Author Information
Fernandes S*, Mali A**, Ritika***, Deo R****.
(Additional
Professor, Assistant Professor, Second
Year Resident,
Department ofAnaesthesia, T N Medical College and BYL Nair Hospital , Mumbai ,
India
Abstract
The Eisenmenger’s syndrome consists of
pulmonary hypertension with a reversed or bidirectional shunt at the
atrioventricular or aortopulmonary level. The pathophysiological effects
usually worsen during pregnancy increasing the risk of a poor maternal outcome.[1]
There are numerous reports of patients with Eisenmenger’s syndrome posted for
non-cardiac surgeries. Both general and regional anaesthesia have been
successfully used in these patients. We discuss the anaesthetic goals and intra-operative management of a primigravida undergoing
dilatation and curettage under total intravenous anaesthesia.
Introduction
Maternal mortality in patients with
Eisenmenger’s syndrome is as high as 30-50% and these women are usually advised
to avoid conception. The increased blood volume of pregnancy is accommodated
due to vasodilation in the pulmonary and the systemic vascular bed. Patients
with Eisenmenger’s are at risk of right ventricular strain due to the
irreversible increase in pulmonary vascular resistance. The decrease in
systemic vascular resistance that normally occurs during pregnancy can
exaggerate the right to left shunt thus worsening the hypoxemia.
Case-Report
A 23year old female gravida 1,para 0 , weighing 30 kg, known
case of Eisenmenger’s syndrome was admitted with pain in the abdomen since 3 days
and bleeding per vaginum since 8days.She gave history of consuming an abortifacient
at a private clinic two weeks ago. At three years of age she was advised surgery
for ventricular septal defect but did not undergo the procedure due to
financial constraints. She had been advised to avoid strenuous work as she suffered dyspnoea Grade II . She was hospitalised for
chest pain, syncope and dyspnoea Grade IV two years ago. Electro-encephalography did not
reveal any epileptiform focus. She was advised Tab Sildenafil 25 mg BD.
Pre-operative physical examination
revealed Grade II clubbing, pulse rate of 90/min with occasional missed beats,
blood pressure of 100/70mmHg and room air saturation of 95% .No cyanosis, peripheral
oedema or rise in jugular venous pressure was observed. Lungs were clear to
auscultate, there was a pansystolic murmur over the left sternal border and a loud P2.
ECG showed rSR | in I, aVL, R in V1 and RS in V1-V3 with occasional
ventricular premature complexes. Two dimensional echocardiography with colour
Doppler revealed a large midmuscular VSD with bidirectional shunt, good
biventricular function and Pulmonary artery systolic pressure (PASP) by
Tricuspid regurgitation (TR) jet of 110mmHg. Her haemoglobin was 12.5 g/dL with
a hematocrit of 40% and a platelet count of 212000/cmm. Prothrombin time 19.6 sec,
Prothrombin index 71.43 and International Normalised Ratio (INR) 1.51. Ultrasonography showed a intrauterine sac but no yolk sac or
foetal pole. She had received Tab Misoprost 200mcg sublingually 4 hourly.
Infective endocarditis prophylaxis was given. Monitoring included Electrocardiography,
Noninvasive Blood Pressure, Capnometry
and Pulse-oximetry. Intravenous line was
secured with a 18 G intracath with
special precaution to avoid any air entrapment that could predispose to
paradoxical air embolism. We did not place an arterial line and central venous
catheter since it was a minor procedure. The
obstetrician had planned dilatation and endometrial curettage under a paracervical block but the patient was extremely
anxious.She was given i.v midazolam 0.5mg, i.v fentanyl 70 μg and i.v. ketamine
30 mg. She maintained a saturation of 99% breathing spontaneously with face
mask. Intra-operatively she continued to have Venticular Premature Contractions
(VPCs) but remained hemodynamically stable. Post-operative course was
uneventful and patient was discharged on day 3.
Discussion
Eisenmenger’s syndrome a term coined by Paul Wood is defined as
Pulmonary Vascular Obstructive Disease that develops as a consequence of a
large pre-existing left to right shunt such that pulmonary artery pressures approach systemic levels and the direction of
flow becomes bilateral or right to left.
Congenital heart defects that can result in Eisenmenger’s syndrome include
simple defects such as Atrial septal defect (ASD), Ventricular septal defect (VSD)
and Patent ductus arteriosus (PDA) as
well as complex defects such as Atrioventricular septal defect, truncus
arteriosus, aortopulmonary window and univentricular heart. The high pulmonary
vascular resistance (PVR) is usually
established by the age of
2 years except in ASD and is sometimes present from birth.[2] In the absence of complications, un-operated patients generally
have an excellent to good functional capacity up to their third decade and
thereafter usually experience a progressive decline in their physical
abilities. Most patients survive to
adulthood with a reported 77% and 42% survival rate at 15 and 25 yr of age
respectively.[3]
Thromboembolic phenomena are
responsible for as many as 43% of all maternal deaths with many occurring as
late as 4-6 weeks after delivery.[4] These women are often unable to
respond to the increased demands for oxygen during pregnancy. The decrease in
PVR seen in normal pregnancy does not occur in these women because PVR is
fixed. The decrease in Systemic vascular resistance (SVR) associated with pregnancy tends to exacerbate the
severity of the right to left shunt. The pregnancy associated decrease in Functional
residual capacity (FRC) also may predispose to hypoxemia.[5]
Primary goals of anesthesia management are: to maintain adequate SVR , maintain intravascular volume and venous
return, avoid aortocaval compression, prevent pain,myocardial depression, hypoxemia,
hypercarbia and acidosis which may cause
an increase in PVR. Several disadvantages are associated with the use of
general anesthesia. Positive pressure ventilation results in decreased venous
return which compromises cardiac output.The volatile anesthetic agents can
cause myocardial depression and decreased SVR .
Hofland et al have successfully conducted a laproscopic cholecystectomy by the
use of xenon anaesthesia and obtained cardiovascular stability.[6] Induction agents such as thiopental or
propofol decrease both contractility and
SVR which may exacerbate a right
to left shunt. Ketamine has been recommended as drug of choice for
induction because it has little effect on pulmonary and systemic vascular resistance, maintains spontaneous respiration and intact laryngopharygeal reflexes.[7]
Pretreatment with phenylephrine to prevent changes in SVR is also recommended although it may cause
similar vasoconstriction in both pulmonary and systemic circulations and
therefore have only little effect on shunt direction.[8] Increase in
SVR will cause increased left to right shunting with a further increase in
pulmonary pressure and right ventricular failure. Volume overload has the same
effect and hence fluids have to be administered judiciously.[9]
Tsutsumi et al performed a paracervical block using 1% lidocaine 12ml under 6 L
oxygen inhalation through a face mask.[10]
Although some physicians have stated that a Pulmonary artery
catheterisation (PAC) is essential for the management of pregnant women with
eisenmengers,[11] there are some who believe that a PAC may be
relatively contraindicated for several reasons.[12] In
the presence of a large intracardiac shunt, measurement of cardiac output by
thermodilution may not be accurate, these patients may not tolerate arrhythmias
, Pulmonary artery pressure (PAP) monitoring rarely yields useful information
in the presence of severe fixed pulmonary hypertension and the PAC may
predispose to pulmonary thromboembolism. To avoid to the risk of invasive
cardiac output monitoring in Eisenmenger syndrome, transthoracic bioimpedence
cardiography has been used.[13] Weber et al discussed the role of
low dose heparinization to prevent thromboembolism,[14] however this
was not considered in our patient as it
was a short procedure and she was ambulatory soon.
A multidisciplinary approach, judicious perioperative monitoring and
knowledge of pathophysiology of Eisenmenger’s syndrome is essential for a
successful outcome.
References
- Lieber S, Dewilde P, Huyghens L, Traey E, Gepts E. Eisenmenger syndrome and pregnancy. Acta Cardiol 1985;40:421-4
- Gary D Webb, Jeffrey F. Disease of
the heart , Pericardium and Pulmonary Vasculature. In: Braunwald’s Heart Disease : A Textbook of Cardiovascular
Medicine , Edn.Philadelphia
.W.B.Saunders 19. Libby Borrow Mann Zipes pg 1829-1853. Saunders 1600 John F Kennedy B oulevard
- Saha A, Balakrishnan KG, Jaiswal PK, Venkitachalam CG, Tharakan J, Titus T, et al. Prognosis for patients with Eisenmenger syndrome of various aetiology. Int J Cardiol. Jul 1994;45(3):199-207.
- American
- Harnett M , Mushlin P , Camann W .
Cardiovascular Disease In :Chestnut DH
,Obstetric Anesthesia . Principles and
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- J.Hofland, I.Gultuna, R Tenbrinck Xenon anaesthesia for laproscopic cholecystectomy in a patient with Eisenmengers syndrome. Br J Anaesth (2001) 86(6): 882-886
- Young.D and Mark,H. Fate of the patient with the Eisenmenger syndrome. Am J Cardiol 1971; 28:658-669
- Tsutsumi Y, Mizuno J, Takada S, Morita S. Paracervical block for dilatation and curettage in a parturient with eisenmenger syndrome. Masui 2010 Mar; 59(8): 379-82
- Spinnato JA, Kraynack BJ, Eisenmengers syndrome in pregnancy: Epidural analgesia for elective caesarean section. N Engl J Med 1981; 304: 1215-7
- Pollack KL, Chestnut DH, Wenstrom KD. Anesthetic Management of a parturient with Eisenmengers syndrome. Anesth Analg 1990;70:212-4
- Cole PJ, Cross M H, Dresner M Incremental spinal anaesthesia for elective caesarean in a patient with Eisenmengers syndrome. Br J Anaesth: 2001,86(5): 723-6
- Weber,RK, Buda,AJ and Levene,D.L.General anesthesia in Eisenmenger’s syndrome. Can Med Assoc J, 1977;117:1413-1414.
Citation
Fernandes S, Mali A, Ritika Deo R. Dilatation
And Curettage In A Patient Of Eisenmenger’s Syndrome: Anaesthesia Implications. JPGO 2015. Volume 2 No. 3.
Available from: http://www.jpgo.org/2015/03/dilatation-and-curettage-in-patient-of.html