CASE REPORT |
https://doi.org/10.5005/jp-journals-10049-2050 |
Anesthesia Management of HoLEP in Patient of Multiple Myeloma with Permanent Pacemaker In Situ
Department of Anesthesiology, Kokilaben Dhirubhai Ambani Hospital & Medical Research Institute, Navi Mumbai, Maharashtra, India
Corresponding Author: Manish M Kela, Department of Anesthesiology, Kokilaben Dhirubhai Ambani Hospital & Medical Research Institute, Navi Mumbai, Maharashtra, India, Phone: +91 8850724463, e-mail: drmanishkela@gmail.com
Received: 27 April 2024; Accepted: 11 June 2024; Published on: 26 July 2024
ABSTRACT
The author describes a successful perioperative management of 76-year-old male posted for holmium laser enucleation of the prostate (HoLEP) surgery. The patient was diagnosed with case of multiple myeloma and is on treatment with chemotherapeutic agents.
Associated comorbidities include hypertension with ischemic heart disease (IHD), status postcoronary artery bypass grafting (CABG) with permanent pacemaker in situ.
How to cite this article: Kela MM. Anesthesia Management of HoLEP in Patient of Multiple Myeloma with Permanent Pacemaker In Situ. Res and Innov Anesth 2024;9(1):28–30.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
Keywords: Case report, Holmium laser enucleation of the prostate, Multiple myeloma, Spinal anesthesia.
INTRODUCTION
Multiple myeloma is the most common primary bone tumor associated with neoplastic proliferation of plasma cells with an abnormal production of monoclonal immunoglobulins.
The clinical features are bone pain, renal failure, hypercalcemia, anemia, and infections.1,2
Nowadays, more patients with multiple myeloma are coming for surgeries as introduction of new chemotherapy drugs has improved the survival rates and quality of life in these patients.
CASE DESCRIPTION
A 76-year-old known hypertensive was admitted to hospital for holmium laser enucleation of the prostate (HoLEP) surgery. He was a known case of multiple myeloma for 2 years, for which he was taking bortezomib, lenalidomide, dexamethasone, and aspirin 75 mg once daily orally for antithrombotic prophylaxis. He had undergone coronary artery bypass grafting (CABG) 20 years ago and permanent pacemaker implantation (PPI) 1 year back.
His blood counts and renal function were normal, with serum calcium of 7.8 mg/dL. Electrocardiogram (ECG) was suggestive of old inferior wall myocardial infarction. Echocardiography showed normal left ventricular function [ejection fraction (EF) 55%] with no regional wall motion abnormality (RWMA). His positron emission tomography (PET) scan did not show metabolically active lesion in whole body. Airway and spine examinations were normal.
Written informed consent was obtained from the patient, and intensive care unit (ICU) was booked for postoperative management.
The patient was advised on fasting guidelines for surgery as per the American Society of Anesthesiologists (ASA) standards.
On the day of surgery, the patient was shifted to the operation room, and standard ASA monitors (ECG, pulse oximeter, and noninvasive blood pressure monitor) were attached. A 20-gauge intravenous cannula was secured in the right upper limb, and ringer lactate was administered at rate of 1 mL/kg/hour.
Pacemaker-trained tech was called during the procedure for programming pacemaker machine. Patient’s baseline mode was DDDR with heart rate of 60/minute. This was converted to VOO mode with heart rate set to 85/minute during perioperative period.
Under all aseptic precautions, spinal block was given with 27 G Quincke’s needle by injecting 3.25 mL drug (3 mL 0.5% bupivacaine + 25 µg fentanyl) into subarachnoid space, and T8 spinal level was achieved. The total duration of surgery was approximately 1.5 hours. The patient was kept warm using warm air blanket. The surgery underwent uneventfully with normal perioperative hemodynamics except for occasional intermittent ventricular ectopics. Postsurgery, patient’s pacemaker mode was changed back to DDDR with heart rate of 60/minute.
Postoperatively, the patient was stable and shifted to ICU for postoperative hemodynamic monitoring.
In the postoperative period, the patient’s renal function tests and serum calcium were normal, and the patient got discharged on the fourth postoperative day.
DISCUSSION
Multiple myeloma is the most common primary malignant bone tumor associated with neoplastic proliferation of plasma cells and an abnormal production of monoclonal immunoglobulins, commonly immunoglobulin G (IgG).1,2 The paraproteinemia is associated with excretion of light chains (κ or λ) in the urine, also known as Bence Jones proteins.
Patients usually do not have any symptoms, and the diagnosis is made incidentally during routine blood tests for other conditions. Symptoms include CRAB criteria (Calcium: Hypercalcemia, Renal insufficiency, Anemia, and Bone pain).
Multiple myeloma patients are at high risk of developing postoperative complications such as acute kidney injury (AKI), pneumonia, infections, and thrombosis.3
Intraoperative care of multiple myeloma patients is challenging for the anesthesiologist. In this case, the problem doubles up because of ischemic heart disease (IHD) with permanent pacemaker in situ.
Since bones are very fragile in multiple myeloma, even trivial trauma can cause fracture. In this case, we ensured gentle handling of patient during shifting and lithotomy positioning. All pressure points were well padded.
We used prophylactic antibiotic (injection cefuroxime 1.5 gm within 1 hour before start of surgery) and maintained strict asepsis during the surgery, as immunosuppressive drugs and neutropenia predispose multiple myeloma patients to infections.
Renal function is affected in multiple myeloma patients due to damage to renal tubules by Bence Jones proteins and hypercalcemia. Renal insufficiency is associated with a poor prognosis and high mortality in these patients.
To prevent renal dysfunction perioperatively, we ensured adequate volume status and hemodynamic, avoided nephrotoxic agents like nonsteroidal anti-inflammatory drugs (NSAIDs), and monitored urine output and serum creatinine postoperatively.
Multiple myeloma patients are at increased risk of thromboembolism due to use of chemotherapeutic drugs, for which they receive antiplatelet and anticoagulant drugs. Since the patient was on lenalidomide, low-dose aspirin was started for thromboprophylaxis.
Central neuraxial and regional nerve blocks can be safely used in these patients. There are reports of successful management of cesarean section and lower limb surgeries under spinal block and peripheral nerve blocks, respectively.4,6
Intraoperatively, to reduce the risk of pacemaker damage, bipolar electrocoagulation was used. A passive electrode was placed on buttock, far away from the cardiac pacing system, to reduce the effect of current on the stimulator.7,8
There are standard protocols regarding perioperative management in patients with pacemakers.9,10 A patient posted for surgery should have a current pacemaker control. Expected battery life should be at least three months. In most patients, a pacemaker card is present, mentioning the type of device, model number, the indication for insertion, and current settings of device.
During the procedure, cardiovascular status was monitored continuously by ECG and pulse oximeter.
CONCLUSION
More patients with multiple myeloma are presenting for surgery due to use of stem cell treatment and newer chemotherapeutic drugs, resulting in increased survival rates.
Therefore, utmost care should be taken to manage multiple myeloma patients to prevent peri- and postoperative complications.
REFERENCES
1. Kyle RA, Rajkumar SV. Multiple myeloma. Blood 2008;111(06):2962–2972. DOI: 10.1182/blood-2007-10-078022
2. Sonneveld P, Segeren CM. Changing concepts in multiple myeloma: from conventional chemotherapy to high-dose treatment. Eur J Cancer 2003;39(01):9–18. DOI: 10.1016/s0959-8049(02)00503-8
3. Park KJ, Menendez ME, Mears SC, et al. Patients with multiple myeloma have more complications after surgical treatment of hip fracture. Geriatr Orthop Surg Rehabil 2016;7:158–162. DOI: 10.1177/2151458516658330
4. Dabrowska DM, Gore C, Griffiths S, et al. Anaesthetic management of a pregnant patient with multiple myeloma. Int J Obstetric Anesth 2010;19:336–339. DOI: 10.1016/j.ijoa.2010.03.010
5. Binici O, Akyoi F. Combined sciatic-psoas compartment nerve block in a patient with multiple myeloma. East J Med 2016;21:197–199. DOI: 10.5505/ejm.2016.09719
6. Kalingarayar S, Nandhakumar A, Thennavan AS. Anaesthesia for fixation of repeated pathological fractures in a patient with multiple myeloma. Indian J Anaesth 2017;61:1009–1011. DOI: 10.4103/ija.IJA_467_17
7. Partin AW, Wein AJ, Kavoussi LR, et al. Campbell-Walsh Urology e-book: 4-volume set. Milton: Elsevier Health Sciences; 2015.
8. Schutz W. Transurethral electro-resection in patients with cardiac pacemakers. Urologe A 1979;18(05):247–249.
9. Chakravarthy M, Prabhakumar D, George A. Anaesthetic consideration in patients with cardiac implantable electronic devices scheduled for surgery. Indian J Anaesth 2017;61(09):736–743. DOI: 10.4103/ija.IJA_346_17
10. Crossley GH, Poole J, Rozner M, et al. The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) expert consensus statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and patient management. Heart Rhythm 2011;8(07):1114–1154. DOI: 10.1016/j.hrthm.2010.12.023
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