Journal of Clinical Anesthesia (2014) xx, xxx–xxx
Case Report
Chest ultrasonography in emergency Cesarean delivery in multi-valvular heart disease with pulmonary edema during spinal anesthesia Sukhen Samanta MD, PDCC (Senior Resident)a,⁎, Sujay Samanta MD (Senior Resident)b , Tanmoy Ghatak MD, PDCC (Senior Resident)b , V.K. Grover MD (Professor) c a
Department of Anesthesia & Critical Care (Trauma Centre), JPNA Trauma Centre, AIIMS, New Delhi, India 110029 Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Luckow, India 226014 c Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education & Research, Chandigarh, India 160012 b
Received 15 January 2013; revised 4 December 2013; accepted 4 December 2013
Keywords: Valvular heart disease; Cesarean section; Spinal anaesthesia; Chest ultrasound
Abstract Valvular heart disease in a parturient presenting for Cesarean section is challenging. A 25 year old primigravida parturient with severe mitral stenosis, mild mitral regurgitation, mild aortic regurgitation, and mild pulmonary arterial hypertension required Cesarean delivery after developing pulmonary edema. Low-dose spinal with hyperbaric bupivacine 0.5% 1.8 mL plus 25 μg of fentanyl was used for anesthesia. Chest ultrasonography (US) and transthoracic echocardiography (TTE) were used for monitoring purposes. Spinal-induced preload reduction improved the pulmonary edema, as evidenced by chest US. Chest US and TTE helped in fluid management. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Rheumatic heart diseases (RHD) are common in developing countries. It commonly affects multiple heart valves. Symptomatic RHD, especially mitral stenosis in pregnancy, increases the risk of adverse maternal and neonatal outcomes [1]. An emergency Cesarean delivery was performed successfully in a 25 year old parturient with severe mitral stenosis, mild mitral regurgitation (MR), and mild aortic regurgitation (AR) complicated by pulmonary edema with low-dose spinal anesthesia. Ultrasonography ⁎ Corresponding author. 17 Dr. A. N. Paul Lane, Bally, Howrah, West Bengal, India 711201. Tel.: + 91 9 87 153 2301. E-mail address: [email protected] (S. Samanta). http://dx.doi.org/10.1016/j.jclinane.2013.12.009 0952-8180/© 2014 Elsevier Inc. All rights reserved.
(US) was used as a monitoring tool. Chest US was performed for detection and monitoring of pulmonary edema in the perioperative period. Written, informed consent was obtained from the patient.
2. Case report A 25 year old, 51 kg primigravida at full term presented with active labor pain. She complained of dyspnea at rest and coughing that produced pink frothy sputum. She was referred to our hospital while receiving oxygen supplementation delivered by facemask. She had a diagnosed case of mitral stenosis associated with mild mitral regurgitation, aortic
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regurgitation, and mild pulmonary arterial hypertension. Her electrocardiogram (ECG) showed left atrial (LA) enlargement with right ventricular (RV) hypertrophy. Emergency transthoracic echocardiography (TTE) demonstrated severely stenosed mitral valve (0.9 cm2), peak/mean pressure gradient 28/17 mmHg, grade I mitral and aortic regurgitation with mild pulmonary arterial hypertension with LV ejection fraction of 40%. She was receiving digoxin (0.25 mg), one tablet daily for 5 days/week and furosemide (40 mg), one tablet twice daily with potassium chloride. She had also been receiving penicillin injection every 21 days for rheumatic fever prophylaxis. On preanesthetic examination in the operating room (OR), her pulse was 90 beats per minute (bpm), regular with no pulse deficit, and blood pressure was 126/66 mmHg. Auscultation showed mid-diastolic murmur grade 3/6 with slight loud S1, opening snap at the apical area. Her functional status was New York Heart Association (NYHA) functional class IV with a respiratory rate of 35–40 breaths per minute (breaths/min). Lung auscultation showed bilateral crepitations, which were confirmed on chest US showing B lines (Fig. 1). Her obstetrical examination showed a uterus of 37 weeks’ size with a nonreassuring fetal heart rate. There was no hepatomegaly. Her blood laboratory values showed hypokalemia (K 2.9 mEq/L) while coagulation and platelet count were within normal limits. She received intravenous (IV) ranitidine 50 mg, metoclopramide 10 mg, and ampicillin one gram preoperatively. We planned low-dose spinal anesthesia with hemodynamic monitoring. In the OR, standard basic monitors such as ECG, pulse oximeter, noninvasive blood pressure monitor, end-tidal carbon dioxide, and temperature were applied. Two large-bore IV catheters were secured. A phenylephrine infusion was started in one IV catheter at 2 μg/kg/min and titrated accordingly to maintain systemic vascular resistance (SVR). Baseline oxygen saturation (SpO2) was 88% with oxygen supplementation. One anesthesiologist prepared the subarachnoid block (SAB) while the other secured the arterial catheter in the left radial artery. Hyperbaric bupivacaine (0.5%) 1.8 mL with 25 μg of
fentanyl was given in SAB in the left lateral position, resulting in a level up to the T5 segment. Oxygenation improved significantly with reduced bilateral crepitations on auscultation. Perioperative bilateral chest US (Micromaxx Sonosite, Gurgaon, India) showed decreased B lines (Fig. 2) while TTE demonstrated reduced LA and RA chamber volumes. Potassium correction was started in a diluted IV solution of 40 mEq at a rate of 20 mEq/hr through a large peripheral vein. Early cord clamping was attempted to prevent auto transfusion. The infant’s birth weight was 2.4 kg, cord blood pH was 7.32, and APGAR scores were 8 at one minute and 9 at 5 minutes. After delivery, an oxytocin infusion of 25 U was started in titration. Methylergonovine was omitted. The patient received approximately 400 mL of hydroxyethyl starch intraoperatively. Total estimated blood loss was 800 mL without any need for transfusion. She remained hemodynamically stable throughout the surgery, with good urine output. Postoperatively, she was maintained in a headup position with oxygen supplementation using a Venturi mask. She was closely monitored for an additional 60 minutes in the Postanesthesia Care Unit. As her hemodynamics remained stable, she was moved to the High Dependency Unit (HDU) with the Venturi mask. A bolus of furosemide 40 mg was injected before transport to the HDU (at the time of recovery from spinal anesthesia). Her subsequent hospital course was uneventful. She was then referred to the Cardiothoracic and Cardiology Departments for further medical and surgical treatment.
Fig. 1 Chest ultrasonography showing B line artifacts before spinal anesthesia.
Fig. 2 Chest ultrasonography showing clearing of B lines after spinal anesthesia.
3. Discussion The parturient with heart disease is always challenging. Pregnancy and labor adds additional stress to an already compromised cardiovascular system. Patients with mitral stenosis have reduced blood flow from the LA to the left ventricle (LV) and increased LA pressure. Increased heart rate in pregnancy aggravates this condition by reducing diastolic filling time, leading to deceased LV filling and
Chest ultrasound in emergency C-section increased pulmonary blood volume, which causes more chances for pulmonary edema. After delivery of the baby, autotransfusion may precipitate heart failure and pulmonary edema [2]. The parturient with mitral stenosis has an increased incidence of congestive heart failure (CHF), and atrial fibrillation [3]. Digoxin is prescribed to increase myocardial contractility while reducing the ventricular rate in patients with atrial fibrillation. Diuretics cause hypokalemia, which aggravates digoxin toxicity. Fluctuation in hemodynamic status during labor, delivery, and in the immediate postpartum period may result in CHF and an increased chance of pulmonary edema. As there was also a high possibility of developing infective endocarditis, ampicillin was administered. Considering the risk of aspiration, she also received aspiration prophylaxis. Judicious use of fluids and diuretics are mandatory in frank pulmonary edema. Spinal anesthesia was used. Low-dose spinal anesthesia for vaginal instrumental delivery has been reported with good results in these patients [4]. Spinal-induced vasodilatation reduced preload (seen on TTE), thereby lessening the chance of pulmonary edema (as seen on chest US). Lung comets [5] or B lines on chest radiography were reduced in the postspinal period. Invasive cardiac monitoring such as radial artery cannulation is helpful for guiding fluid and drug therapy, especially in NYHA functional class III and IV patients [6]. We used arterial monitoring and perioperative TTE and US to assess the patient’s cardiac and fluid status. A decrease in SVR in a patient with fixed
3 cardiac output was prevented by small bolus doses, or titrated infusion, of phenylephrine.
3.1. Conclusions Low-dose spinal anesthesia was used for Cesarean delivery in a parturient with heart disease and frank pulmonary edema. Perioperative US is a good monitoring tool for better fluid and hemodynamic management.
References [1] Siu SC, Colman JM, Sorensen S, et al. Adverse neonatal and cardiac outcomes are more common in pregnant women with cardiac disease. Circulation 2002;105:2179-84. [2] Steer PJ, Gatzoulis MA, Baker P, editors. Heart Disease and Pregnancy. London: Royal College of Obstetricians and Gynaecologists Press; 2006. p. 157-68. [3] ACC/AHA guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/ American Heart Association. Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease). J Am Coll Cardiol 1998;32:1486–588. [4] Langesaeter E, Dragsund M, Rosseland LA. Regional anaesthesia for a Caesarean section in women with cardiac disease: a prospective study. Acta Anaesthesiol Scand 2010;54:46-54. [5] Picano E, Frassi F, Agricola E, Gligorova S, Gargani L, Mottola G. Ultrasound lung comets: a clinically useful sign of extravascular lung water. J Am Soc Echocardiogr 2006;19:356-63. [6] Hemmings GT, Whalley DG, O’Connor PJ, Benjamin A, Dunn C. Invasive monitoring and anesthesia management of patients with mitral stenosis. Can J Anaesth 1987;34:182-5.
Case Report
Chest ultrasonography in emergency Cesarean delivery in multi-valvular heart disease with pulmonary edema during spinal anesthesia Sukhen Samanta MD, PDCC (Senior Resident)a,⁎, Sujay Samanta MD (Senior Resident)b , Tanmoy Ghatak MD, PDCC (Senior Resident)b , V.K. Grover MD (Professor) c a
Department of Anesthesia & Critical Care (Trauma Centre), JPNA Trauma Centre, AIIMS, New Delhi, India 110029 Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Luckow, India 226014 c Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education & Research, Chandigarh, India 160012 b
Received 15 January 2013; revised 4 December 2013; accepted 4 December 2013
Keywords: Valvular heart disease; Cesarean section; Spinal anaesthesia; Chest ultrasound
Abstract Valvular heart disease in a parturient presenting for Cesarean section is challenging. A 25 year old primigravida parturient with severe mitral stenosis, mild mitral regurgitation, mild aortic regurgitation, and mild pulmonary arterial hypertension required Cesarean delivery after developing pulmonary edema. Low-dose spinal with hyperbaric bupivacine 0.5% 1.8 mL plus 25 μg of fentanyl was used for anesthesia. Chest ultrasonography (US) and transthoracic echocardiography (TTE) were used for monitoring purposes. Spinal-induced preload reduction improved the pulmonary edema, as evidenced by chest US. Chest US and TTE helped in fluid management. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Rheumatic heart diseases (RHD) are common in developing countries. It commonly affects multiple heart valves. Symptomatic RHD, especially mitral stenosis in pregnancy, increases the risk of adverse maternal and neonatal outcomes [1]. An emergency Cesarean delivery was performed successfully in a 25 year old parturient with severe mitral stenosis, mild mitral regurgitation (MR), and mild aortic regurgitation (AR) complicated by pulmonary edema with low-dose spinal anesthesia. Ultrasonography ⁎ Corresponding author. 17 Dr. A. N. Paul Lane, Bally, Howrah, West Bengal, India 711201. Tel.: + 91 9 87 153 2301. E-mail address: [email protected] (S. Samanta). http://dx.doi.org/10.1016/j.jclinane.2013.12.009 0952-8180/© 2014 Elsevier Inc. All rights reserved.
(US) was used as a monitoring tool. Chest US was performed for detection and monitoring of pulmonary edema in the perioperative period. Written, informed consent was obtained from the patient.
2. Case report A 25 year old, 51 kg primigravida at full term presented with active labor pain. She complained of dyspnea at rest and coughing that produced pink frothy sputum. She was referred to our hospital while receiving oxygen supplementation delivered by facemask. She had a diagnosed case of mitral stenosis associated with mild mitral regurgitation, aortic
2
S. Samanta et al.
regurgitation, and mild pulmonary arterial hypertension. Her electrocardiogram (ECG) showed left atrial (LA) enlargement with right ventricular (RV) hypertrophy. Emergency transthoracic echocardiography (TTE) demonstrated severely stenosed mitral valve (0.9 cm2), peak/mean pressure gradient 28/17 mmHg, grade I mitral and aortic regurgitation with mild pulmonary arterial hypertension with LV ejection fraction of 40%. She was receiving digoxin (0.25 mg), one tablet daily for 5 days/week and furosemide (40 mg), one tablet twice daily with potassium chloride. She had also been receiving penicillin injection every 21 days for rheumatic fever prophylaxis. On preanesthetic examination in the operating room (OR), her pulse was 90 beats per minute (bpm), regular with no pulse deficit, and blood pressure was 126/66 mmHg. Auscultation showed mid-diastolic murmur grade 3/6 with slight loud S1, opening snap at the apical area. Her functional status was New York Heart Association (NYHA) functional class IV with a respiratory rate of 35–40 breaths per minute (breaths/min). Lung auscultation showed bilateral crepitations, which were confirmed on chest US showing B lines (Fig. 1). Her obstetrical examination showed a uterus of 37 weeks’ size with a nonreassuring fetal heart rate. There was no hepatomegaly. Her blood laboratory values showed hypokalemia (K 2.9 mEq/L) while coagulation and platelet count were within normal limits. She received intravenous (IV) ranitidine 50 mg, metoclopramide 10 mg, and ampicillin one gram preoperatively. We planned low-dose spinal anesthesia with hemodynamic monitoring. In the OR, standard basic monitors such as ECG, pulse oximeter, noninvasive blood pressure monitor, end-tidal carbon dioxide, and temperature were applied. Two large-bore IV catheters were secured. A phenylephrine infusion was started in one IV catheter at 2 μg/kg/min and titrated accordingly to maintain systemic vascular resistance (SVR). Baseline oxygen saturation (SpO2) was 88% with oxygen supplementation. One anesthesiologist prepared the subarachnoid block (SAB) while the other secured the arterial catheter in the left radial artery. Hyperbaric bupivacaine (0.5%) 1.8 mL with 25 μg of
fentanyl was given in SAB in the left lateral position, resulting in a level up to the T5 segment. Oxygenation improved significantly with reduced bilateral crepitations on auscultation. Perioperative bilateral chest US (Micromaxx Sonosite, Gurgaon, India) showed decreased B lines (Fig. 2) while TTE demonstrated reduced LA and RA chamber volumes. Potassium correction was started in a diluted IV solution of 40 mEq at a rate of 20 mEq/hr through a large peripheral vein. Early cord clamping was attempted to prevent auto transfusion. The infant’s birth weight was 2.4 kg, cord blood pH was 7.32, and APGAR scores were 8 at one minute and 9 at 5 minutes. After delivery, an oxytocin infusion of 25 U was started in titration. Methylergonovine was omitted. The patient received approximately 400 mL of hydroxyethyl starch intraoperatively. Total estimated blood loss was 800 mL without any need for transfusion. She remained hemodynamically stable throughout the surgery, with good urine output. Postoperatively, she was maintained in a headup position with oxygen supplementation using a Venturi mask. She was closely monitored for an additional 60 minutes in the Postanesthesia Care Unit. As her hemodynamics remained stable, she was moved to the High Dependency Unit (HDU) with the Venturi mask. A bolus of furosemide 40 mg was injected before transport to the HDU (at the time of recovery from spinal anesthesia). Her subsequent hospital course was uneventful. She was then referred to the Cardiothoracic and Cardiology Departments for further medical and surgical treatment.
Fig. 1 Chest ultrasonography showing B line artifacts before spinal anesthesia.
Fig. 2 Chest ultrasonography showing clearing of B lines after spinal anesthesia.
3. Discussion The parturient with heart disease is always challenging. Pregnancy and labor adds additional stress to an already compromised cardiovascular system. Patients with mitral stenosis have reduced blood flow from the LA to the left ventricle (LV) and increased LA pressure. Increased heart rate in pregnancy aggravates this condition by reducing diastolic filling time, leading to deceased LV filling and
Chest ultrasound in emergency C-section increased pulmonary blood volume, which causes more chances for pulmonary edema. After delivery of the baby, autotransfusion may precipitate heart failure and pulmonary edema [2]. The parturient with mitral stenosis has an increased incidence of congestive heart failure (CHF), and atrial fibrillation [3]. Digoxin is prescribed to increase myocardial contractility while reducing the ventricular rate in patients with atrial fibrillation. Diuretics cause hypokalemia, which aggravates digoxin toxicity. Fluctuation in hemodynamic status during labor, delivery, and in the immediate postpartum period may result in CHF and an increased chance of pulmonary edema. As there was also a high possibility of developing infective endocarditis, ampicillin was administered. Considering the risk of aspiration, she also received aspiration prophylaxis. Judicious use of fluids and diuretics are mandatory in frank pulmonary edema. Spinal anesthesia was used. Low-dose spinal anesthesia for vaginal instrumental delivery has been reported with good results in these patients [4]. Spinal-induced vasodilatation reduced preload (seen on TTE), thereby lessening the chance of pulmonary edema (as seen on chest US). Lung comets [5] or B lines on chest radiography were reduced in the postspinal period. Invasive cardiac monitoring such as radial artery cannulation is helpful for guiding fluid and drug therapy, especially in NYHA functional class III and IV patients [6]. We used arterial monitoring and perioperative TTE and US to assess the patient’s cardiac and fluid status. A decrease in SVR in a patient with fixed
3 cardiac output was prevented by small bolus doses, or titrated infusion, of phenylephrine.
3.1. Conclusions Low-dose spinal anesthesia was used for Cesarean delivery in a parturient with heart disease and frank pulmonary edema. Perioperative US is a good monitoring tool for better fluid and hemodynamic management.
References [1] Siu SC, Colman JM, Sorensen S, et al. Adverse neonatal and cardiac outcomes are more common in pregnant women with cardiac disease. Circulation 2002;105:2179-84. [2] Steer PJ, Gatzoulis MA, Baker P, editors. Heart Disease and Pregnancy. London: Royal College of Obstetricians and Gynaecologists Press; 2006. p. 157-68. [3] ACC/AHA guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/ American Heart Association. Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease). J Am Coll Cardiol 1998;32:1486–588. [4] Langesaeter E, Dragsund M, Rosseland LA. Regional anaesthesia for a Caesarean section in women with cardiac disease: a prospective study. Acta Anaesthesiol Scand 2010;54:46-54. [5] Picano E, Frassi F, Agricola E, Gligorova S, Gargani L, Mottola G. Ultrasound lung comets: a clinically useful sign of extravascular lung water. J Am Soc Echocardiogr 2006;19:356-63. [6] Hemmings GT, Whalley DG, O’Connor PJ, Benjamin A, Dunn C. Invasive monitoring and anesthesia management of patients with mitral stenosis. Can J Anaesth 1987;34:182-5.
