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Successful use of Thromboelastography (TEG) as point of care for epidural analgesia in a parturient with single Ventricle (s/p Fontan repair); with platelet count is 76000 and severe scoliosis corrected with Harrington rod from T6-L3
Abstract Number: F-57
Abstract Type: Case Report/Case Series
Parturients with single ventricle physiology presents unique challenges to the anesthesiologist (1). It can be complicated by other medical conditions such as severe thrombocytopenia and corrected scoliosis with Harrington rod placement. We present successful use of labor epidural analgesia in a parturient with single ventricle s/p Fontan repair; with platelet count of 76000 and severe scoliosis corrected with Harrington rod at T6-L3 level, using Thromboelastography (TEG) as point of care. TEG proved to be an invaluable tool in the anesthetic management of this high risk patient.
A 21-year-old G1 parturient at 39 1/7 weeks gestation with past history s/p Fontan repair for congenital dextrocardia with hypoplastic left heart and mitral valve atresia and severe scoliosis corrected with Harrington rod placement admitted for vaginal delivery in consultation with cardiologist. On admission patient's platelet count was 85000 and on arrival to the L&D suite platelet count had decreased further to 76000. TEG was done which showed normal platelet function and coagulation status. Given the patient’s cardiac condition, we decided to proceed with epidural for labor analgesia; continuous spinal catheter if epidural failed. After reviewing the patient's previous spine radiograph, epidural was successfully placed at the L4/L5 level. Following the negative test dose, epidural infusion started with 0.1% ropivicaine with 2mcg/ml of fentanyl at 10cc/hr with good pain relief. Approximately 24 hrs after the induction labor, she had a vacuum assisted vaginal delivery of a live male infant with 9/9 APGAR scores and discharged home in stable condition.
Parturients presenting for labor with single ventricle is rare. Managing these patients required a multidisciplinary team approach and understanding the patient's single ventricle physiology is of utmost importance. Our plan to proceed with labor epidural analgesia was clouded by the patient's previous back surgery and more acutely by new onset thrombocytopenia. This complex patient was successfully managed with epidural analgesia utilizing TEG as point of care.
TEG is an indispensable tool when considering neuraxial block for peripartum anesthetic management in these high risk obstetric patients.
Jooste EH, Haft WA, Ames WA, Sherman FS, Vallejo MC. “Anesthetic care of parturients with single ventricle physiology”. J Clin Anesth. 2013 Aug;25(5):417-23.