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Two Outlets On A One-Way Street: Successful Use of Epidural Anesthesia for Cesarean Section for a Parturient with Double-Outlet Single Ventricle
Abstract Number: SU-36
Abstract Type: Case Report/Case Series
There is an increasing number of single ventricle parturients who are presenting for labor management. These patients are at increased risk for morbidity and mortality, and pose some unique challenges to the anesthesiologist. We herein present the successful use of an epidural-based anesthetic for cesarean delivery in a parturient who is underwent an infantile lateral tunnel Fontan repair for complex double-outlet right ventricle anomaly with severe sub-pulmonary stenosis, a restrictive, non-committed VSD, and later developed sinus node dysfunction requiring a permanent atrial pacing system.
A 30 year old G1 parturient at 31 weeks of gestation with the above cardiac anomaly was admitted for PPROM and PTL requiring a semi-urgent cesarean delivery after tocolysis failed. She was followed closely by a pediatric cardiologist who had optimized her for her procedure. The patient had mild SOB but was otherwise stable. Her only home medication was digoxin. Her preoperative echocardiogram showed preserved single ventricular function with minimal VSD flow. Based on her congenital defects, we placed an awake arterial line under local anesthesia to help maintain hemodynamic stability throughout induction. We then positioned and placed a L4-L5 epidural in the OR. After a negative test dose, we dosed the epidural to maintain hemodynamics near baseline using 3 ml increment dosing of 2% lidocaine with small dose fentanyl until a T6 sensory level was obtained. Hemodynamic support was maintained with small doses of phenylephrine, and a co-load of 500 ml lactated ringer’s solution. The cesarean delivery was uneventful, and a healthy female infant was born with an APGAR of 8 and 9. She was transferred to telemetry postpartum care where she had an uneventful recovery, and was discharged home POD 3.
Parturient with single ventricle in pregnancy has increased over the last few decades due to the advances in pediatric cardiovascular surgery. Understanding the single ventricle physiology is of utmost importance when managing these parturients. These patients are preload dependent, require normal to slightly reduced afterload in order to maintain CO, and aggravating factors that would worsen pulmonary hypertension should be avoided (hypoxia, hypercarbia, acidosis).
Our anesthetic goal in this parturient was to maintain hemodynamic stability by avoiding the reduction in preload, preventing sudden decreases in afterload experienced after single shot spinal or use of volatile anesthetics, and maintain spontaneous ventilation. Slow, incremental dosing epidural allowed us to achieve these goals.