Analiza znieczulenia pacjentek z tetralogią Fallota do cięcia cesarskiego – opis przypadków

Wojciech Dąbrowski¹, Elżbieta Poniedziałek-Czajkowska², Jadwiga Biernacka¹, Jarosław Wośko¹, Andrzej Nestorowicz¹

Summary
Background. Anaesthesia for caesarean section in a patient with an uncorrected cyanotic congenital heart defect presents a serious challenge for an anaesthesiologist. Chronic cardiac or multiorgan failure, and sudden changes in pulmonary blood flow, may lead to serious complications and early death in the perinatal period. We describe two cases of caesarean section performed in adult patients with uncorrected tetralogy of Fallot (uF-4). Case 1. A 38-yr-old primagravida with uF-4, PAP 60 mm Hg (7,88 kPa), PaO₂ 40 mm Hg (6.67 kPa), and a haematocrit of 51, was scheduled for elective caesarean section in the 33^rd week of her pregnancy. She had arbitrarily stopped using her medication a few weeks earlier. The procedure was performed under epidural anaesthesia extending up to the Th_5-6 level, using a lidocaine/bupivacaine mixture. Methylergometrine was given for uterine contraction. At the end of the procedure, transient myocardial ischemia occurred which resolved after sublingual nitroglycerine. Transient hypotension was treated with fractional doses (0.05-0.01 mg) of phenylephrine, and SaO₂ remained in the range 72-85%. The postoperative period was uneventful and the patient was discharged home 17 days after delivery. Case 2. A 26-yr-old primagravida with uF-4, severe pulmonary hypertension (PAP 89 mm Hg – 11.68 kPa), PaO₂ 46 mm Hg (6.11 kPa), and haematocrit 58, was scheduled for elective caesarean section under general anaesthesia in the 30^th week of her pregnancy. As was the case with the other patient, she had stopped using her regular medication because she felt very comfortable during pregnancy. Anaesthesia was induced with etomidate/fentanyl and succynylcholine and maintained with nitrous oxide/oxygen mixture and atracurium. She required no medication during the procedure. Methylergometrine was given for uterine contraction. The immediate postoperative period was uneventful, however on the second day she developed Eisenmenger syndrome and died. Discussion and conclusion. There is no uniform recommendation for anaesthesia in patients with uncorrected cyanotic congenital heart disease. Both regional and general anaesthesia can be used, but special attention should be paid to maintaining a proper balance between systemic and pulmonary pressures and the avoidance of tachycardia. Any intervention in these patients is very risky and has to be carefully planned and monitored.

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