Low-dose sequential combined spinal-epidural: an anaesthetic technique for caesarean section in patients with significant cardiac disease

Caesarean delivery in a parturient with Holt-Oram syndrome and implantable cardioverter defibrillator: anaesthetic considerations

Holt-Oram syndrome is a rare autosomal dominant disorder characterized by skeletal upper-limb dysplasias and congenital cardiac defects. Clinical manifestations of this syndrome vary, and range from sub clinical radiologic findings to overt, life-threatening disease. The author of this article reports safe and effective use of low dose sequential combined spinal and epidural anaesthesia for caesarean section in a parturient with Holt-Oram syndrome and automatic implantable cardioverter defibrillator (AICD). Concerns with regards to anaesthetic management include problems with vascular access, possible arrhythmias, the presence of an AICD, and the possibility of cardiovascular instability. The characteristics of this syndrome and anaesthetic implications are discussed.

The anesthetic management for cesarean delivery in a patient with Shone's syndrome

Shone's syndrome is a rare congenital cardiac condition that consists of up to four obstructive left-sided cardiac lesions. We report a 17-yr-old nullipara with Shone's syndrome who presented for cesarean delivery. She had mild mitral stenosis and mild left ventricular outflow tract obstruction. Epidural anesthesia was attempted, but the patient developed severe hypotension associated with fetal bradycardia necessitating immediate cesarean delivery under general anesthesia. The peripartum anesthetic and management considerations for these patients are discussed.

Anesthesia for cesarean section in a patient with Holt-Oram syndrome

Holt-Oram syndrome is a rare genetic disorder affecting the heart and upper limbs (atriodigital dysplasia). The manifestations of the limb defects may vary in severity from subtle carpal bone defects and triphalangeal thumb to digit aplasia and upper extremity phocomelia. Cardiac abnormalities include atrial and/or ventricular septal defects, anomalies in pulmonary venous return and various dysrhythmias. We present the anesthetic management of a parturient with this syndrome who underwent elective cesarean section and tubal ligation, conducted under combined spinal-epidural anesthesia with a low dose of intrathecal bupivacaine. Our goal was to avoid an excessively high sympathetic block or excessive sympathetic stimulation accompanied by potential deleterious effects on cardiac rhythm. Cardiac monitoring was continued in the postoperative period for 6 h because of the possibility of dysrhythmia.

Modifying labor routines for the woman with cardiac disease

The childbearing woman with cardiac disease presents a unique challenge to healthcare providers. The physiologic adaptations that accompany pregnancy and labor predispose the woman with cardiac disease to cardiac decompensation. Ideally, these women are identified to perinatal nursing staff prior to admission to the hospital in labor or for obstetrical procedures in order to provide adequate time for review of the specific cardiac lesion and development of an interdisciplinary plan of care. This article provides a comprehensive review of typical intrapartum routines that require modification and discusses strategies for adapting labor management for the woman with cardiac disease.

Ultra-low dose combined spinal-epidural anesthesia with intrathecal bupivacaine 3.75 mg for cesarean delivery: a randomized controlled trial

BACKGROUND

We wished to investigate the feasibility of an ultra low-dose combined spinal-epidural technique in providing surgical anesthesia for uncomplicated cesarean deliveries in a randomized, double-blind controlled trial.

METHOD

Forty-four normotensive, non-obese patients were randomized to receive either intrathecal hyperbaric bupivacaine 3.75 mg (low dose group, n=22) or 9 mg (conventional group, n=22), in addition to intrathecal fentanyl 25 microg, morphine 100 microg, and epidural 1.5% lidocaine 3 mL. Sensorimotor anesthesia and hemodynamic data were assessed at 2.5-min intervals for the first 15 min.

RESULTS

The maximal sensory block achieved in the low-dose group was significantly lower than that in the conventional group (median T3, [range T2-T6] vs. T2 [C2-T6], P<0.001) with a longer time taken to reach maximal sensory block. The low-dose group had less motor block, faster sensory regression to T10 dermatome and faster motor recovery to Bromage 0 (all P<0.001). The block failed to reach T6 bilaterally within 10 min in one patient in the low-dose group and two in the conventional group, with no significant difference in the need for epidural supplementation before or after delivery of the baby. The low-dose group experienced less hypotension (14% vs. 73%, P<0.001) with less ephedrine usage (0.68 vs. 17.5 mg, P<0.001). There was no difference in operating conditions and other side effects (shivering, pruritus).

CONCLUSION

We conclude that this technique results in a significantly lower incidence of maternal hypotension and has a role in high-risk parturients in whom maintenance of stable hemodynamics is imperative.