OB Case

[pgg]

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19 year old female G1P0 presented in labor at 38 weeks. History significant for hypoplastic left heart syndrome s/p Fontan repair long ago. The patient states she's asymptomatic with no functional limitations. Taking PNV and nothing else. 65" 90 kg, MP 1 airway. She wants an epidural.

Any thoughts?

 

[huktonfonix]

yes on the epidural. Gotta keep her preload up though, since her PA flow is dependent on it. Would be nice to know her systemic ventricle function as well.

 

[Planktonmd]

The epidural should be well tolerated as long as you make sure she is not hypovolemic.
Actually the epidural here can improve the passive venous circulation by lowering the single ventricle's filling pressure and as a result lowering the LA pressure and increasing the blood flow from the pumonary arteries to the LA.

 

[bullard]

Your OBs don't have the common sense to give you a heads up/consult a week or two before this woman rolls in? That sucks.

Would anybody place invasive monitors before the epidural? (I'd say no.) What if she goes to section? (I'd say art line for sure.)

 

[cchoukal]

Just make sure she takes really deep breaths...

 

[Gern Blansten]

Your OBs don't have the common sense to give you a heads up/consult a week or two before this woman rolls in? That sucks.

Would anybody place invasive monitors before the epidural? (I'd say no.) What if she goes to section? (I'd say art line for sure.)

Since you mention monitors in the plural, most people who hear this would assume you might also be referring to other invasive monitors such as a PA cath. Knowing the plumbing of a Fontan's, I would definitely NOT try and float a PA catheter for a variety of reasons. Some may find these discussions helpful to learn more about the physiology:

http://emedicine.medscape.com/article/890196-overview

http://emedicine.medscape.com/article/890196-treatment

 

[huktonfonix]

Also, I had no idea how these things worked in my cardiac rotation until I read Jaffe (Surgical Procedures for the Anesthesiologist). Great explanation and pictures of the congenital heart diseases and repairs. I may not neccesarily agree with all of the the anesthetic management, but its still an excellent book to have.

 

[bullard]

Since you mention monitors in the plural, most people who hear this would assume you might also be referring to other invasive monitors such as a PA cath. Knowing the plumbing of a Fontan's, I would definitely NOT try and float a PA catheter for a variety of reasons. Some may find these discussions helpful to learn more about the physiology:

http://emedicine.medscape.com/article/890196-overview

http://emedicine.medscape.com/article/890196-treatment

Haha, kind of a trick question. I wouldn't try to float a Swan either. But one could still place a femoral line and follow CVPs, no? The absolute values would be relatively useless but the trend could be helpful.

 

[MTGas2B]

In my institution we had a hypoplastic left heart woman go to section. She had been floating around on the OB service for several weeks, so all of us were hoping not to be the one on call when she went to section. Of course it happens in the middle of the night. During her pre-op visits we had warned her that if we had to "go to sleep" for her section it could kill her, and stressed that an epidural was essential.

She gets an epidural, section goes smooth. As she's lying there while being closed (our OBs are very slow), she nods off and falls asleep, then she would wake herself up saying, "I can't fall asleep, I might die"

 

[pgg]

Cases like this are what I love about anesthesiology. You have to think through the patient's altered anatomy and physiology, then superimpose the physiologic changes of pregnancy, labor, and the postpartum period on that, then consider how anesthetic plans A, B, and C will stir things up. I think it's remarkable that these HLHS/Fontan patients are starting to survive to high functioning adulthood and show up for noncardiac surgery.

She'd been seen by her cardiologist, who forwarded the cryptic and nonsensical recommendation that she be allowed to push for no more than two hours. Seems to me that either she can push, or she can't - that time limit made no sense. This was even less helpful than the usual "avoid hypoxia, tachycardia, and hypotension" rubber stampage.

A few things to add to the discussion:

• These are high risk pregnancies - about 45% result in fetal losses before term.
• Because they're extremely dependent on preload, aortocaval compression carries even greater risks and decub position or LUD are critical.
• Regional techniques need to account for the fact that they're frequently on anticoagulants. They're often even more hypercoagulable than the usual hypercoagulable parturient. Couple reasons for this:
  • cyanosis leads to polycythemia --> no beneficial low-viscosity physiologic anemia
  • hepatic congestion --> deficiencies in protein C, S, and antithrombin
• Floating invasive monitors into the right circulation is probably a bad idea (mentioned above by Gern)
• The sympathectomy afforded by neuraxial techniques is often helpful. Pulmonary blood flow is driven by CVP - LVEDP, so a reduction in SVR, HR, and contractility can improve pulmonary flow; however, they can also reduce venous return and harm pulmonary flow.
• Maternal hypoxia/hypercarbia carries the additional risk of increasing pulmonary vascular resistance and hurting pulmonary flow, so the stakes are even higher with airway misadventures.

This particular patient got her epidural and had an uncomplicated SVD.

 

[Licoricestick]

Cases like this are what I love about anesthesiology. You have to think through the patient's altered anatomy and physiology, then superimpose the physiologic changes of pregnancy, labor, and the postpartum period on that, then consider how anesthetic plans A, B, and C will stir things up. I think it's remarkable that these HLHS/Fontan patients are starting to survive to high functioning adulthood and show up for noncardiac surgery.

👍
Great thread. You've just sent my reading off in a whole host of new directions - thanks!

 

[Pooh & Annie]

👍
Great thread. You've just sent my reading off in a whole host of new directions - thanks!

ditto!

 

[Bertelman]

She gets an epidural, section goes smooth. As she's lying there while being closed (our OBs are very slow), she nods off and falls asleep, then she would wake herself up saying, "I can't fall asleep, I might die"

 

[Consigliere]

She'd been seen by her cardiologist, who forwarded the cryptic and nonsensical recommendation...

Best part of your post. You'll see a lot of this in private practice; depending on where you practice.