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International Journal of Obstetric Anesthesia

further fluid leak, and to avoid immersion bathing and scrubbing the site for five days so as to not interfere with the SwiftSet (http://surgical.covidien.com/products/ wound-closure/topical-skin-adhesives). The patient reported no further CSF leak for the next week of follow-up. It has been suggested that CSF leak after neuraxial anesthesia might be an underreported phenomenon.1,3 It is likely, however, that most fluid leaks are more minor and transient than in our case. Furthermore, in some cases fluid might not be CSF but could be tissue edema or extravasation of epidural local anesthetic solutions. Although we did not specifically test the fluid to confirm that it was CSF,1 we believe the fluid was very likely CSF as no epidural solutions were injected, only a few milliliters of local anesthetic were injected intrathecally, and the patient was thin and non-edematous. Currently, there are no guidelines on management of CSF leaks for anesthesia providers, although a conservative approach can be used with mild leaks as most resolve spontaneously.1,3 In the rare case of large volume CSF leak, as would be seen in the surgical population, the definitive treatment is surgical exploration and/ or suturing.5 Skin suturing was suggested as an option by our neurosurgery colleagues; however, we elected to apply tissue adhesive and adhesive strips with a plan to use suturing if this approach failed. Use of tissue adhesive for managing CSF leaks has been previously reported in the surgical literature,6 but not following inadvertent dural puncture with a Tuohy needle. Of note, our patient remained free of PDPH symptoms despite losing a significant amount of CSF. Interestingly, previous case reports have revealed a lack of headache or mild headache that resolved spontaneously in seven of nine patients who had persistent CSF leak after neuraxial anesthesia.1 Adding our patient to this small group would result in a 20% incidence of PDPH in patients with significant persistent CSF leak as opposed to the typical incidence of 70-80% following inadvertent dural puncture with a Tuohy needle.7,8 It is not known whether this association is coincidental or if there is altered CSF flow dynamics in these patients, which leads to an increased propensity to develop persistent CSF leak but is protective against PDPH. In conclusion, we believe this is the first report of using tissue adhesive for persistent CSF leak following unintentional dural puncture. We would suggest this as a viable first alternative to suturing and/or surgical exploration for anesthesia providers who are faced with this problem. J.R. Privratsky, S.L. McCartney, T.K. Allen, A.S. Habib Department of Anesthesiology Duke University Medical Center, Durham, NC, USA E-mail address: [email protected]

References 1. Plumb JO, Levy DM, Holborow JP, Paech MJ. CSF leak after epidural analgesia: an under-reported complication? Int J Obstet Anesth 2012;21:285–6. 2. Steel AG, Watson BJ, Abdy S, Allen JG. Persistent cerebrospinal fluid leak. Anesth Analg 2004;99:1266–7. 3. Chan BO, Paech MJ. Persistent cerebrospinal fluid leak: a complication of the combined spinal-epidural technique. Anesth Analg 2004;98:828–30. 4. Jawalekar SR, Marx GF. Cutaneous cerebrospinal fluid leakage following attempted extradural block. Anesthesiology 1981;54:348–9. 5. Kitchel SH, Eismont FJ, Green BA. Closed subarachnoid drainage for management of cerebrospinal fluid leakage after an operation on the spine. J Bone Joint Surg Am 1989;71:984–7. 6. Rotenberg BW, Marchie A, Cusimano MD. Skin sealants: an effective option for closing cerebrospinal fluid leakage. Can J Surg 2004;47:466–8. 7. Banks S, Paech M, Gurrin L. An audit of epidural blood patch after accidental dural puncture with a Tuohy needle in obstetric patients. Int J Obstet Anesth 2001;10:172–6. 8. Costigan SN, Sprigge JS. Dural puncture: the patients’ perspective. A patient survey of cases at a DGH maternity unit 1983– 1993. Acta Anaesthesiol Scand 1996;40:710–4. 0959-289X/$ - see front matter

c 2014 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ijoa.2014.10.002

Anaesthetic management of a parturient with uncorrected tetralogy of Fallot undergoing caesarean section Tetralogy of Fallot (TOF) is the commonest form of cyanotic congenital heart defect, amounting to 10% of all cases. With ongoing advances in surgical techniques, many of these patients now reach childbearing age and often tolerate pregnancy relatively well. However, without surgical intervention, 70% of those with TOF die in the first decade and only about 3% survive into the fourth decade. Therefore, presentation of uncorrected TOF in pregnancy is rare1 and poses a significant risk to both mother and baby.2,3 We report the case of a 29-year-old G1P0 parturient, recently arrived from the Cameroon, who presented to our institution at 30 weeks of gestation. Past medical history included a heart murmur (without definitive diagnosis) and poor exercise tolerance. On examination a pan-systolic murmur, clubbing and oxygen saturations of 89% were noted. Echocardiography showed TOF with 50% aorta override, a large sub-aortic ventricular septal defect with bidirectional shunting, and pulmonary stenosis (pressure gradient 80 mmHg). The right ventricle was moderately dilated and hypertrophied. The parturient was managed with specialist multidisciplinary care and remained relatively well until 34 weeks, when she developed worsening dyspnoea and exertional chest

Previous case reports of uncorrected Tetralogy of Fallot requiring caesarean section Country

CS category

Gestation (weeks)

Solanki5

India

3

34

Srivastava6

India

2

Unknown

Dabrowski7 Case 1

Poland

3

Case 2

Poland

Czech Republic

Gal8

Anaesthetic technique

Cardiovascular drugs

Uterotonics

Intraoperative events

Postoperative events

Neonatal outcome

Phenylephrine infusion started at 20 lg/min

Avoided

Nil

Nil

Birth weight 1900g. Apgar scores 8 & 9 at 1 & 5 min, cord pH 7.22

GA Induction: ketamine 2 mg/kg thiopental 1 mg/kg, suxamethonium 1.5 mg/kg Maintenance: O2/N2O/sevoflurane, vecuronium 0.08 mg/kg

Phenylephrine boluses 50 lg propranolol 1 mg

Avoided

flSpO2 postdelivery treated with propranolol

Nil noted

Not documented

33

Epidural 2% lidocaine 8 mL + 0.5% bupivacaine 5 mL

Phenylephrine boluses 50–100 lg

Ergometrine 0.2 mg

Myocardial ischaemia requiring sublingual GTN

Nil

Not documented

3

30

GA Induction: Etomidate 0.1 mg/kg, fentanyl 5 lg/kg, suxamethonium 1 mg/kg Maintenance: N2O/O2, atracurium 0.25 mg/kg

None

Ergometrine 0.2 mg

Nil

Developed Eisenmenger’s and died on Day 2

Not documented

3

32

Epidural 0.5% bupivacaine 4 mL + 10 mL + fentanyl 100 lg

None

None documented

Nil

No complications

Not documented

CSE Spinal: 0.5% hyperbaric bupivacaine 0.5 mL + fentanyl 25 lg Epidural top-ups: 0.5% bupivacaine 2+3 mL + 100 lg fentanyl; 0.25% bupivacaine 5 mL + 50 lg fentanyl

International Journal of Obstetric Anesthesia

Table 1

CS: caesarean section; CSE: combined spinal–epidural; GA: general anaesthesia; GTN: glyceryl trinitrate.

89

90 pain. She was admitted for optimisation, including supplemental oxygen, diuretics and steroids for fetal lung maturation. Caesarean section was performed at 36 weeks. After establishing direct arterial and central venous pressure monitoring, a combined spinal–epidural anaesthetic was inserted in the sitting position without difficulty at L3–4 using a needle-through-needle technique. A lowdose spinal mixture of 0.5% hyperbaric bupivacaine 0.7 mL plus fentanyl 15 lg was administered and the patient then positioned supine with left tilt. However, after 10 min the patient had only sacral numbness, without motor block. Slow sequential epidural top-ups (3 mL increments of 0.5% plain bupivacaine) were therefore administered over a 45-min period. A total volume of 18 mL was required to produce a T5 block to both cold and light touch. A phenylephrine infusion was started, initially at a rate of 40 lg/min, following administration of the spinal anaesthetic and was subsequently titrated to the arterial blood pressure. A noradrenaline infusion was also prepared in case further vasoconstriction was required. Other pre-prepared drugs included propranolol to relieve infundibular spasm and improve pulmonary blood flow in the event of an acute hypoxic episode. Following delivery of a healthy baby (Apgar scores 8 and 9 at 1 and 5 min) an oxytocin infusion (10 U/h for 4 h) and rectal misoprostol were used to promote uterine tone. Estimated operative blood loss was 600 mL and the patient received 1500 mL of intravenous Hartmann’s solution. She was transferred to the coronary care unit postoperatively and was discharged home on Day 4 following an uneventful postoperative course. However, she required readmission on Day 6 with right sided ventricular heart failure. Symptoms improved with diuresis and, after stabilisation, she was discharged home on Day 19. The four characteristic features of TOF include: (1) right ventricular outflow tract obstruction (RVOTO), which is usually infundibular and/or valvular; (2) ventricular septal defect (VSD); (3) aorta with biventricular connection (overriding aorta); and (4) right ventricular hypertrophy (RVH). The principal risk for parturients with TOF is cardiac decompensation secondary to additional physiological demands from pregnancy and parturition. Increased right to left shunting of blood, and hence increased cyanosis, may result from a reduction in systemic vascular resistance (SVR), increased pulmonary outflow tract obstruction and to a lesser extent increased pulmonary vascular resistance. Low-dose sequential CSE is an established anaesthetic technique for caesarean section in patients with significant cardiac disease.4 Evidence for anaesthetic best practice in parturients with TOF is limited. There are only five published cases of parturients with uncorrected TOF requiring caesarean section (Table 1).5–8 General and neuraxial anaesthetic techniques have been

International Journal of Obstetric Anesthesia advocated, although both have significant risk of perioperative morbidity and mortality. Anaesthetic management of patients with TOF therefore requires a thorough understanding of anatomical defects and physiological adaptations, and also the events and drugs that can alter the magnitude of right to left shunt. Whichever technique is chosen, it is imperative to maintain intravascular volume (to maintain right ventricular preload and hence reduce any dynamic RVOTO), maintain SVR (to reduce right to left shunt and augment right coronary perfusion to the hypertrophied right ventricle) and minimise increases in pulmonary vascular resistance (by the avoidance of further hypoxaemia, hypercarbia, acidosis, pain and hypothermia). Avoidance of chronotropy and inotropy (by managing pain and anxiety) is also important as both can worsen the dynamic RVOTO. Prevention of postpartum haemorrhage is crucial but must be weighed against the potential cardiovascular effects of the uterotonics. Our patient’s postoperative course emphasises the need for close monitoring in the early postpartum period where decompensation can occur due to return of prepregnancy maternal physiology. J.A. Parker, C. Grange Nuffield Department of Anaesthetics John Radcliffe Hospital, Oxford, UK E-mail address: [email protected]

References 1. Hofman JI. Incidence of congenital heart disease: I. Postnatal incidence. Pediatr Cardiol 1995;16:103–13. 2. Veldtman GR. Outcomes of pregnancy in women with tetralogy of Fallot. J Am Coll Cardiol 2004;44:174–80. 3. Drenthen W, Boersma E, Balci A, et al. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J 2010;31:2124–32. 4. Hamlyn EL, Douglas CA, Plaat F, Crowhurst JA, Stocks GM. Low dose sequential combined spinal epidural: an anaesthetic technique for caesarean section in patients with significant cardiac disease. Int J Obstet Anesth 2005;14:355–61. 5. Solanki A, Jain A, Singh A, Sharma A. Low-dose sequential combined-spinal epidural anesthesia for Cesarean section in patient with uncorrected tetralogy of Fallot. Saudi J Anaesth 2011;5:320–2. 6. Srivastava A, Chaturvedi A, Sinha G. Pregnancy with uncorrected tetralogy of Fallot: anaesthetic management of a case for LSCS. Internet J Anesth 2009;21:1. http://ispub.com/IJA/21/1/8333 [accessed October 2014]. 7. Dabrowski W, Poniedzialek-Czajkowska E, Biernacka J, Wosko J, Nestorowicz A. Anaesthesia for caesarean section in patients with tetralogy of Fallot. Anestezjol Intens Ter 2004;36:191–4. 8. Gal R, Cundrle I, Zimova I, Hruba J. Cesarean section in patient with uncorrected tetralogy of Fallot in epidural anaesthesia. Anest Neodkl Pece 2000;11:144–5. [Czech]. 0959-289X/$ - see front matter

c 2014 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ijoa.2014.10.002

Anaesthetic management of a parturient with uncorrected tetralogy of Fallot undergoing caesarean section.

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