Doxorubicin-induced dilated cardiomyopathy for modified radical mastectomy: A case managed under cervical epidural anaesthesia
The report is about a 58-yrs-old female with carcinoma breast who had received neoadjuvant chemotherapy (CTx) consisting of Dox. She was posted for modified radical mastectomy (MRM). Pre-anaesthetic checkup (PAC) revealed Dox-induced cardiomyopathy. Patient had fatigability ever since the start of chemotherapy. On clinical examination, she had New York Heart Association (NYHA) grade 2 dyspnoea, heart rate 96/min, normal sinus rhythm, Blood Pressure (BP) 136/86 mmHg right arm supine position, pedal oedema no murmur, jugular venous pressure (JVP) was raised, fine crepitation in bilateral bases and generalised weakness since the start of chemotherapy (CTx) which has persisted even after completion of CTx. Electrocardiogram (ECG) revealed sinus tachycardia with left axis deviation and left ventricular hypertrophy. In chest, roentgenogram cardiothoracic ratio was 65% with mild basilar congestion. Echocardiography (ECHO), before starting chemotherapy, was a normal study. Post CTx ECHO showed Left ventricular end systolic size (LVES): 57 mm, Left ventricular end diastolic size (LVED): 70 mm, Left atrial diameter: 40 mm, Ejection Fraction: 25% and moderate Pulmonary artery hypertension (PAH). Rest all investigations were normal.\nRegional anaesthesia was planned owing to the high risk involved with general anaesthesia (GA) and consent for cervical epidural was obtained.\nInformed consent was obtained with special mention to possibility of failed epidural block or epidural-related complications such as respiratory depression, hypotension, cervical cord injury or epidural hematoma leading to quadriplegia and a need for postoperative ventilator support and need to administer GA in need of an emergency. The patient was also assured about the established safety of cervical epidural in trained hands.\nMonitoring utilised for the procedure included five lead ECG with ST segment monitoring, pulseoximeter (SPO2), invasive blood pressure and central venous pressure monitoring, Esophageal Doppler (CardioQ ODM) and Bispectral index score (BIS).\nCervical epidural was placed in the C6-7 space in sitting position using 18G touhy needle and epidural space identified using the hanging drop method. The catheter was directed downwards ensuring 4 cm of catheter in the epidural space. After catheter placement, patient was made to lie supine on the table. Three ml of lignocaine 2% with adrenaline 1:200,000 was injected as the test dose after aspiration for cerebrospinal fluid (CSF). After a normal response to test dose, 12 ml bupivacaine 0.25% with 2 mg morphine was administered over 5 minutes in graduated doses while monitoring for the haemodynamic response. After 15 min of injection level of block was assessed. Adequate level of anaesthesia was obtained extending from C3 to T6. Patient was given sedation using midazolam in 2 mg in aliquots of 0.5 ml each and infusion of propofol was started and titrated to obtain a BIS of 60-80.\nApart from slight discomfort while dissecting the breast tissue in its caudad extent, for which 4 ml lignocaine 2% was given in the epidural space, MRM could proceed without any major problem and the patient remained extremely stable throughout out the surgery [].\nPatient was shifted to the post anaesthesia care unit (PACU) with the specific order to look for respiratory depression, excessive somnolence and hypotension. Maximum visual analogue score (VAS) for pain up to 24 hrs after surgery was 2 and she did not require any analgesic in the postoperative phase.