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Anesthetic Management of Brugada Syndrome in Labor and Delivery: A Case Report
Abstract Number: S4D-7
Abstract Type: Case Report/Case Series
Brugada syndrome is a rare condition associated with right bundle branch block and ST segment elevation and with ventricular arrhythmias and sudden death in structurally normal hearts . The disorder is caused by mutations of ion channels in the cardiac conduction system, and as such, variables that influence conduction, including physiological stress and electrolyte abnormalities, can induce arrhythmias.
A 28 year-old G7P4024 at 37 weeks and 2 days presented to the labor and delivery service for scheduled induction of labor (IOL) and bilateral tubal ligation (BTL). She has a history significant for chronic atrial fibrillation on a beta blocker and Brugada syndrome with dual chamber automatic implantable cardiac defibrillator (AICD). She has had four prior vaginal deliveries under neuraxial anesthesia. During the second pregnancy, she experienced two cardiac arrests and an ensuing two-day coma. Subsequently, she received an AICD, which has discharged twice for sustained ventricular arrhythmia, both during the peripartum period of previous pregnancies.
A multidisciplinary approach including anesthesia and cardiology was elicited and the AICD was interrogated prior to admission and recorded 31 episodes of non-sustained ventricular tachycardia in the 90 days prior to admission. Other testing included serial electrocardiograms (ECG) which showed paroxysmal atrial fibrillation and echocardiogram which was unremarkable.
For the IOL, the patient was placed on continuous cardiac monitoring, including 5-lead ECG, blood pressure, oxygen saturation, and fetal heart tracings. A combined spinal-epidural technique (CSE) was performed with an intrathecal injection of 25mcg fentanyl followed by an epidural infusion of 8mL/hour of 0.1% bupivacaine and 2mcg/mL fentanyl. She was checked frequently to ensure adequate pain control. The patient had a spontaneous vaginal delivery and a viable male infant weighing 2.46 kg with Apgars of 91 and 95 4 hours after her CSE placement. The BTL was performed 3 hours later with the existing epidural for which she received a total of 75mcg fentanyl and divided doses of 10mL of 2% lidocaine plain. Her postoperative stay was without complications with plans to follow up with cardiology.
To date, there are scant reports on the management of patients with Brugada syndrome in the peripartum setting and anesthesia. Cardiology involvement, cardiac monitors, and access to a defibrillator are essential. Although there are conflicting results with the use of bupivacaine since it blocks and is linked longer to sodium channels, we utilized a CSE not only to decrease the risk of sympathetic output during labor but also to minimize the use of bupivacaine (infusion only) thus minimizing the risk of arrhythmias . Other factors that may lead to dysrhythmias such as a sympathetic surge, electrolyte imbalances, hyperthermia, and certain drugs should be avoided .