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Department of Anaesthesia, Leeds General Inrmary, Great George Street, Leeds LS1 3EX, UK
*Corresponding author
We describe a new approach to anaesthesia for elective Caesarean section in a woman with
Eisenmenger's syndrome. Incremental regional anaesthesia was performed using a microspinal
catheter and haemodynamic monitoring included transthoracic bioimpedance cardiography.
This approach allowed the disadvantages of general anaesthesia and invasive cardiac output
monitoring to be avoided.
Br J Anaesth 2001; 86: 7236
Keywords: complications, Eisenmenger's syndrome; anaesthesia, obstetric; anaesthetic
techniques, subarachnoid
Accepted for publication: January 4, 2001
The Board of Management and Trustees of the British Journal of Anaesthesia 2001
Cole et al.
Eisenmenger's syndrome includes any condition in which a catheter that revealed a central venous pressure (CVP) of 13
communication between the systemic and pulmonary mm Hg. Meticulous attention was paid to the avoidance of
circulations gives rise to pulmonary vascular disease, bubbles in lines and syringes because of the risk of
which in turn causes a right to left shunt. It is a rare paradoxical embolus.
condition that poses a signicant risk of maternal death, With the patient in the sitting position, a 32-gauge
with the mortality of between 30 and 70%, having changed Ruschke catheter was inserted through a 24-gauge Sprotte
little over the last 50 yr.14 Eighty per cent of deaths occur spinal needle at the third to fourth lumbar spinal interspace.
between the 2nd and 30th post-natal day,1 but it remains In order to avoid maldistribution of the injected solution, the
unclear whether the choice of anaesthetic technique inu- catheter was pushed only 23 cm past the needle tip. Before
ences the outcome. The primary anaesthetic goal is to avoid giving any drugs through the catheter, the patient was placed
any haemodynamic change that might increase the right to in the supine position with left lateral tilt, and oxygen
left shunt and thereby increase hypoxaemia. With this in therapy was instituted via a Hudson mask. This increased
mind, many practitioners have avoided regional anaesthetic the oxygen saturation from 77 to 80%. Non-invasive cardiac
techniques in favour of general anaesthesia. We describe a output monitoring was then established using the transthor-
regional technique that, to our knowledge, has not been acic bioimpedence method (NCCOM3, BoMED
previously reported in this context. Manufacturing, Irvine, CA, USA), indicating a cardiac
output of 3.0 litre min1. Antibiotic prophylaxis was
administered. No formal uid preload was performed, but
Case report a slow infusion of 0.9% saline was commenced.
A 28-yr-old woman with complex cyanotic heart disease After rst giving diamorphine 300 mg through the spinal
was referred at 27 weeks gestation to our Antenatal catheter, incremental doses of 0.25 ml 0.5% hyperbaric
Anaesthetic Clinic. Her cardiac pathology had been classi- bupivacaine were titrated against anaesthetic and haemo-
ed as a form of Eisenmenger's syndrome and consisted of dynamic effects. Over a period of 30 min, a total of 2.25 ml
mitral atresia, a single ventricle, atrial septal defect, produced a block height to the eighth thoracic dermatome
transposition of great arteries with pulmonary hypertension, tested to touch with blunt forceps. During this time
and subsequent pulmonary vascular obstructive disease. Her oxygenation remained unchanged, arterial pressure fell by
condition had not been considered amenable to surgery, 10 mm Hg, cardiac output rose to 3.7 litre min1, and CVP
other than by heart/lung transplant. This was contra- gradually fell to 6 mm Hg. This latter change was corrected
indicated by her marked thoracic scoliolis, which had with a 300 ml bolus of saline. No maternal symptoms or
resulted in signicant restrictive respiratory disease. Her fetal distress occurred.
medical management consisted of nifedipine and frusemide, The LSCS proceeded uneventfully without pain or
and she underwent regular venesection for secondary discomfort and no further drugs were administered through
polycythaemia to maintain haemoglobin at approximately the spinal catheter. The usual bolus of oxytocin was omitted
15 g dl1. Despite counselling and advice that pregnancy in favour of uterine massage and a slow oxytocin infusion.
carried a signicant risk of death, she was determined to This produced adequate uterine contraction and blood loss
have children. After four miscarriages, her fth pregnancy was minimal. During uterine repair, an episode of dizziness
had progressed without signicant problems apart from coincided with a decrease in arterial pressure to 93/50.
some fetal growth retardation. A bolus of ephedrine 3 mg restored the arterial pressure,
Her condition at 27 weeks gestation had deteriorated from increased the cardiac output to its highest level of 4.9 litre
her non-pregnant state, with central cyanosis and dyspnoea, min1, and resolved the dizziness. This was the largest
worsening with speech. At that time, the obstetricians had haemodynamic change during the whole procedure. A total
made a provisional plan to perform an elective Caesarean of 1500 saline was given. Haemodynamics and oxygenation
section (LSCS) at 35 weeks, so the anaesthetic choices and in air were almost identical to pre-operative values at the
risks were explained to the patient and her family at an completion of surgery.
Anaesthetic Antenatal Clinic consultation. A formal man- Post-operative analgesia consisted of rectal diclofenac
agement plan was reserved until nearer the delivery date in 100 mg at the end of surgery, followed by regular 8 hourly
order to take changes in her condition into consideration. doses of 50 mg supplemented by a codeine/paracetamol
She was subsequently admitted at 29 weeks because of combination on request. The patient was transferred to the
increasing dyspnoea, and her diuretic and thromboprophy- Obstetric High Dependency Unit from where, after 36 h, she
lactic treatments were optimized. Because of continuing was transferred to a routine post-natal ward. At 48-h follow-
dyspnoea and poor fetal growth, it was decided to perform up, she gave maximal scores for peri-operative comfort and
the LSCS at 32 weeks. overall satisfaction, experiencing no nausea, vomiting, or
In the anaesthetic room, the patient was dyspnoeic with spinal headache. After 10 days she was discharged from
an oxygen saturation of 77% in air and an arterial pressure hospital, and 1 yr later both the patient and child are doing
of 120/60. Peripheral venous and radial arterial lines were well. Ignoring medical advice, she is now planning another
sited followed by a right internal jugular triple lumen pregnancy.
724
LSCS in a patient with Eisenmenger's syndrome
725
Cole et al.
obstetric practice, but the tachycardia it can produce would through an even larger spinal needle. An alternative is the
be undesirable in a patient with Eisenmenger's syndrome. Braun `catheter-over-needle' system17 where a 22-gauge
Whilst a norepinephrine infusion has been documented to spinal catheter covers a 27-gauge Quinke spinal needle with
maintain SVR throughout the peri-operative period,13 an the sharp point outside the catheter.
excessive dose of metaraminol has caused near catas-
trophe,14 presumably by increasing pulmonary vascular
resistance and increasing the degree of right to left shunt. References
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