[Downloaded free from http://www.joacc.com on Wednesday, September 28, 2016, IP: 95.49.95.63]
Case Report Anesthetic management of a patient with Eisenmenger’s syndrome for an emergency caesarean section in an under resourced area Joanna Samantha Rodrigues, Thrivikram Shenoy, Manasa Acharya
ABSTRACT
Department of Anaesthesiology, Kasturba Medical College, Mangalore, Karnataka, India
Address for correspondence: Dr. Joanna Samantha Rodrigues, Department of Anaesthesiology, Kasturba Medical College, Mangalore, Karnataka, India. E-mail:
[email protected]
Eisenmenger’s syndrome, although uncommon, has a plethora of literature available on its anesthetic management for caesarean sections. Options of management have varied from general anesthesia to continuous spinal to epidurals. However, management without the essential invasive monitoring devices poses a formidable challenge to the anesthetist. We present a case of a 26-year-old primigravida with Eisenmenger’s syndrome with pulmonary hypertension in labor who underwent an emergency cesarean section under epidural anesthesia in a hospital that lacked agents to maintain the cardiovascular stability as well as monitoring equipment - a situation not so uncommon in low resourced areas. The intra-operative course was uneventful but tragically she died on the 3 rd postoperative day. Key words: Caesarean section, Eisenmenger’s syndrome, epidural anesthesia, pulmonary hypertension, under resourced area
INTRODUCTION
CASE REPORT
P
ulmonary hypertension, with congenital heart disease, is seen in large systemic-to-pulmonary communications, such as ventricular septal defect (VSD) and patent ductus arteriosus. On progression, it leads to shunt reversal a condition termed Eisenmenger syndrome.[1]
A 26-year-old primigravida at 35 weeks of gestation, in labor, weighing 45 kg, known case of VSD with severe pulmonary arterial hypertension, diagnosed 5 years ago, who developed Eisenmenger’s syndrome at the 2nd month of gestation was referred to our hospital for emergency caesarean section.
Pregnancy in this setting is associated with substantial maternofetal risk. Maternal mortality is high, with a cumulative risk of 30-70%.[2,3] The principle of any anesthetic technique chosen is to maintain systemic vascular resistance (SVR), avoiding its fall or increase in pulmonary vascular resistance (PVR). In a developing country like India, encountering a set up lacking modern facilities is common. Burdened financially, such a patient presents a herculean challenge.
Preoperatively, apart from exertional dyspnea, she was asymptomatic. Physical examination revealed Grade II clubbing, pulse rate of 82/min, blood pressure (BP) of 108/80 mmHg and room air oxygen saturation (SpO2) of 80% with no rise in jugular venous pressure. Central cyanosis was observed. Lungs were clear to auscultate, and cardiac examination showed regular rate and rhythm with loud P2 and pansystolic murmur over the lower left sternal border. Electrocardiography (ECG) showed right axis deviation, right ventricular hypertrophy and inverted P waves in lead II III and Lead avf. Two-dimensional echo color Doppler revealed a large subacute VSD, mild tricuspid regurgitation with a bidirectional shunt and an ejection fraction of 58% with severe pulmonary hypertension. Pulmonary artery pressure was not indicated. Hemoglobin (Hb) was 12.2 g%, and platelet count of 129,000/mm3. Arterial blood gas was unavailable. The cardiologist advised to undergo an emergency caesarean section under high risk. Peripheral
Access this article online Quick Response Code: Website: www.joacc.com DOI: 10.4103/2249-4472.155196
Journal of Obstetric Anaesthesia and Critical Care / Jan-Jun 2015 / Vol 5 | Issue 1
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[Downloaded free from http://www.joacc.com on Wednesday, September 28, 2016, IP: 95.49.95.63] Rodrigues, et al.: Emergency section for a patient with Eisenmenger’s syndrome in an under resourced area
venous access was secured. Meticulous attention was paid to the avoidance of bubbles in lines and syringes because of the risk of paradoxical embolus. She was premedicated with ranitidine 150 mg and metoclopramide 10 mg intravenous 20 min prior to surgery. In the operation theatre, standard monitors — ECG leads, noninvasive BP, saturation probe were connected. Oxygen via Hudson mask at 8 l/min was supplemented. SpO2 increased to 88%. The preinduction BP and heart rate were 126/62 mmHg and 82/min respectively. Under all aseptic precautions with the patient in the left lateral position an epidural catheter was inserted at the L3-L4 intervertebral space. Incremental doses of 3-5 mL of 2% lidocaine without epinephrine were administered every 5 min, and a sensory block to the level of T8 was achieved with 12 mL lidocaine over 30 min. Adequate analgesia was achieved. No hypotension developed intra-operatively. No further top up doses of epidural were required. A live male baby with Apgar score of 5 at 1 min and 8 at 5 min was extracted. Intravenous infusion of oxytocin 15 units was administered slowly over 30 min. A volume of 800 mL Ringer’s solution was administered during the 48 min surgery. Estimated blood loss was 200 mL. Urine volume was 200 mL. Patient was shifted to the intensive care unit. Unfortunately despite all our efforts, our patient developed respiratory distress and fever on the 3rd postoperative day along with severe anemia (Hb 6 g%) and leukocytosis (25,000/cm3) and she ultimately succumbed to her illness.
DISCUSSION In Eisenmenger’s syndrome, there is a reversal of a left to right shunt occurring due to high right-sided heart pressure as compared to the left side. Pregnancy-induced systemic vasodilation is detrimental in parturients with Eisenmenger’s syndrome. Reduced SVR may increase right-to-left shunting[4] and decrease pulmonary blood flow, leading to further hypoxemia with significant risks for both mother and fetus. Anesthetic management herein requires balancing SVR and PVR. Regional and general anesthesia have been used. Inadvertent hypotension can occur with both techniques. The problems of general anesthesia are decrease in venous return and cardiac output. Many induction and maintenance agents depress myocardial function and reduce SVR. Drugs chosen should be those causing least hemodynamic disturbance, that is, opioid agonists or etomidate. Due to their unavailability, we opted for epidural anesthesia. The hazards of general anesthesia are avoided by regional anesthesia, although the level of block required using a regional technique might produce excessive sympathetic block and an uncontrolled decrease in the SVR.[5] 28
Epidural anesthesia has been used successfully in this condition[6,7] and because of its slow onset; this technique has minimal precipitous hemodynamic changes. However, meta-analysis doesn’t show a significant difference in perioperative mortality between general and regional anesthesia, and both approaches have significant morbidity and mortality.[8] Argus eyed monitoring forms the mainstay of intra-operative management. Though our set up lacked invasive arterial BP and central venous pressure (CVP) monitoring, we relied immensely on the pulse oximetry to assess the degree of right to left shunt. We had no access to cardio stable drugs like etomidate or free supply of opioids. We could have referred the patient to our premiere, medical college hospital but the financial and time constraints prohibited us as our patient was in active labor. Fluid management is a double edged sword. We provided adequate uterine tilt, monitored the urine output and dehydration status to judiciously administer fluids. Oxygen is a pulmonary vasodilator decreasing the blood flow across the right-to-left shunt thereby improving the saturation. So it should be provided throughout the perioperative period. At the end of the procedure with oxygen supplementation, our patient achieved a saturation of 98%. Thromboembolism prophylaxis should be encouraged by early ambulation and if prolonged immobilization is anticipated subcutaneous administration of heparin should be given.[9] On the 3rd postoperative day, our patient developed respiratory distress. We suspected either pulmonary embolism, right heart failure, transfusion-related acute lung injury, septicemia or disseminated intravascular coagulation. The most common cause of respiratory distress in such patients being right heart failure due to fluid shifts and iatrogenic fluid overload which can be detected by CVP monitoring or a pulmonary artery catheter. The blood cultures, however, revealed sepsis and was probably the cause of death. If this patient had received treatment in a tertiary carefully equipped hospital, which offered invasive intra- and post-operative monitoring modalities and essential drugs, we would have probably reaped a different outcome.
CONCLUSION Although we were successfully able to anaesthetize a patient, with Eisenmenger’s syndrome in an emergent situation, with minimal resources and financial restraints, the utility of an invasive monitoring device such as an arterial line or pulmonary artery catheter would have provided more information about the cardiac pressures intra-operatively and enabled vigilant monitoring in the postoperative period along with tactful management thereby reducing the mortality rate. Journal of Obstetric Anaesthesia and Critical Care / Jan-Jun 2015 / Vol 5 | Issue 1
[Downloaded free from http://www.joacc.com on Wednesday, September 28, 2016, IP: 95.49.95.63] Rodrigues, et al.: Emergency section for a patient with Eisenmenger’s syndrome in an under resourced area
REFERENCES
6.
1.
7.
2.
3.
4. 5.
Lyons B, Motherway C, Casey W, Doherty P. The anaesthetic management of the child with Eisenmenger’s syndrome. Can J Anaesth 1995;42:904-9. Cole PJ, Cross MH, Dresner M. Incremental spinal anaesthesia for elective caesarean section in a patient with Eisenmenger’s syndrome. Br J Anaesth 2001;86:723-6. Kandasamy R, Koh KF, Tham SL, Reddy S. Anaesthesia for caesarean section in a patient with Eisenmenger’s syndrome. Singapore Med J 2000;41:356-8. Foster JM, Jones RM. The anaesthetic management of the Eisenmenger syndrome. Ann R Coll Surg Engl 1984;66:353-5. Fang G, Tian YK, Mei W. Anaesthesia Management of Caesarean Section in Two Patients with Eisenmenger’s Syndrome. Anesthesiol Res Pract 2011;2011:972671.
Journal of Obstetric Anaesthesia and Critical Care / Jan-Jun 2015 / Vol 5 | Issue 1
8. 9.
Spinnato JA, Kraynack BJ, Cooper MW. Eisenmenger’s syndrome in pregnancy: Epidural anesthesia for elective cesarean section. N Engl J Med 1981;304:1215-7. Rosenberg B, Simon K, Peretz BA, Roguin N, Birkhahn HJ. Eisenmenger’s syndrome in pregnancy. Controlled segmental epidural block for cesarean section. Reg Anaesth 1984;7:131-3. Ammash NM, Connolly HM, Abel MD, Warnes CA. Noncardiac surgery in Eisenmenger syndrome. J Am Coll Cardiol 1999;33:222-7. O’Kelly SW, Hayden-Smith J. Eisenmenger’s syndrome: Surgical perspectives and anaesthetic implications. Br J Hosp Med 1994; 51:150-3.
Cite this article as: Rodrigues JS, Shenoy T, Acharya M. Anesthetic management of a patient with Eisenmenger’s syndrome for an emergency caesarean section in an under resourced area. J Obstet Anaesth Crit Care 2015;5:27-9. Source of Support: Nil, Conflict of Interest: None declared.
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