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RegionalRegional anesthesiaanesthesia in the in the highhigh--riskrisk cardiaccardiac paparturrturientient
M. VercauterenM. Vercauteren, MD, , MD, PhDPhDUniversityUniversity HospitalHospital AntwerpAntwerp, BELGIUM, BELGIUM
The The highhigh--riskrisk parturientparturient
MaternalMaternal diseasedisease : : sometimessometimes worseworse or or betterbettereffecteffect of pain & of pain & laborlabor & & bearingbearing down : down :
CO , PAPCO , PAP--SVRSVR--PVRPVRpostdeliverypostdelivery autotransfusion : PCWP autotransfusion : PCWP
DeliveryDelivery maymay help to help to solvesolve probleproblemm–– bleedingbleeding , , preeclampsiapreeclampsia / HELLP/ HELLP–– CPR, CPR, somesome cardiaccardiac diseasesdiseases
High risk High risk parturientparturient
understandunderstand diseasedisease involvedinvolveddiseasedisease pregnancypregnancyddiseaseisease laborlabordiseasedisease fetusfetusimpact of impact of anesthesiaanesthesiaimpact of impact of perinatalperinatal drugsdrugs
MortalityMortality riskrisk
<1%<1%•• ValvularValvular regurgitationregurgitation / / prolapsprolaps /mild PS/mild PS•• RepairedRepaired, , ASDASD, VSD, VSD
11--15%15%•• Stenotic Stenotic lesionslesions, , severesevere PSPS, , previousprevious AMIAMI•• MetalicMetalic valvesvalves
>25%>25%•• NYHA III/NYHA III/IVIV, , severesevere AoSAoS, Marfan, PHT, Marfan, PHT•• LV LV dysfunctiondysfunction, , arrhythmiasarrhythmias, , cyanosiscyanosis
CardiacCardiac disordersdisorders
ValvularValvular diseasediseaseIschemicIschemic diseasediseaseSeptalSeptal defectsdefectsCardiomyopathyCardiomyopathyPrimaryPrimary PulmPulm. . HypertensionHypertensionOthersOthers : : •• MarfanMarfan, , ToFToF, Eisenmenger, Eisenmenger’’s complexs complex
ValvularValvular : in : in generalgeneral
LifeLife treatheningtreathening risksrisks•• EndocarditisEndocarditis ((newnew guidelinesguidelines ?)?)•• OxytocinOxytocin ((nevernever in bolus) in bolus) •• EmbolismEmbolism•• PulmonaryPulmonary hypertensionhypertension / / edemaedema•• ArrhythmiasArrhythmias•• BloodlossBloodloss
PulmonaryPulmonary
PulmonaryPulmonary edemaedema•• CongestiveCongestive heartheart failurefailure•• FluidFluid retentionretention / return (/ return (preloadpreload) ) afterafter birthbirth•• ExcessiveExcessive fluidsfluids ((prehydrationprehydration + drugs) + drugs) •• AutotransfusionAutotransfusion & return (& return (preloadpreload) ) afterafter birthbirth•• ProceedProceed withwith epiduralepidural , , furosemidefurosemide ????•• ColloidsColloids ??
Acute Acute pulmonarypulmonary hypertensionhypertension•• Stress, Stress, hypertensionhypertension, pain, , pain, SVRSVR, , HRHR, drugs, drugs
ArrhythmiasArrhythmias
More More withwith mitralmitral valvevalve diseasediseaseReducedReduced cardiaccardiac fillingfilling (time)(time)•• Effect Effect onon coronarycoronary perfusionperfusion
AccentuatedAccentuated byby•• OxytocinOxytocin•• EphedrineEphedrine
BloodBlood lossloss
MayMay bebe enhancedenhanced byby•• AvoidanceAvoidance of of oxytocicsoxytocics•• AnticoagulantsAnticoagulants (more TE risk)(more TE risk)•• OperativeOperative deliverydelivery
SpecificSpecific problemsproblems•• LessLess capacitycapacity toto compensatecompensate•• ββ--blockerblocker useuse
MaternalMaternal and and fetalfetal outcomeoutcome
MaternalMaternal (0.6(0.6--2%) & 2%) & fetalfetal mortalitymortalityPreterm Preterm deliverydelivery, , lowerlower BWBWIUGR and IUGR and ApgarApgar<8<8InstrumentalInstrumental deliverydelivery ((lessless stressfulstressful))•• butbut identicalidentical CC--sectionsection raterate
MalhotraMalhotra et al, 2004et al, 2004
n=312 n=312 valvularvalvular vsvs 321 321 healthyhealthy parturientsparturients
ValvularValvular defectsdefectsRegurgitationRegurgitation•• mitralmitral insufficiencyinsufficiency•• mitralmitral valvevalve prolapsprolaps•• aorticaortic insufficiencyinsufficiency
Stenotic Stenotic conditionsconditions•• mitralmitral stenosisstenosis•• aorticaortic stenosisstenosis•• pulmonicpulmonic stenosisstenosis
Mixed Mixed diseasediseaseCorrectedCorrected problemsproblems
RegurgitationRegurgitation : : avoidavoid........
BradycardiaBradycardia -- DysrhythmiaDysrhythmia•• IncreasesIncreases LV LV fillingfilling time, more time, more regurgitationregurgitation•• EphedrineEphedrine betterbetter thanthan phenylephrinephenylephrine
PreloadPreload & & afterloadafterload increaseincrease•• LRA LRA desirabledesirable ((fluidfluid preloadingpreloading !)!)•• AfterloadAfterload decreasedecrease : AVR : AVR benefitsbenefits more more thanthan MVRMVR
MyocardialMyocardial depressiondepression : LVF!: LVF!•• LV LV enlargementenlargement : : earlierearlier in AVRin AVR
BeneficialBeneficial effect of effect of pregnancypregnancy (BV, SVR, HR)(BV, SVR, HR)
MitralMitral valvevalve stenosisstenosis
frequent, frequent, severesevere ifif areaarea <1cm<1cm22
diastolicdiastolic pressurepressure gradientgradient & & durationdurationLA LA dilateddilated //thrombusthrombus //arrhythmiaarrhythmia(AF)(AF)•• maternalmaternal mortalitymortality significantlysignificantly increasedincreased
ifif tachycardiatachycardia oror AFAF•• reducedreduced LVF and LVF and atrialatrial enlargementenlargementballoon balloon valvuloplastyvalvuloplasty possiblepossibleCHFCHF, , PEPE, , secondsecond PHTPHT, , RVFRVF, , TricITricI
AorticAortic valvevalve stenosisstenosis
IschemiaIschemia (O(O22 supplysupply, , workloadworkload, LV , LV wallwall))
NYHA NYHA •• MayMay bebe severesevere butbut symptomlesssymptomless
EchocardiographyEchocardiography•• LV LV hypertrophyhypertrophy, , gradientgradient , , valvularvalvular areaarea•• <1cm<1cm22 : : severesevere, <0.6cm, <0.6cm22 : : criticalcritical
BetablockerBetablocker : LVF ??: LVF ??•• more more fillingfilling time and time and coronarycoronary flowflow
Stenotic defects : Stenotic defects : avoidavoid........
SVR SVR increaseincrease and and tachycardiatachycardia•• ketamineketamine , , atropine , atropine , ephedrineephedrine
severesevere bradycardiabradycardia : : phenylephrinephenylephrine ??markedmarked afterloadafterload reductionreduction•• LRA : OK LRA : OK ifif moderate AL moderate AL decreasedecrease
hypovolemiahypovolemia : : normonormo--volemicvolemic expansionexpansionmyocardialmyocardial depressiondepression, , dysrhythmiasdysrhythmiaseepinephrinepinephrine in in locallocal anestheticsanesthetics
OtherOther valvularvalvular problemsproblemsMitralMitral valvevalve prolapsprolaps•• AvoidAvoid tachycardiatachycardia, AL , AL reductionreduction,,……..‘‘OperatedOperated’’ patientspatients•• HF, PHT and HF, PHT and arrhythmiaarrhythmia maymay persistpersist•• AnticoagulationAnticoagulation : : heparinheparin betterbetter ??
–– ProtamineProtamine, LMWH , LMWH bleedingbleeding risk <12h?risk <12h?–– WarfarinWarfarin : PPSB : PPSB oror FFPFFP–– BleedingBleeding oror thromboembolismthromboembolism ? ?
Mixed Mixed problemsproblems : predominant ? : predominant ?
CoronaryCoronary arteryartery diseasediseaseIncreasedIncreased risk risk whenwhen•• in in thirdthird trimester , trimester , deliverydelivery <2weeks<2weeks•• CC--sectionsection•• ageage <30yrs , diabetes , <30yrs , diabetes , hypertensionhypertension
laborlabor : : epiduralepiduralCC--sectionsection : : epiduralepidural > > spinalspinalphenylephrinephenylephrine > > ephedrineephedrineLV LV failurefailure : GA+ : GA+ lowlow--dosedose EA ?EA ?
SeptumSeptum defects defects
LeftLeft toto RightRight shunt : shunt : avoidavoid
•• SVR SVR increasesincreases•• severesevere SVR SVR decreasedecrease (ASD)(ASD)•• volume volume overloadoverload , , tachycardiatachycardia (VSD)(VSD)
RightRight toto LeftLeft shunt (PHT) shunt (PHT) •• FallotFallot’’s s TetralogyTetralogy, Eisenmenger, Eisenmenger’’s complexs complex•• AvoidAvoid prepre-- and and afterloadafterload reductionreduction
PerinatalPerinatal//ParipartumParipartum DilatedDilated CMCM••LRA LRA beneficialbeneficial : : afterloadafterload reductionreduction
HypertrophicHypertrophic ObstructiveObstructive CMCM•• strictlystrictly normovolemianormovolemia, , avoidavoid tachycardiatachycardia•• nono inotropicsinotropics oror afterloadafterload reductionreduction•• MVR MVR frequentlyfrequently presentpresent•• preferablypreferably vaginalvaginal deliverydelivery•• RA : RA : ‘‘lowlow--LALA dosedose’’ techniquetechnique•• ifif CC--sectionsection : : generalgeneral anesthesiaanesthesia
CardiomyopathyCardiomyopathy
PulmonaryPulmonary HT HT CausesCauses ((functionalfunctional and and structuralstructural))•• PrimaryPrimary•• SecundarySecundary : : CHDCHD, , HIVHIV, , SLESLE, , TEDTED, , COPDCOPD……
TreatmentTreatment•• NitricNitric oxideoxide•• ProstacyclinProstacyclin ((VDVD, , PLTPLT, , AntiAnti--InflInfl, , ……))•• EndothelinEndothelin receptor receptor antagonistsantagonists•• PhosphodiesterasePhosphodiesterase inhibitorsinhibitors•• ViagraViagra, , VasopressinVasopressin
PulmonaryPulmonary HT : HT : avoidavoid........HypoxiaHypoxia , , hypercapniahypercapnia , stress, stressketamineketamine , N, N220 0 PG , PG , oxytocinoxytocin , , ergometrineergometrineMyocardialMyocardial depressiondepressionBradycardiaBradycardiaAfterloadAfterload reductionreductionPreloadPreload reductionreduction
WhatWhat aboutabout clinicalclinicalpracticepractice and and experienceexperience ??
LaborLabor analgesiaanalgesiaLowLow dosedose epiduralepidural mostlymostly wellwell toleratedtoleratedStress response : Stress response : mitigatesmitigates ValsalvaValsalvaeffectseffects byby decreasingdecreasing the the pushingpushing reflexreflexMore More stablestable hemodynamicshemodynamics duringduringcontractionscontractions and and expulsionexpulsion (forceps)(forceps)AL AL decreasedecrease : benefit in : benefit in regurgitationregurgitationCSE / CSE / EpiduralEpidural : : nono locallocal anestheticsanesthetics ??•• opioidopioid, , neostigmineneostigmine, , clonidineclonidine, adrenaline, adrenaline……
CSA ?CSA ?
LaborLabor CSA : CSA : AdvantagesAdvantages
AdjustableAdjustable, , titratabletitratableOpioidOpioid alonealone : F 15: F 15--2525µµg, S 5g, S 5--7.57.5µµggLaborLabor : : rapidrapid conversionconversion toto CSCSLowerLower doses (?)doses (?)•• notnot in most in most reportsreports ((leakageleakage ?)?)
BetterBetter hemodynamichemodynamic stabilitystability•• RobsonRobson et al, BJA 1993; 70: 634et al, BJA 1993; 70: 634--88
hypotensionhypotension 2/20 2/20 ptsptsHeadacheHeadache lessless important important thanthan benefitsbenefits
LaborLabor analgsiaanalgsia : : stenosisstenosisEpiduralEpidural•• HemmingsHemmings 1987, 1987, ShinShin 19931993•• SuntharalingamSuntharalingam 20012001•• AfterAfter MVR : MVR : NakaoNakao 20052005
Spinal Spinal •• KeeKee , n=3, , n=3, CSECSE , , startstart opioidsopioids alonealone•• VanhelderVanhelder 1998, 1998, CSECSE : mixed : mixed AoAo/M, /M, alsoalso II•• RansomRansom 1995, 1995, CSACSA : : sufentanilsufentanil•• Vd Velde 2003, Vd Velde 2003, CSACSA : : sufentanilsufentanil 2x (+ 2x (+ ropiropi))•• Pan & DPan & D’’Angelo 2004, Angelo 2004, CSECSE : : bupibupi + F + M+ F + M
CC--section : section : regurgitationregurgitationEpiduralEpidural•• Mitral Valve Mitral Valve ProlapsProlaps
–– Tanaka 1994Tanaka 1994–– Ruiz Castro 1996Ruiz Castro 1996–– AlcontaraAlcontara 1987 1987
•• AoAo regurgitationregurgitation–– AldersonAlderson 1987 (+ 1987 (+ preeclampsiapreeclampsia : : deathdeath))–– ZangrilloZangrillo 2005 2005
•• BetweenBetween MV replacement & MV replacement & reoperationreoperation–– NakaoNakao 20052005
CC--section : section : stenosisstenosisEpiduralEpidural•• AoAo StenosisStenosis
–– Brian 1993, Brian 1993, TamuraTamura 19971997–– ColcloughColclough 1990 /1990 /’’95, Peng 1997, 95, Peng 1997, XiaXia 2006 2006
•• PulmonicPulmonic stenosisstenosis–– ConwayConway 1994, Campbell 2003 (+ 1994, Campbell 2003 (+ AoIAoI))
•• Mitral Mitral stenosisstenosis–– ZiskindZiskind 1990, 1990, AfranguiAfrangui & & MalinowMalinow 19981998–– KubotaKubota 2003 (n=7), Pan & D2003 (n=7), Pan & D’’Angelo 2004Angelo 2004
CC--section : section : stenosisstenosisSpinalSpinal•• SDSSDS : : MostafaMostafa 1984 (MS)1984 (MS)•• CSECSE : : BosoBoso 2008 (AS)2008 (AS)•• CSA CSA : Pittard & : Pittard & VucevicVucevic 1998 (AS)1998 (AS)
+ 2 + 2 editorialseditorials
SDS to SDS to bebe avoidedavoided !!!!!!
LowLow dose CSE + EVE ?dose CSE + EVE ?
LewLew et alet al, , A & A 2004; 98: 810A & A 2004; 98: 810--44•• BH 5mg + EVE (6ml BH 5mg + EVE (6ml NaClNaCl 0.9%)0.9%)•• BH 8mg BH 8mg •• bothboth + + FentanylFentanyl 1010µµg)g)
•• qualityquality / / spreadspread : : identicalidentical•• fasterfaster MB MB recoveryrecovery•• hypotension : no hypotension : no differencedifference
vsvs
SittingSitting or or laterallateral ??InglisInglis et al, et al, AnaesthesiaAnaesthesia 1995 (SDS)1995 (SDS)BembridgeBembridge, , AnaesthesiaAnaesthesia 1986 (SDS)1986 (SDS)PatelPatel et al, Can J et al, Can J AnesthAnesth 1993 (CSE)1993 (CSE)KohlerKohler et al, A A et al, A A ScandScand 2002 (SDS 32002 (SDS 3’’))CoppejansCoppejans et al, et al, AnesthAnesth AnalgAnalg 2006 (CSE)2006 (CSE)
SittingSitting injection of injection of hyperbarichyperbaric BB•• SlowerSlower / / lessless rostral rostral spreadspread•• LessLess ((laterlater) hypotension) hypotension•• More More epiduralepidural supplementationsupplementation
RA for RA for nonnon--valvularvalvular diseasediseaseHOCM, PPCM, single HOCM, PPCM, single ventricleventricleAoAo dissection, dissection, coronarycoronary (CAD)(CAD)severalseveral case reports: case reports: CSE / CSE / CSACSA
HonigHonig et al, et al, AnAnäästhetiststhetist 1998 (CAD)1998 (CAD)IshiyamaIshiyama et al, A&A 2003 (HOCM)et al, A&A 2003 (HOCM)Ben Ben LetaifaLetaifa, , AnnAnn FrFr An An ReanRean 2002 (2002 (MarfanMarfan, , PuEdPuEd, MVI), MVI)OkutomiOkutomi et al, Acta et al, Acta AnaesthAnaesth ScandScand 2002 (HOCM, 2002 (HOCM, laborlabor))Dubois et al, Dubois et al, AnnAnn FrFr AnesthAnesth ReanimReanim 2003 (single 2003 (single ventrventr n=2)n=2)VelichovicVelichovic & & LeichtLeicht, IJOA 2004 (, IJOA 2004 (PPCMPPCM, n=3), n=3)LandauLandau et al, et al, ActaActa AnaesthAnaesth ScandScand 2004 (2004 (doubledouble outletoutlet RVRV))SmithSmith et al, IJOA 2008 (CAD, CS n=3, et al, IJOA 2008 (CAD, CS n=3, laborlabor n=1)n=1)
RA for RA for nonnon--valvularvalvular diseasedisease
EisenmengerEisenmenger’’s s complexcomplex ????AtanasoffAtanasoff, Acta , Acta AnaesthesiolAnaesthesiol ScandScand 19901990ColeCole et al, BJA 2001et al, BJA 2001SakurabaSakuraba et al, J et al, J AnesthAnesth 20042004
MARTIN et al, RAPM 2002; 27: 509MARTIN et al, RAPM 2002; 27: 509--13 (13 (reviewreview))--103 103 anestheticsanesthetics + 21 + 21 laborlabor analgesiaanalgesia-- mortalitymortality : : overalloverall 14%, RA 5%, GA 18% (NS)14%, RA 5%, GA 18% (NS)
major major surgerysurgery : 24%, minor 5% (p<0.05): 24%, minor 5% (p<0.05)laborlabor RA : 24% !!RA : 24% !!
RA for RA for nonnon--valvularvalvular diseasedisease
SevereSevere pulmonarypulmonary hypertension ??hypertension ??BONNIN et al, BONNIN et al, AnesthesiologyAnesthesiology 2005; 102: 11132005; 102: 1113--77--N=14, 15 N=14, 15 pregnanciespregnancies--Vaginal : n=4 (RA) (1 Vaginal : n=4 (RA) (1 dieddied, 1 , 1 worseworse) ) --CS CS underunder GA : n=4 (1 GA : n=4 (1 dieddied, 2 , 2 worseworse) ) --CS CS underunder CSE : n=5 (1 CSE : n=5 (1 dieddied, 4 stable), 4 stable)-- mortalitymortality :: n=2 n=2 beforebefore deliverydelivery
overall 36%overall 36%a place a place forfor lowlow dosedose CSE ??CSE ??
PerioperativePerioperative monitoringmonitoringECG , ECG , pulsepulse oxymetryoxymetryUS (US (EFEF?) ?) oror TEE (TEE (awakeawake ?)?)BloodBlood pressurepressure : : radialradial arteryartery•• AnticipatedAnticipated bloodblood loss, loss, prepre--eclampsiaeclampsia•• CO CO measurementmeasurement ??
Central Central venousvenous lineline ??WhatWhat willwill itit learnlearn ? Risk of ? Risk of arrhythmiasarrhythmiasPulmonaryPulmonary arteryartery cathetercatheter ??•• NYHA III/NYHA III/IVIV, , sheethsheeth onlyonly ? ? VascVasc trauma ?trauma ?
ConclusionsConclusionsMultidisciplinaryMultidisciplinary approachapproach (at 24wks ?)(at 24wks ?)LowLow--dosedose epiduralepidural is is mostlymostly OK OK forfor laborlaborSingleSingle--dosedose spinalspinal mostlymostly notnot the best the best ideaideaProblemsProblems notnot solvedsolved afterafter birthbirth oror surgerysurgeryInvasiveInvasive monitoringmonitoring ? ? CC--sectionsection : : notnot alwaysalways best best choicechoiceAllAll RA RA techniquestechniques are are notnot the the samesame•• OutweighOutweigh PROPRO’’s and s and CONsCONs•• IndividualIndividual judgementjudgement
HR
PL/AL
Contr
C-section
Ao-I
RA
Mi-I
RA
Mi-S
RA
CAD
RA>GA
SummarySummary : : avoidavoid……
HR
PL/AL
Contr
C-section
Ao-S GA>RA
PS/PHT GA
L to R R to L
GA/RA GA
Eisenm GA PPCM HOCM
RA GA
SummarySummary : : avoidavoid……
ConclusionsConclusions
ContraindicationsContraindications forfor RA (& RA (& pregnancypregnancy ?)?)•• FallotFallot’’s s tetralogytetralogy unlessunless repairedrepaired
–– GelsonGelson et al 2008, RA 67% (16pt / 26del)et al 2008, RA 67% (16pt / 26del)
•• EisenmengerEisenmenger’’s complexs complex•• AnticoagulationAnticoagulation•• HypertrophicHypertrophic subaorticsubaortic stenosisstenosis, HOCM, HOCM•• PrimaryPrimary pulmonarypulmonary hypertensionhypertension•• SevereSevere AoAo//pulmpulm stenosisstenosis (<0.6(<0.6--0.9cm0.9cm22))
AvoidAvoid ‘‘heroismheroism’’
The most important part of The most important part of ‘‘patientpatient carecare’’is is ‘‘caringcaring forfor the the patientpatient’’
DavidDavid L.L.BrownBrownRAPM 2003RAPM 2003