Anaesthetic management of laparoscopic cholecystectomy in a patient with mitral stenosis with pulmonary hypertension

Abstract

Pneumoperitoneum caused by CO2 for laparoscopic surgery results into cardiovascular and respiratory changes. In compromised patient with cardiac diseases this cardio respiratory changes aggravate increases in PaCo2 and enlarge gradient between PACO2 and PETCO2.(1,2) Further increases in abdominal pressure caused insufflation for clear vision will decrease lung capacity by pushing diaphragm upwards and is usually associated with severe hypertension and tachycardia. In a patient mitral stenosis, these changes associated with Laparoscopic surgery may be detrimental resulting into pulmonary edema, cardiac failure, and atrial fibrillation. We describe a case of mitral stenosis patient with pulmonary hypertension posted for laparoscopic cholecystectomy thinking post -operative benefits of laparoscopy. Patient was taken up for surgery under general with epidural anaesthesia for decreasing intraoperative analgesia requirement and post operative pain relief Patient had grade three dyspnoea with associated pulmonary hypertension which had increased risk for anaesthesia Patient was taken up with ASA grade 4 risk and postoperative ventilator was kept ready. Electrolytes and PT, INR levels after stopping antiplatelet agents were normal. after antibiotic prophylaxis for myocardial endocarditis patient was sedated with buprenorphine and midazolam to decrease stress response .Propofol and Sevoflurane was used with MAC levels maintained at 1.2 to 1.5 at end tidal conc. BIS monitor applied to maintain depth of anaesthesia. CVP catheterization was done to prevent excessive increase in venous pressure and concomitant changes of pulmonary edema as Patient already had pulmonary hypertension. Controlled ventilation carried out to maintain ETCO2 at normal range. Intraoperative intraabdominal pressure maintained at 10-12 mm of Hg . Postoperative patient was monitored for pain hypertension and, tachycardia (inj. norphine 90 μg diluted to 10 ml of normal saline epidural was to control pain and its complication. Changes which are commonly associated with mitral stenosis may be severely accentuated with laparoscopic surgery with Increased ETCO2 and high intraabdominal pressure with decrease in lung capacity and severe changes in airway resistance Such patient with moderate mitral stenosis with pulmonary hypertension becomes predictors of cardiac morbidity When considering cardiac patient for surgery post operative benefits of laparoscopic surgery must be balanced with intraoperative risk involved