GKD Anest Yoð Bak Dern Derg. 2017; 23(3): 105-108 | DOI: 10.5222/GKDAD.2017.105

Geç Tanýlý Konstrüktif Perikardit Sonucu Geliþen Konjestif Hepatopatide Anestezi Yönetimi

Aslýhan Aykut¹, Zeliha Aslý Demir¹, Mehlika Kuþvuran Kutay¹, Doðan Emre Sert², Zeki Çatav^2
1Türkiye Yüksek Ýhtisas Hastanesi, Anesteziyoloji ve Reanimasyon Kliniði, Ankara
²Türkiye Yüksek Ýhtisas Hastanesi, Kalp ve Damar Cerrahi Kliniði, Ankara

Konstrüktif perikardit nadir görülen ancak diyastolik doluþlarýnýn bozulmasýna neden olarak ciddi hasar oluþturabilen klinik bir sendromdur. Bu yazýda geç taný almýþ konstrüktif perikardit nedeniyle siroz tanýsý konan bir olgunun perioperatif anestezi öyküsünü sunmayý amaçladýk. Kýrk dokuz yaþ, 70kg erkek hasta, daha önce bilinç kaybý, nefes darlýðý, sarýlýk nedeniyle hastaneye kaldýrýldý. Periferik ödem, asit, gastrointestinal kanama, hepatomegali, ensefalopati, antiHCV pozitifliði nedeniyle hastanýn HCV sirozu + hepatik ensefalopati teþhisi kondu. Yenilenen tahlillerde HCV negatifti ve taný tekrar gözden geçirildi. Kardilojik muayenesinde konstriktif perikardit tanýsý alýp, operasyon kararý verildi. Hasta apatik, kýsmen oryante, Elektroensefalogram (EEG)’da orta derecede yavaþlama ile yüksek nörolojik riski altýnda tutuldu. Anestezi indüksiyonu öncesi kan basýncý 114/60, kalp hýzý 95, sað-sol near infrared spektroskopi (NIRS,rSO2) 43/45, patient state index (PSI) 95, SpO297. Anestezi indüksiyonunda; Ketamin, midazolam, lidokain, fentanil, rokuronyum kullanýldý. Ýndiksiyonla birlikte transamin ve dobutamin infüzyonu baþlatýldý. Ýndüksiyondan sonra sað-sol rSO2 57/59, PSI 41, spektral kenar frekanslarý (SEF) 6.6 / 6.5, santral venöz basýnç (CVP) 26. Transözofageal ekokardiyografi (TEE), özofagus varisleri nedeniyle yapýlmak istenmedi. Ameliyat sýrasýnda milrinon infüzyonu baþlatýldý. Postoperatif 4 saat sonra ekstübe edildi, inotrop infüzyonlarý ise 2 gün sonra sonlandýrýldý. Sol kalp pulmoner venöz dönüþü inspirasyon esnasýnda azalýr. Bu, interventriküler septumu sola kaydýrýr ve sol ventrikül kavitesi ve strok volüm azalýr. Strok volümdeki düþüþe verilen en önemli refleks yanýt adrenerjik uyarýlmadýr. Bu nedenle perioperatif dönemde adrenerjik uyarýmý korumak önemlidir. Barorefleks duyarlýlýðýnda azalma da kardiyak sirozun bir bileþeni olarak gösterilmiþtir. Bu nedenle, anestezi indüksiyonunun neden olabileceði adrenerjik depresyonu önlemek için indüksiyon ajanlarý ketamin ve dobutamin ile kombine edilmiþtir.

Anahtar Kelimeler: Konstrüktif Perikardit, Kardiyak Siroz, Kardiyak Anestezi, Sað Kalp Yetmezliði, Perikardiyektomi

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Delayed Diagnosis Of Constructive Pericarditis Finalized Congested Hepatopathy: Anesthesia Management

Aslýhan Aykut¹, Zeliha Aslý Demir¹, Mehlika Kuþvuran Kutay¹, Doðan Emre Sert², Zeki Çatav^2
1Turkey Yüksek Ýhtisas Hospital, Department of Anesthesiology and Reanimation, Ankara
²Turkey Yüksek Ýhtisas Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey

Constrictive pericarditis is a rare clinical syndrome that can cause severe damage to the diastolic filling.In this article, we aimed to present the perioperative anesthesia story of a case with a delayed diagnosis of cirrhosis due to constructive pericarditis.49y, 70kg, male patient, was admitted to a hospital due to unconsciousness, shortness of breath, jaundice before. He had peripheral edema, ascites, gastrointestinal bleeding, hepatomegaly, encephalopathy, antiHCV positivity, patient was diagnosed as having HCV cirrhosis+hepatic encephalopathy.HCV was negative in the revised examinations, he was removed diagnosis.On cardiology examination, he was diagnosed as constrictive pericarditis and decision of operation was made. Patient was operated on with high risk of neurological impairment with apathetic, slow-sense and responsive, partially oriented, moderate deceleration in Electroencephalography(EEG). Before anesthesia induction, blood pressure114/60,heartrate95, right-left Near infrared spectroscopy(NIRS,rSO2) 43/45,patient state index(PSI)95, SpO297. In anesthesia induction;ketamine,midazolam,lidocaine,fentanyl,rocuronium were used. Meanwhile,transamin and dobutamine infusion was initiated. After induction, right-left rSO2 57/59,PSI 41,SEF6.6/6.5. CVP26.TEE wasnot wanted by surgery because of esophageal varices.Intraoperatively, milrinone was initiated. After 4hours he was extubated,infusions were terminated after2days. The left heart pulmonary venous return decreases during inspiration.This, shifts interventricular septum to the left and reduces left ventricular cavity so that stroke volume is reduced.The most important compensatory response to decrease in stroke volume is the adrenergic stimulation.So it is important to maintain adrenergic stimulation in perioperative period.A decrease in baroreflex sensitivity has been shown as a component of cardiac cirrhosis also.Therefore, to prevent adrenergic depression that may be caused by anesthesia induction,induction agents were combined with ketamine and dobutamine.

Keywords: Constrictive Pericarditis, Cardiac Cirrhosis, Cardiac Anesthesia, Right Heart Failure, Pericardiectomy

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