Obstructive HCM for sinus surgery26-year-old man, 75 kg, for elective endoscopic sinus surgery with adrenaline-soaked packs

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A 26-year-old with obstructive HCM and exertional faints, for elective sinus surgery. Patient
   • Urgency: elective sinus surgery, so it can wait for answers. Stem trigger
   • Active cardiac condition? Possibly: unexplained faints mark sudden-death risk until cardiology says otherwise. Disease
   • Risk score: no RCRI items, so RCRI 0.
   • Functional capacity: two flights without symptoms, over 4 METs.
   • Decision: defer until cardiology has reviewed his faints and settled the ICD question.
   • Hypovolaemia, vasodilation and sympathetic drive narrow his outflow tract further.

2. Prepare

   How do you prepare?

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   • Cardiology review and updated echo; ICD question answered before elective surgery. Disease
   • Bisoprolol continues without a break.
   • Anxiolytic premedication and a fluid load before induction.
   • Surgeon warned: avoid or minimise adrenaline, and tell me before the packs go in. Surgery
   • Defibrillator ready; phenylephrine and esmolol drawn up. Crisis

3. Plan

   How do you conduct the anaesthetic?

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   • Arterial line and TEE available. Disease
   • Etomidate induction to avoid a sudden fall in SVR or a rise in heart rate.
   • Deep before laryngoscopy: volatile, or esmolol 10–25 mg, to blunt intubation. Airway
   • Small tidal volumes, faster rate, and no PEEP to protect his preload.
   • Volatile at moderate depth to mildly depress contractility. Disease
   • No head-up tilt or deliberately low BP for a dry field; both cut his preload. Surgery
   • Close monitoring after; treat pain, shivering and anxiety promptly. After surgery

4. Crisis

   After the packs go in, BP falls to 70/45, HR 118, with a new loud systolic murmur. What do you do?

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   • Adrenaline-driven outflow obstruction: tell the surgeon to remove the packs. (Crisis)
   • Fluid bolus and phenylephrine 50–100 mcg to restore afterload.
   • Once phenylephrine restores BP, esmolol in 10–25 mg boluses to slow and soften contraction.
   • TEE to confirm SAM and outflow obstruction.
   • No ephedrine, inotropes, nitrates or diuretics.
   • New AF or VT: immediate cardioversion.