Abstract

We presented two cases in which patients with chronic heart failure experienced significant hypotension and respiratory distress during the left lateral decubitus position before spinal anesthesia for orthopedic surgery.

Keywords

heart failure, hypotension, lateral decubitus, trepopnea

The left lateral decubitus position has been linked to increased sympathetic nervous activity in patients with congestive heart failure or acute myocardial infarction. ¹ Furthermore, individuals with a larger left ventricle size and lower cardiac output tend to spend less time sleeping in the left lateral decubitus position, posing potential risks of hemodynamic compromise. ² We presented two cases in which patients with chronic heart failure experienced significant hypotension and respiratory distress during the left lateral decubitus position before spinal anesthesia for orthopedic surgery.

The Tri-Service General Hospital Institutional Review Board (TSGHIRB-A202315051) waived the requirement for patient informed consent as no identifiable personal medical information was included in this report for the two patients.

A 90-year-old Taiwanese man, measuring 175 cm in height and weighing 70 kg, was admitted for right hip replacement. His medical history included atrial fibrillation, and he had previously undergone pericardiocentesis twice for pericardial effusion many years ago. Preoperative echocardiography revealed a large pericardial effusion (maximal width 20 mm), dilated left atrium and right atrium, and normal left ventricular ejection fraction (70%), without clinical symptoms or signs of cardiac tamponade or heart failure. Standard monitoring, including three-lead electrocardiography, noninvasive blood pressure monitors, and pulse oximetry, was applied upon arrival to the operation room. After we established arterial blood pressure monitoring (130/70 mmHg, heart rate 90–120 beats per minute), the patient was positioned in the left lateral decubitus position for spinal anesthesia. Without any intravenous premedication during position preparation, his blood pressure markedly dropped to 80/40 mmHg (heart rate 120–130 beats per minute), recovering immediately upon returning to the supine position (Figure 1A). Subsequently, a cardiovascular surgeon was consulted, and a pericardial window operation was performed on the same day. The patient smoothly received spinal anesthesia in the left lateral decubitus position for right hip surgery one month later.

An 80-year-old Taiwanese female, 160 cm in height and 70 kg in weight, was admitted due to a right femoral shaft fracture. She reported a history of hypertension, atrial fibrillation, and cardiomegaly for many years. Preoperative echocardiography indicated a dilated right atrium (5.6 cm), right ventricle (4.4 cm), severe tricuspid regurgitation, and normal left ventricular ejection fraction (76%). In addition to standard monitoring, arterial blood pressure monitoring was established in a supine position upon arrival at the operating room. The patient was positioned in the left lateral decubitus position for spinal anesthesia. During skin disinfection without any intravenous premedication, her blood pressure gradually decreased from 150/65 mmHg (heart rate 65–80 beats per minute) to 90/40 mmHg (heart rate 70–80 beats per minute), accompanied by dyspnea and wheezing. Her blood pressure returned to normal after returning to the supine position, and respiratory distress spontaneously subsided in the subsequent reverse Trendelenburg position (Figure 1B). The operation was postponed, and diuretics were prescribed to achieve a negative fluid balance of 2,000 mL over the next 5 days. The patient then received spinal anesthesia for the orthopedic operation in the left lateral decubitus position without any adverse events.

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Fig. 1. Preoperative Chest X-rays Revealed Cardiomegaly in Case 1 (A) and Case 2 (B) (Upper)
Hemodynamic variables changed from the supine to the left lateral decubitus position before spinal anesthesia and subsequently recovered after returning to the supine position, without any intravenous medications (lower).

In these two cases, the left lateral decubitus position can potentially compress an enlarged left ventricle against the lateral chest wall due to gravity, resulting in an increase in pulmonary venous pressure and sympathetic nervous activity. ³ This compression may contribute to trepopnea, hypotension, and reduced cardiac output in patients with chronic heart failure. It is essential to consider these factors before and after performing procedures such as spinal anesthesia, epidural analgesia, upper gastrointestinal endoscopy, or thoracic surgery in the left lateral decubitus position.

Conflict of Interest

The authors declare no conflict of interest.

References