Prolonged recovery in an acromegalic patient with dilated cardiomyopathy: Points to ponder

Introduction: Dilated cardiomyopathy is an uncommon yet life threatening complication in acromegalic patients. Anesthetic management can be a challenge in the event of poor preoperative optimization in the event of emergency surgery. Case Summary: A 33 year old female patient with visual field defects of the right eye since 6 months was diagnosed to have pituitary macro adenoma and posted for trans sphenoidal excision. The case was an emergency in view of progressive visual loss owing to pressure effects on the optic chiasma. On examination, vitals where stable albeit the presence of B/L basal creptitations. 2D Echo revealed dilated cardiomyopathy with EF = 18% and was started on ACE inhibitors, beta blockers, statins and diuretics 2 days prior surgery. Anesthesia was induced with inj etomidate 0.2 mg/kg, inj fentanyl 2 mcg/kg and inj rocuronium 1 mg/kg. Anaesthesia was maintained with nitrous oxide: Oxygen (50:50), sevoflurane and atracurium 0.25 mg/kg. Dobutamine infusion started at 5 mcg/kg/min, surgery proceeded uneventfully. Vitals were maintained throughtout. After the surgery patient was reversed with inj neostigmine 0.05 mg/kg. However owing to poor neuromuscular tone and breathing the patient was electively ventilated for one day. This prolonged action of anesthetic drugs could be attributed to the low cardiac output status of the patient. Conclusion: Anesthetic management requires minimal use of anesthetics with minimal perturbations in hemodynamics. Adequate Preoperative optimization and ICU care could help in improving post operative outcomes in acromegaly patients with DCM.