regional anesthesia in the high-risk cardiac parturient

RegionalRegional anesthesiaanesthesia in the in the highhigh--riskrisk cardiaccardiac paparturrturientient

M. VercauterenM. Vercauteren, MD, , MD, PhDPhDUniversityUniversity HospitalHospital AntwerpAntwerp, BELGIUM, BELGIUM

The The highhigh--riskrisk parturientparturient

MaternalMaternal diseasedisease : : sometimessometimes worseworse or or betterbettereffecteffect of pain & of pain & laborlabor & & bearingbearing down : down :

CO , PAPCO , PAP--SVRSVR--PVRPVRpostdeliverypostdelivery autotransfusion : PCWP autotransfusion : PCWP

DeliveryDelivery maymay help to help to solvesolve probleproblemm–– bleedingbleeding , , preeclampsiapreeclampsia / HELLP/ HELLP–– CPR, CPR, somesome cardiaccardiac diseasesdiseases

High risk High risk parturientparturient

understandunderstand diseasedisease involvedinvolveddiseasedisease pregnancypregnancyddiseaseisease laborlabordiseasedisease fetusfetusimpact of impact of anesthesiaanesthesiaimpact of impact of perinatalperinatal drugsdrugs

MortalityMortality riskrisk

<1%<1%•• ValvularValvular regurgitationregurgitation / / prolapsprolaps /mild PS/mild PS•• RepairedRepaired, , ASDASD, VSD, VSD

11--15%15%•• Stenotic Stenotic lesionslesions, , severesevere PSPS, , previousprevious AMIAMI•• MetalicMetalic valvesvalves

>25%>25%•• NYHA III/NYHA III/IVIV, , severesevere AoSAoS, Marfan, PHT, Marfan, PHT•• LV LV dysfunctiondysfunction, , arrhythmiasarrhythmias, , cyanosiscyanosis

CardiacCardiac disordersdisorders

ValvularValvular diseasediseaseIschemicIschemic diseasediseaseSeptalSeptal defectsdefectsCardiomyopathyCardiomyopathyPrimaryPrimary PulmPulm. . HypertensionHypertensionOthersOthers : : •• MarfanMarfan, , ToFToF, Eisenmenger, Eisenmenger’’s complexs complex

ValvularValvular : in : in generalgeneral

LifeLife treatheningtreathening risksrisks•• EndocarditisEndocarditis ((newnew guidelinesguidelines ?)?)•• OxytocinOxytocin ((nevernever in bolus) in bolus) •• EmbolismEmbolism•• PulmonaryPulmonary hypertensionhypertension / / edemaedema•• ArrhythmiasArrhythmias•• BloodlossBloodloss

PulmonaryPulmonary

PulmonaryPulmonary edemaedema•• CongestiveCongestive heartheart failurefailure•• FluidFluid retentionretention / return (/ return (preloadpreload) ) afterafter birthbirth•• ExcessiveExcessive fluidsfluids ((prehydrationprehydration + drugs) + drugs) •• AutotransfusionAutotransfusion & return (& return (preloadpreload) ) afterafter birthbirth•• ProceedProceed withwith epiduralepidural , , furosemidefurosemide ????•• ColloidsColloids ??

Acute Acute pulmonarypulmonary hypertensionhypertension•• Stress, Stress, hypertensionhypertension, pain, , pain, SVRSVR, , HRHR, drugs, drugs

ArrhythmiasArrhythmias

More More withwith mitralmitral valvevalve diseasediseaseReducedReduced cardiaccardiac fillingfilling (time)(time)•• Effect Effect onon coronarycoronary perfusionperfusion

AccentuatedAccentuated byby•• OxytocinOxytocin•• EphedrineEphedrine

BloodBlood lossloss

MayMay bebe enhancedenhanced byby•• AvoidanceAvoidance of of oxytocicsoxytocics•• AnticoagulantsAnticoagulants (more TE risk)(more TE risk)•• OperativeOperative deliverydelivery

SpecificSpecific problemsproblems•• LessLess capacitycapacity toto compensatecompensate•• ββ--blockerblocker useuse

MaternalMaternal and and fetalfetal outcomeoutcome

MaternalMaternal (0.6(0.6--2%) & 2%) & fetalfetal mortalitymortalityPreterm Preterm deliverydelivery, , lowerlower BWBWIUGR and IUGR and ApgarApgar<8<8InstrumentalInstrumental deliverydelivery ((lessless stressfulstressful))•• butbut identicalidentical CC--sectionsection raterate

MalhotraMalhotra et al, 2004et al, 2004

n=312 n=312 valvularvalvular vsvs 321 321 healthyhealthy parturientsparturients

ValvularValvular defectsdefectsRegurgitationRegurgitation•• mitralmitral insufficiencyinsufficiency•• mitralmitral valvevalve prolapsprolaps•• aorticaortic insufficiencyinsufficiency

Stenotic Stenotic conditionsconditions•• mitralmitral stenosisstenosis•• aorticaortic stenosisstenosis•• pulmonicpulmonic stenosisstenosis

Mixed Mixed diseasediseaseCorrectedCorrected problemsproblems

RegurgitationRegurgitation : : avoidavoid........

BradycardiaBradycardia -- DysrhythmiaDysrhythmia•• IncreasesIncreases LV LV fillingfilling time, more time, more regurgitationregurgitation•• EphedrineEphedrine betterbetter thanthan phenylephrinephenylephrine

PreloadPreload & & afterloadafterload increaseincrease•• LRA LRA desirabledesirable ((fluidfluid preloadingpreloading !)!)•• AfterloadAfterload decreasedecrease : AVR : AVR benefitsbenefits more more thanthan MVRMVR

MyocardialMyocardial depressiondepression : LVF!: LVF!•• LV LV enlargementenlargement : : earlierearlier in AVRin AVR

BeneficialBeneficial effect of effect of pregnancypregnancy (BV, SVR, HR)(BV, SVR, HR)

MitralMitral valvevalve stenosisstenosis

frequent, frequent, severesevere ifif areaarea <1cm<1cm22

diastolicdiastolic pressurepressure gradientgradient & & durationdurationLA LA dilateddilated //thrombusthrombus //arrhythmiaarrhythmia(AF)(AF)•• maternalmaternal mortalitymortality significantlysignificantly increasedincreased

ifif tachycardiatachycardia oror AFAF•• reducedreduced LVF and LVF and atrialatrial enlargementenlargementballoon balloon valvuloplastyvalvuloplasty possiblepossibleCHFCHF, , PEPE, , secondsecond PHTPHT, , RVFRVF, , TricITricI

AorticAortic valvevalve stenosisstenosis

IschemiaIschemia (O(O22 supplysupply, , workloadworkload, LV , LV wallwall))

NYHA NYHA •• MayMay bebe severesevere butbut symptomlesssymptomless

EchocardiographyEchocardiography•• LV LV hypertrophyhypertrophy, , gradientgradient , , valvularvalvular areaarea•• <1cm<1cm22 : : severesevere, <0.6cm, <0.6cm22 : : criticalcritical

BetablockerBetablocker : LVF ??: LVF ??•• more more fillingfilling time and time and coronarycoronary flowflow

Stenotic defects : Stenotic defects : avoidavoid........

SVR SVR increaseincrease and and tachycardiatachycardia•• ketamineketamine , , atropine , atropine , ephedrineephedrine

severesevere bradycardiabradycardia : : phenylephrinephenylephrine ??markedmarked afterloadafterload reductionreduction•• LRA : OK LRA : OK ifif moderate AL moderate AL decreasedecrease

hypovolemiahypovolemia : : normonormo--volemicvolemic expansionexpansionmyocardialmyocardial depressiondepression, , dysrhythmiasdysrhythmiaseepinephrinepinephrine in in locallocal anestheticsanesthetics

OtherOther valvularvalvular problemsproblemsMitralMitral valvevalve prolapsprolaps•• AvoidAvoid tachycardiatachycardia, AL , AL reductionreduction,,……..‘‘OperatedOperated’’ patientspatients•• HF, PHT and HF, PHT and arrhythmiaarrhythmia maymay persistpersist•• AnticoagulationAnticoagulation : : heparinheparin betterbetter ??

–– ProtamineProtamine, LMWH , LMWH bleedingbleeding risk <12h?risk <12h?–– WarfarinWarfarin : PPSB : PPSB oror FFPFFP–– BleedingBleeding oror thromboembolismthromboembolism ? ?

Mixed Mixed problemsproblems : predominant ? : predominant ?

CoronaryCoronary arteryartery diseasediseaseIncreasedIncreased risk risk whenwhen•• in in thirdthird trimester , trimester , deliverydelivery <2weeks<2weeks•• CC--sectionsection•• ageage <30yrs , diabetes , <30yrs , diabetes , hypertensionhypertension

laborlabor : : epiduralepiduralCC--sectionsection : : epiduralepidural > > spinalspinalphenylephrinephenylephrine > > ephedrineephedrineLV LV failurefailure : GA+ : GA+ lowlow--dosedose EA ?EA ?

SeptumSeptum defects defects

LeftLeft toto RightRight shunt : shunt : avoidavoid

•• SVR SVR increasesincreases•• severesevere SVR SVR decreasedecrease (ASD)(ASD)•• volume volume overloadoverload , , tachycardiatachycardia (VSD)(VSD)

RightRight toto LeftLeft shunt (PHT) shunt (PHT) •• FallotFallot’’s s TetralogyTetralogy, Eisenmenger, Eisenmenger’’s complexs complex•• AvoidAvoid prepre-- and and afterloadafterload reductionreduction

PerinatalPerinatal//ParipartumParipartum DilatedDilated CMCM••LRA LRA beneficialbeneficial : : afterloadafterload reductionreduction

HypertrophicHypertrophic ObstructiveObstructive CMCM•• strictlystrictly normovolemianormovolemia, , avoidavoid tachycardiatachycardia•• nono inotropicsinotropics oror afterloadafterload reductionreduction•• MVR MVR frequentlyfrequently presentpresent•• preferablypreferably vaginalvaginal deliverydelivery•• RA : RA : ‘‘lowlow--LALA dosedose’’ techniquetechnique•• ifif CC--sectionsection : : generalgeneral anesthesiaanesthesia

CardiomyopathyCardiomyopathy

PulmonaryPulmonary HT HT CausesCauses ((functionalfunctional and and structuralstructural))•• PrimaryPrimary•• SecundarySecundary : : CHDCHD, , HIVHIV, , SLESLE, , TEDTED, , COPDCOPD……

TreatmentTreatment•• NitricNitric oxideoxide•• ProstacyclinProstacyclin ((VDVD, , PLTPLT, , AntiAnti--InflInfl, , ……))•• EndothelinEndothelin receptor receptor antagonistsantagonists•• PhosphodiesterasePhosphodiesterase inhibitorsinhibitors•• ViagraViagra, , VasopressinVasopressin

PulmonaryPulmonary HT : HT : avoidavoid........HypoxiaHypoxia , , hypercapniahypercapnia , stress, stressketamineketamine , N, N220 0 PG , PG , oxytocinoxytocin , , ergometrineergometrineMyocardialMyocardial depressiondepressionBradycardiaBradycardiaAfterloadAfterload reductionreductionPreloadPreload reductionreduction

WhatWhat aboutabout clinicalclinicalpracticepractice and and experienceexperience ??

LaborLabor analgesiaanalgesiaLowLow dosedose epiduralepidural mostlymostly wellwell toleratedtoleratedStress response : Stress response : mitigatesmitigates ValsalvaValsalvaeffectseffects byby decreasingdecreasing the the pushingpushing reflexreflexMore More stablestable hemodynamicshemodynamics duringduringcontractionscontractions and and expulsionexpulsion (forceps)(forceps)AL AL decreasedecrease : benefit in : benefit in regurgitationregurgitationCSE / CSE / EpiduralEpidural : : nono locallocal anestheticsanesthetics ??•• opioidopioid, , neostigmineneostigmine, , clonidineclonidine, adrenaline, adrenaline……

CSA ?CSA ?

LaborLabor CSA : CSA : AdvantagesAdvantages

AdjustableAdjustable, , titratabletitratableOpioidOpioid alonealone : F 15: F 15--2525µµg, S 5g, S 5--7.57.5µµggLaborLabor : : rapidrapid conversionconversion toto CSCSLowerLower doses (?)doses (?)•• notnot in most in most reportsreports ((leakageleakage ?)?)

BetterBetter hemodynamichemodynamic stabilitystability•• RobsonRobson et al, BJA 1993; 70: 634et al, BJA 1993; 70: 634--88

hypotensionhypotension 2/20 2/20 ptsptsHeadacheHeadache lessless important important thanthan benefitsbenefits

LaborLabor analgsiaanalgsia : : stenosisstenosisEpiduralEpidural•• HemmingsHemmings 1987, 1987, ShinShin 19931993•• SuntharalingamSuntharalingam 20012001•• AfterAfter MVR : MVR : NakaoNakao 20052005

Spinal Spinal •• KeeKee , n=3, , n=3, CSECSE , , startstart opioidsopioids alonealone•• VanhelderVanhelder 1998, 1998, CSECSE : mixed : mixed AoAo/M, /M, alsoalso II•• RansomRansom 1995, 1995, CSACSA : : sufentanilsufentanil•• Vd Velde 2003, Vd Velde 2003, CSACSA : : sufentanilsufentanil 2x (+ 2x (+ ropiropi))•• Pan & DPan & D’’Angelo 2004, Angelo 2004, CSECSE : : bupibupi + F + M+ F + M

CC--section : section : regurgitationregurgitationEpiduralEpidural•• Mitral Valve Mitral Valve ProlapsProlaps

–– Tanaka 1994Tanaka 1994–– Ruiz Castro 1996Ruiz Castro 1996–– AlcontaraAlcontara 1987 1987

•• AoAo regurgitationregurgitation–– AldersonAlderson 1987 (+ 1987 (+ preeclampsiapreeclampsia : : deathdeath))–– ZangrilloZangrillo 2005 2005

•• BetweenBetween MV replacement & MV replacement & reoperationreoperation–– NakaoNakao 20052005

CC--section : section : stenosisstenosisEpiduralEpidural•• AoAo StenosisStenosis

–– Brian 1993, Brian 1993, TamuraTamura 19971997–– ColcloughColclough 1990 /1990 /’’95, Peng 1997, 95, Peng 1997, XiaXia 2006 2006

•• PulmonicPulmonic stenosisstenosis–– ConwayConway 1994, Campbell 2003 (+ 1994, Campbell 2003 (+ AoIAoI))

•• Mitral Mitral stenosisstenosis–– ZiskindZiskind 1990, 1990, AfranguiAfrangui & & MalinowMalinow 19981998–– KubotaKubota 2003 (n=7), Pan & D2003 (n=7), Pan & D’’Angelo 2004Angelo 2004

CC--section : section : stenosisstenosisSpinalSpinal•• SDSSDS : : MostafaMostafa 1984 (MS)1984 (MS)•• CSECSE : : BosoBoso 2008 (AS)2008 (AS)•• CSA CSA : Pittard & : Pittard & VucevicVucevic 1998 (AS)1998 (AS)

+ 2 + 2 editorialseditorials

SDS to SDS to bebe avoidedavoided !!!!!!

LowLow dose CSE + EVE ?dose CSE + EVE ?

LewLew et alet al, , A & A 2004; 98: 810A & A 2004; 98: 810--44•• BH 5mg + EVE (6ml BH 5mg + EVE (6ml NaClNaCl 0.9%)0.9%)•• BH 8mg BH 8mg •• bothboth + + FentanylFentanyl 1010µµg)g)

•• qualityquality / / spreadspread : : identicalidentical•• fasterfaster MB MB recoveryrecovery•• hypotension : no hypotension : no differencedifference

vsvs

SittingSitting or or laterallateral ??InglisInglis et al, et al, AnaesthesiaAnaesthesia 1995 (SDS)1995 (SDS)BembridgeBembridge, , AnaesthesiaAnaesthesia 1986 (SDS)1986 (SDS)PatelPatel et al, Can J et al, Can J AnesthAnesth 1993 (CSE)1993 (CSE)KohlerKohler et al, A A et al, A A ScandScand 2002 (SDS 32002 (SDS 3’’))CoppejansCoppejans et al, et al, AnesthAnesth AnalgAnalg 2006 (CSE)2006 (CSE)

SittingSitting injection of injection of hyperbarichyperbaric BB•• SlowerSlower / / lessless rostral rostral spreadspread•• LessLess ((laterlater) hypotension) hypotension•• More More epiduralepidural supplementationsupplementation

RA for RA for nonnon--valvularvalvular diseasediseaseHOCM, PPCM, single HOCM, PPCM, single ventricleventricleAoAo dissection, dissection, coronarycoronary (CAD)(CAD)severalseveral case reports: case reports: CSE / CSE / CSACSA

HonigHonig et al, et al, AnAnäästhetiststhetist 1998 (CAD)1998 (CAD)IshiyamaIshiyama et al, A&A 2003 (HOCM)et al, A&A 2003 (HOCM)Ben Ben LetaifaLetaifa, , AnnAnn FrFr An An ReanRean 2002 (2002 (MarfanMarfan, , PuEdPuEd, MVI), MVI)OkutomiOkutomi et al, Acta et al, Acta AnaesthAnaesth ScandScand 2002 (HOCM, 2002 (HOCM, laborlabor))Dubois et al, Dubois et al, AnnAnn FrFr AnesthAnesth ReanimReanim 2003 (single 2003 (single ventrventr n=2)n=2)VelichovicVelichovic & & LeichtLeicht, IJOA 2004 (, IJOA 2004 (PPCMPPCM, n=3), n=3)LandauLandau et al, et al, ActaActa AnaesthAnaesth ScandScand 2004 (2004 (doubledouble outletoutlet RVRV))SmithSmith et al, IJOA 2008 (CAD, CS n=3, et al, IJOA 2008 (CAD, CS n=3, laborlabor n=1)n=1)

RA for RA for nonnon--valvularvalvular diseasedisease

EisenmengerEisenmenger’’s s complexcomplex ????AtanasoffAtanasoff, Acta , Acta AnaesthesiolAnaesthesiol ScandScand 19901990ColeCole et al, BJA 2001et al, BJA 2001SakurabaSakuraba et al, J et al, J AnesthAnesth 20042004

MARTIN et al, RAPM 2002; 27: 509MARTIN et al, RAPM 2002; 27: 509--13 (13 (reviewreview))--103 103 anestheticsanesthetics + 21 + 21 laborlabor analgesiaanalgesia-- mortalitymortality : : overalloverall 14%, RA 5%, GA 18% (NS)14%, RA 5%, GA 18% (NS)

major major surgerysurgery : 24%, minor 5% (p<0.05): 24%, minor 5% (p<0.05)laborlabor RA : 24% !!RA : 24% !!

RA for RA for nonnon--valvularvalvular diseasedisease

SevereSevere pulmonarypulmonary hypertension ??hypertension ??BONNIN et al, BONNIN et al, AnesthesiologyAnesthesiology 2005; 102: 11132005; 102: 1113--77--N=14, 15 N=14, 15 pregnanciespregnancies--Vaginal : n=4 (RA) (1 Vaginal : n=4 (RA) (1 dieddied, 1 , 1 worseworse) ) --CS CS underunder GA : n=4 (1 GA : n=4 (1 dieddied, 2 , 2 worseworse) ) --CS CS underunder CSE : n=5 (1 CSE : n=5 (1 dieddied, 4 stable), 4 stable)-- mortalitymortality :: n=2 n=2 beforebefore deliverydelivery

overall 36%overall 36%a place a place forfor lowlow dosedose CSE ??CSE ??

PerioperativePerioperative monitoringmonitoringECG , ECG , pulsepulse oxymetryoxymetryUS (US (EFEF?) ?) oror TEE (TEE (awakeawake ?)?)BloodBlood pressurepressure : : radialradial arteryartery•• AnticipatedAnticipated bloodblood loss, loss, prepre--eclampsiaeclampsia•• CO CO measurementmeasurement ??

Central Central venousvenous lineline ??WhatWhat willwill itit learnlearn ? Risk of ? Risk of arrhythmiasarrhythmiasPulmonaryPulmonary arteryartery cathetercatheter ??•• NYHA III/NYHA III/IVIV, , sheethsheeth onlyonly ? ? VascVasc trauma ?trauma ?

ConclusionsConclusionsMultidisciplinaryMultidisciplinary approachapproach (at 24wks ?)(at 24wks ?)LowLow--dosedose epiduralepidural is is mostlymostly OK OK forfor laborlaborSingleSingle--dosedose spinalspinal mostlymostly notnot the best the best ideaideaProblemsProblems notnot solvedsolved afterafter birthbirth oror surgerysurgeryInvasiveInvasive monitoringmonitoring ? ? CC--sectionsection : : notnot alwaysalways best best choicechoiceAllAll RA RA techniquestechniques are are notnot the the samesame•• OutweighOutweigh PROPRO’’s and s and CONsCONs•• IndividualIndividual judgementjudgement

HR

PL/AL

Contr

C-section

Ao-I

RA

Mi-I

RA

Mi-S

RA

CAD

RA>GA

SummarySummary : : avoidavoid……

HR

PL/AL

Contr

C-section

Ao-S GA>RA

PS/PHT GA

L to R R to L

GA/RA GA

Eisenm GA PPCM HOCM

RA GA

SummarySummary : : avoidavoid……

ConclusionsConclusions

ContraindicationsContraindications forfor RA (& RA (& pregnancypregnancy ?)?)•• FallotFallot’’s s tetralogytetralogy unlessunless repairedrepaired

–– GelsonGelson et al 2008, RA 67% (16pt / 26del)et al 2008, RA 67% (16pt / 26del)

•• EisenmengerEisenmenger’’s complexs complex•• AnticoagulationAnticoagulation•• HypertrophicHypertrophic subaorticsubaortic stenosisstenosis, HOCM, HOCM•• PrimaryPrimary pulmonarypulmonary hypertensionhypertension•• SevereSevere AoAo//pulmpulm stenosisstenosis (<0.6(<0.6--0.9cm0.9cm22))

AvoidAvoid ‘‘heroismheroism’’

The most important part of The most important part of ‘‘patientpatient carecare’’is is ‘‘caringcaring forfor the the patientpatient’’

DavidDavid L.L.BrownBrownRAPM 2003RAPM 2003