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Abstract
Background and Aims s-ICD (subcutaneous-Implantable Cardioverter Defibrillator) is crucial in patients at risk of cardiac adverse events. Positioning technique requires in deep sedation or general anesthesia two incisions with generator placed between ‘serratus’ and ‘latissimus’ muscles while defibrillator lead goes through parasternal incision. We report a case of s-ICD implantation under regional anesthesia and sedation.
Methods A male patient, aged-44, BMI 21, severe post-ischaemic cardiomyopathy (EF 26%, TAPSE 14 mm, PAP 67 mmHg, BNP 1428), ASA 3, was scheduled for s-ICD implantation. After valid informed consent, US-SAPB was performed aseptically, using 80-mm echogenic, atraumatic needle, at mid-axillary line, fifth rib, left hemithorax. Anatomy and needle’s tip correctly viewed. After negative aspiration, in boluses, 0.5% ropivacaine 20 ml were injected. In full asepsis US-PsB, left second and fourth intercostal spaces, was performed; 50-mm echogenic, atraumatic needle. Anatomy and needle’s tip correctly viewed. 0.375% ropivacaine 4 ml was injected for each block. No complications. Pneumothorax was excluded by LUS. 10-MHz linear probe was used. MAC (Monitored Anesthesia Care) was provided. Patient was sedated with midazolam 2 mg e.v., propofol 50 mg e.v. and dexmedetomidine in continuous intravenous infusion (0,5mcg/kg/h), in spontaneous breathing and 30% O2 mask.
Results Operation began 15 minutes after beginning of MAC, 45 minutes after blockades placement. Patient vital signs, although severely sick, remained stable. No pain reported. Patient was observed in PACU and discharged with Aldrete-score 10.
Conclusions In our experience we perform ultrasound-guided interfascial plane blocks with high profile of efficacy and safety in s-ICD placement also in sick patients.