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Management of a parturient with Brugada Syndrome
Abstract Number: SU-37
Abstract Type: Case Report/Case Series
A 31 year old female with known history of Brugada Syndrome G1P0 at 40.2 weeks gestation presented for induction of labor. She was seen in our obstetric anesthesiology preoperative clinic during her second trimester to plan her care during labor.
Brugada syndrome is a genetic disease with a mutation in cardiac voltage gated sodium channels leading to abnormalities in cardiac action potentials, which can lead to fatal arrhythmias such as ventricular tachycardia or fibrillation. Often Brugada patients have an automatic implanted cardiac defibrillator for primary prevention of such arrhythmias. Since the use of local anesthetics via epidural is one of the primary modes of anesthesia care during labor, this creates a conundrum. A literature review on Brugada syndrome, and how it pertains to obstetric anesthesia was done. Due to the lack of specific recommendations, a plan was devised by our anesthesia team to minimize exposure to local anesthetics. The plan was to avoid early epidural if possible, and use a combined spinal-epidural for labor analgesia. Twenty micrograms (mcg) of Fentanyl and 1.25 milligrams (mg) of Bupivacaine were administered intrathecally initially. The patient had good pain relief, and an epidural infusion was started after the spinal analgesia had subsided. She was started on an epidural infusion that included 0.25% Lidocaine with 1:400,000 epinephrine and 3 mcg/mL of fentanyl. Studies have shown that lidocaine is less arrhythmogenic compared to bupivacaine in patients with Brugada Syndrome. Her labor progressed quickly, and reached 10 cm of cervical dilation two hours after the combined spinal-epidural was placed. She delivered a healthy infant. No anesthetic complications were noted. Her blood lidocaine level was 0.8 mcg/mL (reference range 1.2 - 5 mcg/mL, toxic levels >5 mcg/mL) at one hour after the epidural infusion was stopped. She remained on telemetry intrapartum and 24 hours postpartum. She had an uneventful postpartum course, and was discharged home on postpartum day 2.