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Anaesthesia for Caesarean section in a parturient with newly diagnosed ventricular bigeminy
Abstract Number: F-66
Abstract Type: Case Report/Case Series
Ventricular bigeminy is a cardiac arrhythmia which has the potential to degenerate into ventricular
tachycardia or fibrillation. This is a case report highlighting the anaesthetic management and
postoperative care of a parturient with newly-diagnosed ventricular bigeminy undergoing urgent lower segment caesarean section(LSCS). A multi-disciplinary approach with appropriate monitoring and tailored anaesthetic technique is needed to achieve favourable materno-fetal outcome.
A healthy 31 year old primigravida was electively admitted for induction of labour at 38 weeks gestation. Maternal bradycardia was noted and ECG performed revealed ventricular bigeminy with heart rate between 38-45. Urgent cardiology referral was made. Impression was likely PVCs from right ventricular outflow tract obstruction. Decision was made for urgent LSCS.
Low dose combined spinal-epidural was performed in the sitting position, at the L4-L5 interspace. 1.8ml of 0.5% heavy bupivacaine, fentanyl 20mcg and morphine 100mcg were administered. Haemodynamic date such as heart rate, blood pressure and cardiac index were monitored using NEXFIN. Intermittent boluses of ephedrine were given. A healthy 2.5kg male baby was delivered. Intravenous duratocin 100mcg was adminstered.
The patient remained stable and was discharged on the third day. Outpatient investigations revealed high PVC load and beta blocker was commenced with advice on ablation techniques.
The NEXFIN device is a new, non-invasive continuous cardiac output monitor using finger arterial pulse-contour analysis. Arterial pressure is measured directly from a finger cuff using a volume-clamp method, where brachial arterial pressure is reconstructed using waveform filtering with pressure level correction. Advantages include ease of use, rapid installation and non-invasiveness. This avoids the potential serious complications associated with arterial line insertion.
A recent paper validated the use of NEXFIN in the obstetric population, where haemodynamic stability maintained during spinal anaesthesia for LSCS led to good outcomes. As there is no autoregulation of uteroplacental perfusion, maternal hypotension may lead to placental hypoperfusion and fetal ischaemia. The use of NEXFIN device provided continuous cardiac output and blood pressure monitoring, which enabled timely intervention to maintain haemodynamic stability.
Whilst the presence of more than 5 PVCs per minute has been reported to increase cardiac risk, recent studies have shown that aggressive attempts to maintain sinus rhythm do not improve outcomes in asymptomatic patients. Anti-arrhythmic was not administered and the patient remained stable.
Multi-disciplinary team involvement and vigilant monitoring contributed to the successful outcome. NEXFIN-a new finger plethysmography system allows easy installation within minutes and could therefore offer a quick haemodynamic overview, especially in the emergency setting.