International Journal of Obstetric Anesthesia (2015) xxx, xxx–xxx 0959-289X/$ - see front matter c 2015 Elsevier Ltd. All rights reserved.

CORRESPONDENCE Cesarean section in parturients with uncorrected tetralogy of Fallot We read with interest the report by Parker and Grange describing the anesthetic management of a woman with uncorrected tetralogy of Fallot (TOF) undergoing cesarean section using low-dose sequential combined spinalepidural anesthesia.1 We congratulate the authors on their successful management and would like to share our experience of two similar cases. Our patients were both nulliparous with diagnosed TOF and neither had undergone surgery. The first woman was 19 years of age, 158 cm tall, weighing 65 kg, with central cyanosis and clubbing. She had a harsh pan-systolic murmur, oxygen saturations of 84% on room air and a hematocrit of 50%. Her functional status worsened with advancing pregnancy (New York Heart Association (NYHA) class III), and cesarean delivery was performed at 35 weeks of gestation. The second patient was 23 years of age, 160 cm tall, weighing 75 kg and presented as NYHA class I with oxygen saturations of 93% on room air and a normal hematocrit. She underwent elective cesarean delivery at 38 weeks of gestation after declining vaginal delivery. Anesthetic goals in both cases were to provide adequate anesthesia, maintain preload, avoid tachycardia and increased contractility, avoid increases in pulmonary vascular resistance and maintain systemic vascular resistance. General anesthesia with spinal analgesia was chosen in both cases using a similar technique. Intravenous ranitidine 50 mg and metoclopramide 10 mg and intrathecal fentanyl 25 lg were given. In addition to routine monitoring, radial artery cannulation was instituted. With the patients lying supine with 30° head up and 15° left lateral tilt, general anesthesia was induced with intravenous fentanyl 100 lg, ketamine 50 mg and propofol 1 mg/kg; tracheal intubation was facilitated with succinylcholine 100 mg. Anesthesia was maintained with sevoflurane 1–2% in 60–100% oxygen in air, and muscle relaxation was accomplished with intermittent atracurium boluses. Using volume-controlled ventilation, oxygen saturation was maintained between 88–93% and 95–99% in the first and second cases, respectively. After delivery, intravenous oxytocin (3 U slow bolus, followed by a 10 U infusion over 2 h) and morphine 5 mg were administered. Blood pressure and heart rate were stable throughout the procedures. Arterial sampling guided maintenance of PaCO2 at approximately

30 mmHg. Estimated blood loss was 500 mL in both cases; Ringer acetate 1000 mL was infused over 1 h. At the end of surgery intravenous ketorolac 30 mg and paracetamol 1 g and rectal misoprostol were administered. After tracheal extubation, the patients were monitored in the intensive care unit for 24 h: maternal and neonatal outcomes were good. The combination of ketamine and propofol ensured adequate anesthetic depth, minimized the decrease in systemic vascular resistance accompanying propofol use, and the tachycardia and increased contractility resulting from ketamine.2 The cardiovascular effects of sevoflurane appear favorable in this patient category.3 Factors increasing pulmonary vascular resistance (hypoxia, hypercarbia and acidosis) can be managed with controlled mechanical ventilation provided high intrathoracic pressures are avoided.4 We relied on PaCO2 rather than end-tidal CO2 to regulate minute ventilation as the latter may largely underestimate the true PaCO2 level in uncorrected TOF patients.5 Phenylephrine was planned to treat hypotension, with propranolol available if hypoxemia worsened.6 Adequate analgesia was mandatory to avoid a stress-induced increase in pulmonary pressure, heart rate and contractility. We used multimodal analgesia and believe spinal fentanyl potentiated intra- and postoperative analgesia without deleterious cardiovascular effects. We agree with the authors regarding their anesthetic goals in these patients. These may be better achieved using balanced general anesthesia with controlled mechanical ventilation. Further reports are, however, still needed to decide the optimal anesthetic technique in this rare condition. M.M. Tawfik, A.I. Tarbay, M. Abdelkhalek Department of Anesthesia and Surgical Intensive Care, Mansoura University Hospitals, Mansoura, Egypt E-mail address: m2tawfi[email protected]

References 1. Parker JA, Grange C. Anaesthetic management of a parturient with uncorrected tetralogy of Fallot undergoing caesarean section. Int J Obstet Anesth 2015;24:88–90. 2. Smischney NJ, Beach ML, Loftus RW, Dodds TM, Koff MD. Ketamine/propofol admixture (ketofol) is associated with improved hemodynamics as an induction agent: a randomized, controlled trial. J Trauma Acute Care Surg 2012;73:94–101.

2 3. Rivenes SM, Lewin MB, Stayer SA, et al. Cardiovascular effects of sevoflurane, isoflurane, halothane, and fentanyl–midazolam in children with congenital heart disease. Anesthesiology 2001;94:223–9. 4. Clivatti J, Smith RL, Sermer M, Silversides C, Carvalho JC. Cardiac output monitoring during Cesarean delivery in a patient with palliated tetralogy of Fallot. Can J Anesth 2012;59:1119–24.

International Journal of Obstetric Anesthesia 5. Cannesson M, Earing MG, Collange V, Kersten JR. Anesthesia for noncardiac surgery in adults with congenital heart disease. Anesthesiology 2009;111:432–40. 6. Twite MD, Ing RJ. Tetralogy of Fallot: perioperative anesthetic management of children and adults. Semin Cardiothorac Vasc Anesth 2012;16:97–105.

Cesarean section in parturients with uncorrected tetralogy of Fallot.

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