///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

Elective cesarean section for acute type B aortic dissection under general anesthesia and remifentanil infusion

Abstract Number: 94
Abstract Type: Case Report/Case Series

Matthew W Martin MD1 ; Alexandra S Bullough MBChB2; Sean Neill MCChB3; Jennifer Vance MD4

Introduction:

Acute aortic dissection is a rare occurrence in women of childbearing age, though 50% of aortic dissections in women <40yrs occur during pregnancy . Stanford Type B (descending aorta) dissections are extremely rare in the obstetric population and usually undergo medical management. There is a paucity of literature regarding anesthetic management of a parturient with an acute Type B dissection. We report the first case and successful anesthetic management of a 27yo parturient at 38 weeks gestation diagnosed with an acute type B aortic dissection undergoing an elective cesarean section under GA with remifentanil.

Case Report:

A 27yo G1P0 ASA 4 presented for cesarean section at 38 weeks gestation with an acute Type B aortic dissection. The patient presented with acute dyspnea. Her chest CT showed an acute type B aortic dissection starting 2cm distal to the left subclavian artery with extension to the iliac arteries. Her past medical/surgical history was unremarkable. The patients medications included pre-natal vitamins and there were no drug allergies. Physical examination was unremarkable and an airway examination revealed, a Mallampati III grade with a normal thyroid-mental distance, >3cm mouth opening, and normal jaw protrusion. The patient was 66in tall and weight was 81kg.

The patient was admitted to the Cardiovascular ICU and started on Esmolol and Fenoldopam infusions. A lumbar epidural was placed at the L1/L2 interspace for anticipated labor and post-operative pain. A radial arterial line and internal jugular introducer were placed pre-operatively for hemodynamic monitoring.

The patient was transported to the operating room with continuous hemodynamic and fetal monitoring. The esmolol infusion was continued and a remifentanil infusion was initiated. The patients epidural infusion was also continued throughout the case. The patient was pre-oxygenated and a rapid sequence induction was performed with propofol and suxamethonium, which yielded a grade 1 laryngoscopic view. Hemodynamic stability was maintained throughout induction and a 7.5 mm ETT was successfully placed. Anesthesia was maintained with isoflurane, remifentanil infusion and cisatricurium. The neonate was delivered without incident. After delivery of the infant a transesophageal echocardiogram (TEE) was performed and revealed no propagation of the dissection flap. The patient was extubated awake and taken to the ICU in hemodynamically stable condition.

Post-operatively, the patient was transitioned to oral metoprolol for BP control and discharged post-operative day 6.

Discussion:

With the increased incidence of cardiovascular disease in the obstetric population, a multidisciplinary approach is essential to optimize both maternal and fetal outcomes. We report the first case and successful anesthetic management of a parturient with an acute type B aortic dissection undergoing an elective cesarean section under GA with a remifentanil infusion.

SOAP 2009