Letters to Editor
cases, it is a clinical diagnosis based on exclusion of other infections.[3] Case reports and case series have described dramatic responses to IVIG in adults and children with presumed viral myocarditis. Administrations of IVIG have become common in the management of this condition and have dramatic and immediate response to it.[4] The ECMO was started to support the failing circulation and biventricular myocardial dysfunction. Data from case series suggest that ventricular assist devices or ECMO may provide a bridge to transplant or to recovery in patients with acute myocarditis.[5] In a case series, Chen et al.[6] reported that 80% of patients who received ECMO therapy were bridged to recovery. Finally, With the ECMO support and IVIG, we could prevent an adverse outcome in one of the simple procedure in current era of pediatric cardiac surgery.
Kamlesh B. Tailor, Shankar V. Kadam, Hari Bipin R. Kattana1, Suresh G. Rao1 1
Department of Pediatric Cardiac Anaesthesia and Intensive Care, Department of Pediatric Cardiac Surgery Children’s Heart Centre, Kokilaben Dhirubhai Ambani Hospital and Research Centre, Mumbai, Maharashtra, India Address for correspondence: Dr. Kamlesh B. Tailor, 802, Grace‑E, Vasant Oscar, LBS Marg, Mulund‑W, Mumbai ‑ 400 080, Maharashtra, India. E‑mail: [email protected]
REFERENCES 1. Andrade CL, Olvera S, Reyes PA. Fever and infection after heart surgery. A prospective study of 75 cases. Arch Inst Cardiol Mex 1989;59:487‑91. 2. Pien F, Ho PW, Fergusson DJ. Fever and infection after cardiac operation. Ann Thorac Surg 1982;33:382‑4. 3. Schultz JC, Hilliard AA, Cooper LT Jr, Rihal CS. Diagnosis and treatment of viral myocarditis. Mayo Clin Proc 2009;84:1001‑9. 4. Robinson J, Hartling L, Vandermeer B, Crumley E, Klassen TP. Intravenous immunoglobulin for presumed viral myocarditis in children and adults. Cochrane Database Syst Rev 2005;1:CD004370. 5. Bohn D, Macrae D, Chang AC. Acute viral myocarditis: Mechanical circulatory support. Pediatr Crit Care Med 2006;7:S22‑4. 6. Chen YS, Wang MJ, Chou NK, Han YY, Chiu IS, Lin FY, et al. Rescue for acute myocarditis with shock by extracorporeal membrane oxygenation. Ann Thorac Surg 1999;68:2220‑4.
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176
Labor analgesia in Eisenmenger syndrome: Peripartum concerns The Editor, Eisenmenger syndrome (ES) refers to a clinical condition that develops due to reversal of an initial left to right shunt in a patient with congenital intracardiac defect secondary to pulmonary hypertension and presents with cyanosis. Pregnancy in patients of ES is associated with high maternal mortality.[1,2] A 25‑year‑old woman (height 156 cm and body weight 52 kg), a known case of ES, presented with 34 weeks gestation along with cough, expectoration and breathlessness, bilateral ankle swelling for 15 days and palpitation for 2 months. She was treated with oral thyroxin 50 µg once daily for last 3 months. Her pulse rate was 102/min, regular, blood pressure 130/86 mmHg, respiratory rate 24/min and room air oxygen saturation (SpO2) 79‑81%. On auscultation, bilateral crepitations, loud second heart sound and a pansystolic murmur was present. Echocardiography revealed 18 mm inlet ventricular septal defect with a bidirectional shunt, grossly dilated right atrium and right ventricle, severe mitral regurgitation and ejection fraction 60%. Pulmonary artery systolic pressure was 64 mmHg. Investigations were unremarkable except arterial blood gas analysis showing severe hypoxemia on room air (PaO2 48 mmHg; SaO2 82%) with mixed acidosis; the SpO2 improved marginally to 85% on O2 supplementation. She was scheduled for induced labor and epidural analgesia to relieve pain. After administration of antibiotic prophylaxis, labor was induced by placing 25 µg misoprostol next to cervix at Bishop score of 4. The patient was monitored with electrocardiogram and SpO2. In addition, right internal jugular vein and right radial artery were cannulated for monitoring and access. An epidural catheter was inserted at L3‑4 intervertebral space in sitting position. After test dose of 3 ml of lignocaine with adrenaline, epidural infusion of bupivacaine 0.0625% with fentanyl 2 µg/ml was initiated at a rate of 5 ml/h (30 ml for 6 h) as labor was facilitated with oxytocin infusion, Annals of Cardiac Anaesthesia Vol. 17:2 Apr-Jun-2014
Letters to Editor
both the drugs were administered in titrated doses. Epidural infusion was optimized until the patient was comfortable but aware of contractions. [3] Labor progressed uneventfully in left lateral position with an outlet forceps‑assisted vaginal delivery. Postpartum, she received subcutaneous dalteparin 5000 IU daily and epidural catheter was removed on the 3rd day after 12 h of dalteparin administration; thereafter, dalteparin was continued for next 5 days with bridging therapy with warfarin. She was discharged with oral maintenance therapy. The patient was previously diagnosed with ES. Although her echocardiographic findings raised doubt regarding the diagnosis, there is evidence which supports a possibility of bidirectional flow in ES.[4] In the presence of a congenital cardiac defect with left to right shunt, there is an excess of pulmonary blood flow and continuous exposure of pulmonary vasculature to such excess of blood flow leads to vascular remodeling over the years resulting in, finally, a severe escalation in pulmonary vascular resistance and thus pressure.[1] As pressure rises to a significant level on the pulmonary side, the direction of the initial shunt either reverses or a bidirectional flow is observed, which is known as ES. Here, either an increase in pulmonary vascular resistance or a fall in systemic vascular resistance leads to an enhanced right to left shunting, thus more cyanosis, hypoxia and related complications. The acceptable mode of delivery in ES is controversial. Although, elective cesarean section is preferred to minimize maternal risk; however, high maternal mortality (46‑70%) has been reported with cesarean section.[3] The key in the management of these patients is to control increase in the right to left shunt. There are changes during general anesthesia such as decreases in venous return during positive pressure ventilation, which adversely affect the ES pathophysiology and potentially exacerbate the right to left shunt.[5] Pain itself can lead to a dramatic rise in the serum concentration of catecholamine, possibly leading to a rise in pulmonary vascular resistance, which can worsen the shunt.[2] Hence, abolition of pain with epidural analgesia was considered a logical choice. However, neuraxial blockade by causing sympatholysis can reduce systemic vascular resistance and potentiate right to left shunt.
Annals of Cardiac Anaesthesia Vol. 17:2 Apr-Jun-2014
To maintain a balance between the two opposing effect, we used a combination of low concentration of bupivacaine with an opioid. The total mass of local anesthetic in the epidural space is the most important determinant of the extent and degree of blockade in neuraxial blockade. Therefore, epidural infusion was optimized until the patient was comfortable but aware of contractions. Again, it is well‑known that addition of an opioid to local anesthetic decreases the overall drug requirement. We tried to utilize this synergistic effect of opioid and administered a combination, which probably reduced the overall anesthetic used. By this way, we could achieve analgesia without worsening of cyanosis and hence shunt.[6]
Neha Singh, Pratheeba Natarajan1, Parnandi Bhaskar Rao2, Sagiev Koshly George1, Ramya Gnanasekar1 Departments of Anaesthesiology, Critical Care and Pain Medicine, IMS and SUM Hospital, 2AIIMS, Bhubaneswar, Odisha, 1 Department of Anaesthesiology and Critical Care, P.I.M.S, Puducherry, India Address for correspondence: Dr. Neha Singh, Department of Anaesthesiology, Critical Care and Pain Medicine, Institute of Medical Sciences and SUM Hospital, Bhubaneswar ‑ 751 030, Odisha, India. E‑mail: [email protected]
REFERENCES 1. Neema PK. Eisenmenger syndrome: An unsolved malady. Ann Card Anaesth 2012;15:257‑8. 2. Minicucci S, Segala V, Verdecchia C, Sismondi P, Casabona R, Sansone F. Safe management of cesarean section in a patient of Eisenmenger syndrome. Ann Card Anaesth 2012;15:296‑8. 3. Makaryus AN, Forouzesh A, Johnson M. Pregnancy in the patient with Eisenmenger’s syndrome. Mt Sinai J Med 2006;73:1033‑6. 4. Smedstad KG, Cramb R, Morison DH. Pulmonary hypertension and pregnancy: A series of eight cases. Can J Anaesth 1994;41:502‑12. 5. Maitra G, Sengupta S, Rudra A, Debnath S. Pregnancy and non‑valvular heart disease - Anesthetic considerations. Ann Card Anaesth 2010;13:102‑9. 6. Visser WA, Lee RA, Gielen MJ. Factors affecting the distribution of neural blockade by local anesthetics in epidural anesthesia and a comparison of lumbar versus thoracic epidural anesthesia. Anesth Analg 2008;107:708‑21. Access this article online Quick Response Code:
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.129892
177
Copyright of Annals of Cardiac Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
cases, it is a clinical diagnosis based on exclusion of other infections.[3] Case reports and case series have described dramatic responses to IVIG in adults and children with presumed viral myocarditis. Administrations of IVIG have become common in the management of this condition and have dramatic and immediate response to it.[4] The ECMO was started to support the failing circulation and biventricular myocardial dysfunction. Data from case series suggest that ventricular assist devices or ECMO may provide a bridge to transplant or to recovery in patients with acute myocarditis.[5] In a case series, Chen et al.[6] reported that 80% of patients who received ECMO therapy were bridged to recovery. Finally, With the ECMO support and IVIG, we could prevent an adverse outcome in one of the simple procedure in current era of pediatric cardiac surgery.
Kamlesh B. Tailor, Shankar V. Kadam, Hari Bipin R. Kattana1, Suresh G. Rao1 1
Department of Pediatric Cardiac Anaesthesia and Intensive Care, Department of Pediatric Cardiac Surgery Children’s Heart Centre, Kokilaben Dhirubhai Ambani Hospital and Research Centre, Mumbai, Maharashtra, India Address for correspondence: Dr. Kamlesh B. Tailor, 802, Grace‑E, Vasant Oscar, LBS Marg, Mulund‑W, Mumbai ‑ 400 080, Maharashtra, India. E‑mail: [email protected]
REFERENCES 1. Andrade CL, Olvera S, Reyes PA. Fever and infection after heart surgery. A prospective study of 75 cases. Arch Inst Cardiol Mex 1989;59:487‑91. 2. Pien F, Ho PW, Fergusson DJ. Fever and infection after cardiac operation. Ann Thorac Surg 1982;33:382‑4. 3. Schultz JC, Hilliard AA, Cooper LT Jr, Rihal CS. Diagnosis and treatment of viral myocarditis. Mayo Clin Proc 2009;84:1001‑9. 4. Robinson J, Hartling L, Vandermeer B, Crumley E, Klassen TP. Intravenous immunoglobulin for presumed viral myocarditis in children and adults. Cochrane Database Syst Rev 2005;1:CD004370. 5. Bohn D, Macrae D, Chang AC. Acute viral myocarditis: Mechanical circulatory support. Pediatr Crit Care Med 2006;7:S22‑4. 6. Chen YS, Wang MJ, Chou NK, Han YY, Chiu IS, Lin FY, et al. Rescue for acute myocarditis with shock by extracorporeal membrane oxygenation. Ann Thorac Surg 1999;68:2220‑4.
Access this article online Quick Response Code:
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.129890
176
Labor analgesia in Eisenmenger syndrome: Peripartum concerns The Editor, Eisenmenger syndrome (ES) refers to a clinical condition that develops due to reversal of an initial left to right shunt in a patient with congenital intracardiac defect secondary to pulmonary hypertension and presents with cyanosis. Pregnancy in patients of ES is associated with high maternal mortality.[1,2] A 25‑year‑old woman (height 156 cm and body weight 52 kg), a known case of ES, presented with 34 weeks gestation along with cough, expectoration and breathlessness, bilateral ankle swelling for 15 days and palpitation for 2 months. She was treated with oral thyroxin 50 µg once daily for last 3 months. Her pulse rate was 102/min, regular, blood pressure 130/86 mmHg, respiratory rate 24/min and room air oxygen saturation (SpO2) 79‑81%. On auscultation, bilateral crepitations, loud second heart sound and a pansystolic murmur was present. Echocardiography revealed 18 mm inlet ventricular septal defect with a bidirectional shunt, grossly dilated right atrium and right ventricle, severe mitral regurgitation and ejection fraction 60%. Pulmonary artery systolic pressure was 64 mmHg. Investigations were unremarkable except arterial blood gas analysis showing severe hypoxemia on room air (PaO2 48 mmHg; SaO2 82%) with mixed acidosis; the SpO2 improved marginally to 85% on O2 supplementation. She was scheduled for induced labor and epidural analgesia to relieve pain. After administration of antibiotic prophylaxis, labor was induced by placing 25 µg misoprostol next to cervix at Bishop score of 4. The patient was monitored with electrocardiogram and SpO2. In addition, right internal jugular vein and right radial artery were cannulated for monitoring and access. An epidural catheter was inserted at L3‑4 intervertebral space in sitting position. After test dose of 3 ml of lignocaine with adrenaline, epidural infusion of bupivacaine 0.0625% with fentanyl 2 µg/ml was initiated at a rate of 5 ml/h (30 ml for 6 h) as labor was facilitated with oxytocin infusion, Annals of Cardiac Anaesthesia Vol. 17:2 Apr-Jun-2014
Letters to Editor
both the drugs were administered in titrated doses. Epidural infusion was optimized until the patient was comfortable but aware of contractions. [3] Labor progressed uneventfully in left lateral position with an outlet forceps‑assisted vaginal delivery. Postpartum, she received subcutaneous dalteparin 5000 IU daily and epidural catheter was removed on the 3rd day after 12 h of dalteparin administration; thereafter, dalteparin was continued for next 5 days with bridging therapy with warfarin. She was discharged with oral maintenance therapy. The patient was previously diagnosed with ES. Although her echocardiographic findings raised doubt regarding the diagnosis, there is evidence which supports a possibility of bidirectional flow in ES.[4] In the presence of a congenital cardiac defect with left to right shunt, there is an excess of pulmonary blood flow and continuous exposure of pulmonary vasculature to such excess of blood flow leads to vascular remodeling over the years resulting in, finally, a severe escalation in pulmonary vascular resistance and thus pressure.[1] As pressure rises to a significant level on the pulmonary side, the direction of the initial shunt either reverses or a bidirectional flow is observed, which is known as ES. Here, either an increase in pulmonary vascular resistance or a fall in systemic vascular resistance leads to an enhanced right to left shunting, thus more cyanosis, hypoxia and related complications. The acceptable mode of delivery in ES is controversial. Although, elective cesarean section is preferred to minimize maternal risk; however, high maternal mortality (46‑70%) has been reported with cesarean section.[3] The key in the management of these patients is to control increase in the right to left shunt. There are changes during general anesthesia such as decreases in venous return during positive pressure ventilation, which adversely affect the ES pathophysiology and potentially exacerbate the right to left shunt.[5] Pain itself can lead to a dramatic rise in the serum concentration of catecholamine, possibly leading to a rise in pulmonary vascular resistance, which can worsen the shunt.[2] Hence, abolition of pain with epidural analgesia was considered a logical choice. However, neuraxial blockade by causing sympatholysis can reduce systemic vascular resistance and potentiate right to left shunt.
Annals of Cardiac Anaesthesia Vol. 17:2 Apr-Jun-2014
To maintain a balance between the two opposing effect, we used a combination of low concentration of bupivacaine with an opioid. The total mass of local anesthetic in the epidural space is the most important determinant of the extent and degree of blockade in neuraxial blockade. Therefore, epidural infusion was optimized until the patient was comfortable but aware of contractions. Again, it is well‑known that addition of an opioid to local anesthetic decreases the overall drug requirement. We tried to utilize this synergistic effect of opioid and administered a combination, which probably reduced the overall anesthetic used. By this way, we could achieve analgesia without worsening of cyanosis and hence shunt.[6]
Neha Singh, Pratheeba Natarajan1, Parnandi Bhaskar Rao2, Sagiev Koshly George1, Ramya Gnanasekar1 Departments of Anaesthesiology, Critical Care and Pain Medicine, IMS and SUM Hospital, 2AIIMS, Bhubaneswar, Odisha, 1 Department of Anaesthesiology and Critical Care, P.I.M.S, Puducherry, India Address for correspondence: Dr. Neha Singh, Department of Anaesthesiology, Critical Care and Pain Medicine, Institute of Medical Sciences and SUM Hospital, Bhubaneswar ‑ 751 030, Odisha, India. E‑mail: [email protected]
REFERENCES 1. Neema PK. Eisenmenger syndrome: An unsolved malady. Ann Card Anaesth 2012;15:257‑8. 2. Minicucci S, Segala V, Verdecchia C, Sismondi P, Casabona R, Sansone F. Safe management of cesarean section in a patient of Eisenmenger syndrome. Ann Card Anaesth 2012;15:296‑8. 3. Makaryus AN, Forouzesh A, Johnson M. Pregnancy in the patient with Eisenmenger’s syndrome. Mt Sinai J Med 2006;73:1033‑6. 4. Smedstad KG, Cramb R, Morison DH. Pulmonary hypertension and pregnancy: A series of eight cases. Can J Anaesth 1994;41:502‑12. 5. Maitra G, Sengupta S, Rudra A, Debnath S. Pregnancy and non‑valvular heart disease - Anesthetic considerations. Ann Card Anaesth 2010;13:102‑9. 6. Visser WA, Lee RA, Gielen MJ. Factors affecting the distribution of neural blockade by local anesthetics in epidural anesthesia and a comparison of lumbar versus thoracic epidural anesthesia. Anesth Analg 2008;107:708‑21. Access this article online Quick Response Code:
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.129892
177
Copyright of Annals of Cardiac Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
