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ULTRASOUND GUIDED ILIOINGUINAL AND ILIOHYPOGASTRIC NERVE BLOCK FOR INGUINAL HERNIA REPAIR IN A PATIENT OF MARFAN SYNDROME WITH AORTIC ANEURYSM
A fourty years old male diagnosed as a case of MFS with aortic aneurysm was listed for inguinal hernia repair. Patient was apparently asymptomatic an year back when he presented to the emergency department with complaints of breathlessness on exertion (grade II), nonproductive cough, difficulty in swallowing with neck pain. He had characteristic Marfanoid habitus. On evaluation patient was diagnosed with hypertension There was no history of episodes of, chest pain, orthopnea, syncope, pedal edema. X-ray chest revealed upper mediastinal widening, a slightly above normal cardiac silhouette and notching of the ribs. 2D echocardiogram revealed dilatation of ascending aorta (77 mm), ao annulus 28mm, ascending aorta 36mm. Left subclavian artery massively dialated 60 mm, suggestive of flaps seen in descending aorta. The CT angiogram revealed Stanford type A aortic dissecting aneurysm from the level of common carotid artery upto mid thoracic region with extension into the proximal portion of left subclavian artery. Dimensions of aorta at different level : Aortic root 2.57cm, Ascending aorta 2.87cm, Arch 5.25cm,Proximal descending thorascic aorta 5.40cm. However distal flow was patent and no thrombosis was noted. Patient was prescribed antihypertensives and was advised corrective surgery to be done once patient stabilizes. However patient refused to undergo any surgery. After an year patient presented with right inguinal swelling and was diagnosed as right indirect inguinal hernia. Patient’s routine evaluation was unremarkable with patient having good effort capacity.
Right inguinal hernia repair under ultrasound guided iliohypograstic-illioinguinal nerve block[IIL/IHN] was planned. Routine ASA monitoring protocol was followed. Patient was premedicated with 0.02mg/kg of intravenous midazolam. Supplemental oxygen (6 L/min) was administered via a Hudson mask. After employing routine antiseptic measures, abdominal wall was scanned using a 38 mm broadband linear array transducer probe (6–12 MHz) in the multibeam mode. The IIN was visualized ( usually between the internal oblique and transverse or external oblique muscles and within 1 to 3 cm from the anterior superior iliac spine). A 70 mm, 22 G short-bevel spinal needle was inserted laterally through the entry point of the transducer, and 18 ml of 0.5% bupivacaine was injected after aspiration and fluid expansion in the sheath of the internal oblique and transverse abdominalis muscle layer noted. A skin infiltration was done over surgical incision site with 5ml of 0.25% bupivacaine. Incision was put by the surgeon after 15 minutes of instituting the block and the surgery lasted for 55 minutes without any additional analgesics requirement.
Intraoperative course was uneventful. 1gm paracetamol and 75 mg diclofenac was administered i.v as a part of multimodal analgesia. Patient was pain free for 6 hours post operatively.
Aortic aneurysm can have a strong genetic predisposition. In some families, there appears to be an autosomal dominant trait causing thoracic aortic aneurysm [TAA].[3,4] Syndromes like Marfan syndrome, Elher-Danlos and Loeys-Dietz syndrome (which partly resembles Marfan's syndrome), trauma and infection can also cause aortic aneurysms. Hypertension, increasing age, smoking, bicuspid or unicuspid aortic valve, COPD are some of the factors probably resulting in an increasing rate of growth of aneurysms  Most intact aortic aneurysms do not produce symptoms. As they enlarge, compressive symptoms depending on the site, such as neck pain and dysphagia in case of thoracic aortic aneurysms and abdominal and back pain in case of abdominal aortic aneurism may develop. Compression of nerve roots may cause leg pain or numbness.
Our patient is a diagnosed case of marfan syndrome with aneurysm of ascending aorta with hypertension well controlled on tab. Metaprolol and tab. Telmesartan. It was a known case of inguinal hernia presented with on and off cough with dysphagia neck and chest pain. Inguinal hernia repair (IHR) is one of the most commonly performed surgical procedures worldwide. Different anesthetic techniques, either alone or in association, can be used to carry out IHR .patient may be predisposed to complications intra operatively such as dissection of aneurysm or rupture, intraoperative attack of mi , intraoperative thromboembolic phenomena, our aim was to attain preoperative adequate control of hypertentsion firstly . Ischemic episodes or rupture of aneurysm may precede as a result of significant increases in heart rate, increases in blood pressure or in few cases by an acute decreases in blood pressure. patient should be kept on beta blocker therapy atleast for 2 weeks before surgical procedure and should be continued for atleast a week there after for adequate control oh heart rate perioperatively, use of statins reduces the risk of perioperative or postoperative cardiac events if patient is dyslipidemic. Premedication with hypnotics and anxiolytics should be done such a tab. Alprax should be given one night before the surgery and Ing medazolam should be given as premedication to prevent sudden rise in heart rate or blood pressure. Perioperative hypothermia is associated with catecholamine release and may produce tachycardia and vasoconstriction producing increased afterload. All factors that stimulate sympathetic activity should be avoided such as anxiety, pain, shivering ,hypoxia, hypercarbia. For general anaesthesia . IV opioids such as fentanyl should be given to produce analgesia and cardiovascular reflex blunting in response to intubation . Most intravenous agents depress myocardial contractility and decrease systemic vascular resistance ,and these actions could have an adverse effect on tissue oxygen delivery during induction of anesthesia. Alternatively, some evidence suggests that etomidate may provide hemodynamic stability. Ketamine should be avoided if there is preexisting hypertension but it is useful in neonates with duct dependent circulation present in extrimities. Maintenance:TIVA or agents such as isoflurane or sevoflurane could be used . volatile anesthetic agents may offer cardioprotection by ischemic pre- conditioningmainly isoflurane and opening of the K-ATP channel in mitochondria. To avoid aberrant rise in B.P. intraoperatively I.V. infusion of drugs such as Na nitroprusside or nitroglycerine could be used as it lowers SVR without compromising coronary perfusion. In order to manage sudden tachycardia adequate depth of anesthesia should be maintained, analgesia should be attained using NSAIDS and opioids , and patient could be taken on beta blocker infusion intra operatively. Analgesia is obtained by inj. Paracetamol
Spinal should be avoided as sudden unopposed parasympathetic control may leads to uncontrolled fall in SVR leading to hypotension and tachycardia or Possibly, the combination of hypertension and a decrease use in intra abdominal pressure (due to decreased abdominal muscle tone from spinal anesthesia) resulted in increased transluminal pressure sufficient to permit the aortic aneurysm to rupture. Epidural anesthesia could be used as fall in svr is slow and controlled. Drugs such as ropivacaine should be used as it is stable hemodynamically and on the counter available in different concentrations.
In our patient we avoided general anaesthesia as well as spinal anesthesia to avoid sudden changes in hemodynamic parameters.so here we have used Illioinguinal nerve block (IIN/IHN) block, and infiltration of the surgical field with a long-acting local anesthetic (LA) agent.
CONCLUSION: In our case report, we presented successful management of a patient of marfan syndrome with aortic aneurysm with inguinal hernia with ilioiguinal block. Several retrospective studies and randomized controlled trials have demonstrated the clinical and pharmacoeconomic superiority of local anesthesia over spinal and general anesthesia. Other reports have shown that LA infiltration is associated with lower postoperative visual analogue scale (VAS) scores, reduced analgesic consumption, and longer times to use of the first rescue analgesic.