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 Table of Contents  
Year : 2022  |  Volume : 8  |  Issue : 2  |  Page : 186-189

Unexplored role of hypobaric spinal anesthesia in cardiac patients with low ejection fraction: A case series

Department of Anaesthesia, Bangalore Baptist Hospital, Bengaluru, Karnataka, India

Date of Submission05-Feb-2022
Date of Decision02-May-2022
Date of Acceptance03-May-2022
Date of Web Publication23-Dec-2022

Correspondence Address:
Reena Ravindra Kadni
Department of Anaesthesia, Bangalore Baptist Hospital, Bellary Road, Hebbal, Bengaluru - 560 024, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrsm.jcrsm_10_22

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Anesthetic management of cardiac patients with low ejection fraction (EF) on two-dimensional echocardiography is a challenge. Underlying cardiac condition, type and duration of surgery and overall optimization of the patient determine the plan of anesthesia in these patients. Hypobaric spinal anesthesia (SA) known for its role in anorectal procedures was found to be a suitable tool in the management of cardiac patients with low EF who underwent infraumbilical surgeries in our case series. Hypobaric SA with 0.1% bupivacaine and fentanyl as an adjuvant gave a satisfactory outcome without significant hemodynamic changes with its differential blockade nature. We found it to be a simpler, safer, economical, and efficient technique which lasted for an average duration of 2½ hours, although it is a rarely practiced technique. We conclude that the practice of hypobaric SA can be considered one of the options in the anesthetic management of infraumbilical superficial surgeries of moderate duration in cardiac patients with low EF.

Keywords: Differential blockade, hypobaric, low ejection fraction, spinal anesthesia

How to cite this article:
Kadni RR, Pushpavathi P, Srinath A, Shivanna AD. Unexplored role of hypobaric spinal anesthesia in cardiac patients with low ejection fraction: A case series. J Curr Res Sci Med 2022;8:186-9

How to cite this URL:
Kadni RR, Pushpavathi P, Srinath A, Shivanna AD. Unexplored role of hypobaric spinal anesthesia in cardiac patients with low ejection fraction: A case series. J Curr Res Sci Med [serial online] 2022 [cited 2023 May 28];8:186-9. Available from: https://www.jcrsmed.org/text.asp?2022/8/2/186/364493

  Introduction Top

Patients with low ejection fraction (EF) are at constant risk of developing heart failure and arrhythmias and pose a challenge in anesthetic management. A tailored approach with either neuraxial, regional, or general anesthesia will be required for each patient. Low-dose hyperbaric spinal anesthesia (SA) for cardiac patients has been described in the literature.[1],[2],[3],[4] Hypobaric SA can provide a selective intrathecal spread of local anesthetics (LAs) on the nondependent side with extended analgesia and importantly hemodynamic stability.[5],[6] The role of hypobaric SA is an unexplored option in the management of patients with cardiac diseases with low EF for infraumbilical surgeries.

  Case Series Top

The patients were explained about the cardiac risk involved, and written informed high-risk consent was taken. Institutional Review Board approval was obtained. Neuraxial anesthesia was planned 12 hours after the last fractionated heparin dose. Coagulation profiles such as prothrombin time, international normalized ratio, and activated partial thromboplastin time (APTT) including platelet count were normal in all our three patients. All patients had EF in the range of 30%–40% with regional wall motion abnormalities and varying degrees of diastolic dysfunction, and their preoperative laboratory investigations are shown in [Table 1]. All patients were evaluated by the cardiologist and were considered to be moderate-to-severe cardiac risk.
Table 1: Preoperative investigations of all cases for hypobaric spinal anesthesia indicating their routine, coagulation, and cardiac function status

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Case 1

A 57-year-old American Society of Anesthesiologists (ASA) 3 male patient with dilated cardiomyopathy, alcoholic liver disease (ALD), chronic kidney disease, and type 2 diabetes mellitus (DM) was diagnosed with a right inguinal hernia with impending obstruction. He was planned for elective inguinal hernioplasty. He had a past history of congestive cardiac failure with an EF of 19% and was on conservative management for the last 6 months. EF on the day before surgery on echocardiography was 40%. He was optimized on carvedilol 3.125 mg, furosemide 40 mg, and ivabradine 5 mg BD. The plan of anesthesia was hypobaric SA with graded epidural anesthesia. Along with standard ASA monitors, the radial arterial line was secured with a 20G Vasofix (B-Braun) cannula and the right internal jugular vein central line was secured with a 7F triple lumen (Arrow) catheter under ultrasound guidance. The patient was positioned in the left lateral position (LLP) to anesthetize the surgical field on the right side. Epidural space was located at L3–L4 interspace, and the catheter was fixed. A test dose of 3 ml 2% lignocaine with adrenaline was given, and intravascular/intrathecal placement was ruled out. With a 26G Quincke spinal needle (BD), intrathecal 5 ml of hypobaric 0.1% bupivacaine with fentanyl 25 μg was given, which was prepared by diluting 2 ml of plain 0.25% bupivacaine in 2.5-ml distilled water and 0.5 ml of fentanyl.[5] He was kept in the LLP for 20 min and then in the supine position. Bromage motor blockade was Grade 2, and the sensory level achieved was T6. The surgery proceeded uneventfully for 2½ hours, and the patient was comfortable. Postoperatively, epidural was activated with 6 ml of 0.0625% bupivacaine with fentanyl 2 μg/ml for analgesia. The patient was shifted to the intensive care unit, and the postoperative period was uneventful.

Case 2

A 51-year-old male ASA3 with a history of chronic smoking, alcohol consumption, ischemic heart disease (IHD), DM, peripheral vascular disease (PVD), and hypertension was planned for skin grafting of the raw area over the right below-knee amputated stump. Hypobaric SA with 3 ml of 0.1% bupivacaine with 25-μg fentanyl in LLP was given to anesthetize the surgical field on the right side. As the anticipated duration of surgery was short, a smaller dose was planned. Motor blockade was Grade 1, and sensory level achieved was up to T10. The surgical procedure lasted for 1½ hours and was uneventful.

Case 3

A 54-year-old male ASA 3 with comorbidities of ALD, chronic obstructive pulmonary disease, IHD with percutaneous transluminal coronary angioplasty with partially revascularized left anterior descending stent, DM, hypertension, and smoker with peripheral vascular disease was planned for debridement of the necrotizing wound involving the entire left lower limb. Radial arterial line and 18G intravenous cannula were secured. Hypobaric SA with 5 ml of 0.1% bupivacaine with 25 μg of fentanyl was given in the right lateral position, and surgery continued in the same position. Motor blockade was Grade 3 with the highest sensory level achieved till T6. The procedure went uneventfully for 2½ hours.

The hemodynamic status of the patients is depicted in [Figure 1] and [Figure 2].
Figure 1: Blood pressure dynamics with hypobaric spinal anesthesia

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Figure 2: Heart rate dynamics with hypobaric spinal anesthesia

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  Discussion Top

The present case series describes the role of hypobaric SA in cardiac patients with low EF because of its cardio-stable nature.

Fewer studies describe the role of hypobaric SA as single-shot/continuous SA.[6] Excellent perioperative analgesia and hemodynamic stability were observed in patients undergoing anorectal surgery in jack-knife position with 5-ml intrathecal hypobaric bupivacaine 0.1%.[5] Dramatic reductions in the incidence of hypotension and use of vasopressors were observed when Ben David compared 4-mg intrathecal isobaric bupivacaine with 20-μg fentanyl with higher doses in patients with hip fractures.[7]

In the lateral position, hypobaric SA with bupivacaine proved to be better than isobaric by prolonging the sensory block on the operative side and delaying the use of analgesics.[6] Intrathecal spread depends on the densities of the cerebrospinal fluid and the drug solution used. The sinking effect of the hyperbaric and floating effect of hypobaric is an interplay between density and patient position.[8]

LAs block smaller fibers at lower concentrations than are required to block larger fibers of the same type. Unmyelinated fibers (sympathetic) are resistant to LAs compared with larger myelinated A-δ fibers. Bupivacaine and ropivacaine are relatively selective for sensory fibers and can explain the hemodynamic stability and dominant sensory loss achieved as a differential blockade with lower concentrations of intrathecal drugs.[9]

Commercially available plain LAs have a density of 0.9990 on the verge of becoming hypobaric. We diluted plain 0.25% bupivacaine with sterile distilled water and fentanyl.[5] Fentanyl as an additive improves the quality and duration of analgesia[10] and reduces the dose of LA required. It decreases the density of the LA solution and increases the mean spread and reduces the regression.[8]

The subarachnoid block is a well-acquired skill for anesthesiologists and proves to be a definitive and confirmatory technique. Epidural anesthesia needs more definitive expertise in such high-risk patients, can be associated with delay in onset of analgesia, and can cause patchy or unilateral anesthesia. Epidural anesthesia can meet the goals, but its use in shorter procedures may not be called for. Use of graded epidural,[10],[11] low dose SA[1],[2],[3],[4] or combination of low dose SA with epidural anesthesia and ultrasound guided regional blocks[12] are other options available for infraumbilical surgeries in cardiac patients. Regional anesthesia has minimal effect on contractility and reduces afterload improving cardiac output.[10] USG-guided regional blocks can pose difficulty in certain patients with obesity and edematous lower limb with distorted anatomy.

Low-dose hyperbaric SA (bupivacaine 7.5 mg with sufentanil 5 μg) resulted in a 15% decrease in average mean arterial pressure on cardiac patients with low EF undergoing lower-limb surgeries.[1] It was observed that the decrease of arterial pressure in patients with EF <40% was lower than in patients with EF >40% with low-dose SA for lower-limb surgeries.[2] Low-dose hyperbaric bupivacaine with fentanyl was used in patients with peripartum cardiomyopathy.[3],[4] Sympathetic activity block following SA would be expected to exaggerate the decrease in systemic vascular resistance and increased episodes of hypotension in cardiac patients. The drop in blood pressure and heart rate was <15% in all our cases except for the first case where a drop of blood pressure more than 15% at 60 min was observed. None of our patients required vasopressor supplementation. We observed that hypobaric SA was helpful for 2.5 hours of surgical duration. In case 3, the nondependent position for hypobaric SA helped the surgery to proceed without the need of repositioning.

Low-dose LA, its dilution, and volume facilitated the adequate intrathecal spread and selective sensory blockade maintaining cardiostability in our cases. The motor blockade grading though varied in all patients.

A study on higher number of such cardiac patients can add further insight into its benefits. An abnormal coagulation profile can hinder the performance of this technique in cardiac patients, so investigating the coagulation profile and eliciting a history from the patient regarding the consumption of anticoagulation medications is required.

  Conclusion Top

Hypobaric SA in our case series was found to be simple, safe, and economical and with a phenomenal benefit of hemodynamic stability. It can be considered one of the options in low EF cardiac patients for moderate duration infraumbilical superficial surgeries in settings where there is a lack of resources and difficulty in performing ultrasound-guided regional anesthesia. Although hypobaric SA is a known technique, there is a lack of its implementation practically. We suggest that in certain case scenarios as mentioned, this technique can be useful, as SA is an effective and well-practiced method by the anesthesiologist.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


The author would like to thank Dr. Shyamsundar LG, Senior Consultant, Department of Orthopaedics, Bangalore Baptist Hospital, for providing assistance in reviewing and language editing of the manuscript and Dr. Laji Samuel Abraham, Head of the Department of Anaesthesia, for support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sanatkar M, Farhanchi A, Manouchehrian N, Najafi A, Haddadi S, Rahmati J, et al. Subarachnoid block with low dose of bupivacaine and sufentanil in patients with coronary artery disease. ARYA Atheroscler 2014;10:94-9.  Back to cited text no. 1
Sanatkar M, Sadeghi M, Esmaeili N, Sadrossadat H, Shoroughi M, Ghazizadeh S, et al. The hemodynamic effects of spinal block with low dose of bupivacaine and sufentanil in patients with low myocardial ejection fraction. Acta Med Iran 2013;51:438-43.  Back to cited text no. 2
Gupta K, Gupta SP, Jose S, Balachander H. Low dose spinal anesthesia for peripartum cardiomyopathy. J Anaesthesiol Clin Pharmacol 2011;27:567-8.  Back to cited text no. 3
[PUBMED]  [Full text]  
Varghese N, Budania L, Rao M, Gaude Y, Berwal A. Low dose spinal anaesthesia and transversus abdominis plane block in a parturient with peripartum cardiomyopathy for caesarean section following a bloody epidural tap. Sri Lankan J Anaesthesiol 2019;27:77-9.  Back to cited text no. 4
Maroof M, Khan RM, Siddique M, Tariq M. Hypobaric spinal anaesthesia with bupivacaine (0.1%) gives selective sensory block for ano-rectal surgery. Can J Anaesth 1995;42:691-4.  Back to cited text no. 5
Faust A, Fournier R, Van Gessel E, Weber A, Hoffmeyer P, Gamulin Z. Isobaric versus hypobaric spinal bupivacaine for total hip arthroplasty in the lateral position. Anesth Analg 2003;97:589-94.  Back to cited text no. 6
Ben-David B, Frankel R, Arzumonov T, Marchevsky Y, Volpin G. Minidose bupivacaine-fentanyl spinal anesthesia for surgical repair of hip fracture in the aged. Anesthesiology 2000;92:6-10.  Back to cited text no. 7
Hocking G, Wildsmith JA. Intrathecal drug spread. Br J Anaesth 2004;93:568-78.  Back to cited text no. 8
Butterworth JF 4th. Clinical pharmacology of local anesthetics. In: Cousins MJ, Carr DB, Horlocker TT, Bridenbaugh PO, editors. Cousins and Bridenbaugh's Neural Blockade: In Clinical Anesthesia and Pain Medicine. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2009. p. 96-113.  Back to cited text no. 9
Kotekar N, Nagalkshmi NV, Chandrashekar. A rare case of peripartum cardiomyopathy posted for caesarean section. Indian J Anaesth 2007;51:60-4.  Back to cited text no. 10
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Yadav R, Solanki SL. “Graded” epidural anesthesia for renal transplant in a patient with dilated cardiomyopathy and severe left ventricle systolic dysfunction. Saudi J Anaesth 2017;11:222-4.  Back to cited text no. 11
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Tantry TP, Kadam D, Shetty P, Bhandary S. Combined femoral and sciatic nerve blocks for lower limb anaesthesia in anticoagulated patients with severe cardiac valvular lesions. Indian J Anaesth 2010;54:235-8.  Back to cited text no. 12
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  [Table 1]


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