solution.
Hemodynamic parameters were recorded before blockade, 20 minutes after blockade, after beginning dobutamine by infusion pump, 5 minutes after removing patient from the exaggerated lithotomy position and 20 minutes after surgery completion (Table I). Intraoperative intercurrences were post-positioning decreased cardiac index and increased right chambers pressure. Surgery lasted 35 minutes and anesthetic procedure 1h50m; at surgery completion patient was referred to the ICU where she remained for 24 hours. Patient was discharged in the third postoperative day.
Preoperative evaluation of cardiac patients should take into consideration their clinical factors and functional capacity, in addition to surgery-related factors.
The objective of this preoperative cardiac risk stratification is to introduce changes in perioperative management to decrease morbidity/mortality. Surgery may be postponed due to unstable symptoms, there may be specific preoperative preparation (pharmacological, volemic or mechanic stabilization), preoperative interventions may be needed (valvoplasty, pacemaker, angioplasty, myocardial revascularization), and postoperative period in ICUs should be defined8. Our patient had stable cardiovascular parameters in pre-operative evaluation and was classified as NYHA functional class III, thus included among more severe risk predictors and to be submitted to intermediate risk procedure.
Invasive monitoring was achieved with IAP and PAC (intra-arterial pressure and pulmonary artery catheter) being patient referred to postoperative intensive care unit. This monitoring allowed intraoperative volemic handling, the administration of dobutamine and the diagnosis of position-related hemodynamic effects. Baseline values were CVP = 3 mmHg and PWP = 16 mmHg. The administration of 500 mL of 0.9% saline as volemic test has increased CVP to 6 and PWP to 22 mmHg, showing severe left ventricular failure due to diastolic restriction.
Vaginal hysterectomy was chosen due to its shorter surgical length and lower postoperative inflammatory response as compared to the abdominal procedure4-6. Even for patients with uterus weighing above 250 grams, the vaginal procedure means shorter hospitalization time1,9 versus 3.7 days; p < 0.001) and postoperative ileum (1.1% versus 10.5%; p = 0.006) as compared to the abdominal procedure, without increasing morbidity6.
Exaggerated head-down lithotomy was the surgical position of choice. This position combines the worst characteristics of both positions alone. Exaggerated lithotomy compresses abdominal organs with subsequent diaphragm raising, pulmonary compression (leading to increased intra-thoracic pressures and changes in ventilation-perfusion rate) and decreased venous return.
Head-down position increases myocardial oxygen consumption, increases intracranial pressure and promotes reflex vasodilation7. Abdominal compartment syndrome, rhabdomyolysis, neuropathies, pubic symphyseal separation, lower limbs ischemia, ulcers, pressure alopecia and hypotension are risks associated to this position7,9,10. Sometimes, due to poor tolerance to the position, ventilation control is needed. In our case, decreased cardiac index, increased systemic vascular resistance, increased pulmonary artery and wedge pressures were diagnosed after exaggerated lithotomy.
Dobutamine (5 µg.kg-1.min-1) was started to improve cardiac index and decrease pulmonary artery and wedge pressures, and systemic vascular resistance. The noxious effect of position in a patient with severe cardiac impairment was proven by improved hemodynamic parameters after returning her to the supine position with decreased dobutamine infusion and further withdrawal.
The combination of adequate anesthetic-surgical techniques allows further safety and lower morbidity/mortality in critical patients. Vaginal hysterectomy is safe for severe cardiac disease patients, however it promotes exaggerated lithotomy-related hemodynamic changes which may be poorly tolerated and promote severe cardiovascular complications.
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Dr. Roberto Cardoso Bessa Júnior
Address: Rua Itamonte, 35/602 - Bairro Floresta
ZIP: 31110-220 City: Belo Horizonte, Brazil
Submitted for publication May 18, 2005
Accepted for publication October 31, 2005
* Received from Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, MG