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Department of
Anaesthesiology
Combined Military Hospital
Dhaka, Bangladesh22 Apr 2017
• Name : Buly Akhter
• Spouse : Snk Shamim Mollah
• Age : 21 years
• Gender : Female
• Religion : Islam
• Marital Status : Married
• Hailing from : Borogoni, Chitolmari, Bagerhat
• Date of Admission : 4th November 2016
Particulars of the Patient
• Amenorrhea due to
pregnancy for 35+ weeks
• Lower abdominal pain for
3 days
• Watery vaginal discharge
for 2 days
Chief complaints
The patient had been amenorrhoic due to pregnancy
for 35+ weeks. She had complaints of lower
abdominal pain for last 3 days which was initially dull
and intermittent in nature, radiated towards back and
groins, not associated with hardening of uterus.
She also complained about per-vaginal discharge for
last 2 days, which was initially whitish and foul-
smelling then gradually watery in nature.
H/O Present illness
With these complaints, she got admitted to this CMH
in ORs’ Family Gynae ward. After 2 days of her
admission, she developed severe respiratory
difficulties in the ward which was treated by O2
inhalation, nebulisation and diuretics, but did not
improve significantly.
Then, she was shifted to PACU from the Gynae ward
immediately.
H/O Present illness (Continued)
There was NO history of -
• Diabetes Mellitus
• Systemic Hypertension
• Bronchial asthma
• Pregnancy Induced Hypertension
• Gestational Diabetes Mellitus
• Tuberculosis
• Rheumatic fever
H/O Past illness
Nothing contributory
Drug History
The patient was on Iron, Vitamin B complex &
Calcium supplementation during her pregnancy. She
was on irregular antenatal check up.
Treatment History
Nothing contributory
Family History
Low middle class
Socio-economic History
Married for : Two and half years
Para : 0
Gravida : Primi
Obstetric History
Menstrual period : 5 days
Menstrual cycle : 28 days
Menstrual flow : Regular
LMP : 3 Mar 2016
EDD : 10 Dec 2016
Menstrual History
• Appearance : Anxious
• Built : Average
• Nutritional status : Average
• Decubitus : Propped up
• Anaemia : Mild
• Cyanosis : Absent
• Jaundice : Absent
• Clubbing : Absent
General Examination
• Koilonychias : Absent
• Leukonychia : Absent
• Oedema : Absent
• Dehydration : Absent
• Pulse : 120 b/min
• BP : 130/80 mm of Hg
• Temperature : 98.4˚F
• Lymph node : Not palpable
• Thyroid gland : Not enlarged
General Examination (Continued)
Systemic Examination
Respiratory system:
Inspection Palpation Percussion Auscultation
• Shape: Normal
• Chest
movement:
symmetrical on
both side
• No visible scar
mark
• No visible
engorged vein
• Respiratory
rate: 28/min
• Trachea:
centrally placed
• Apex beat:
normal
• Chest
expansibility:
symmetrical on
both side
• Vocal fremitus:
normal
• Percussion:
Resonant
• Cardiac
dullness:
Normal
• Vesicular
breath
sound with
Bilateral
basal
crepitation
on both
lung
Systemic Examination (Continued)
Cardiovascular system:
Inspection Palpation Auscultation
• Not done • Apex Beat: Left
5th inter costal
space
• Thrill: Present in
apical & left
parasternal area
• 1st & 2nd heart
sound: Normal in
all areas
• Murmur: Mid
diastolic murmur in
mitral area and
Early diastolic
murmur in left
lower parasternal
area
Per-abdominal Examination:
Inspection Palpation Percussion Auscultation
• Normal in
shape
• Umbilicus:
Centrally
placed
• Relaxed
• Symphysio
fundal height:
Reveals 36
weeks of
pregnancy
• Abdominal
girth: 115 cm
• Fetal
movement:
present
• Normal • Fetal heart
rate: 148
beat/min
Systemic Examination (Continued)
Per-vaginal Examination:
• Cervix : Soft
• OS : 1.5 cm dilated
• Presentation : Cephalic
• Station : 0
• Movement : Regular
Systemic Examination (Continued)
Salient Features
A 21-years-old primi reported to Gynae OPD of CMH
Dhaka with the complaints of amenorrhea due to
pregnancy for 35+ weeks. She had complaints of lower
abdominal pain for last 3 days which was initially dull and
intermittent in nature, radiated towards back and groins,
not associated with hardening of uterus. She also noticed
per-vaginal discharge for last 2 days, which was initially
whitish and foul-smelling, then watery in nature.
With those complaints, she got admitted in the ORs’
Family Gynae ward. After 2 days of her admission, she
developed severe respiratory distress in the ward which
was treated by O2 inhalation, nebulisation and diuretics;
but did not improve significantly.
Then, she was shifted from ward to PACU immediately.
The patient was thoroughly examined in PACU and was
found to have tachycardia and tachypnoea.
Salient Features (Continued)
Her CVS examination revealed thrill and mid-diastolic
murmur on apical area and early diastolic murmur on
parasternal area. On respiratory system examination,
there were basal crepitations on both lungs fields.
Her per-abdominal and per-vaginal examination revealed
36 wks of pregnancy with labour. Her other systems
shown no abnormality. Then, the patient was referred to
Cardiologist for further cardiac evaluation.
Salient Features (Continued)
Provisional diagnosis
Primi gravida with 35+ weeks of
pregnancy with PROM with preterm
labour with Valvular heart disease
Differential diagnosis
 Primi gravida with 35+ weeks of
pregnancy with PROM with preterm
labour with Fluid over load
 Primi gravida with 35+ weeks
of pregnancy with PROM with
preterm labour with Pneumonia
Investigations
Complete Blood count:
• Hb conc. : 11.00 gm/dl
• Total Red Blood cells : 3.75×1012/L
• Hct : 34.10%
• Total White blood cells : 13×109/L
• Differential Leucocyte count :
• Neutrophils - 80%
• Eosinophils - 01%
• Basophils - 00%
• Lymphocytes - 15%
• Monocytes - 04%
• Others - 00%
Investigations (Continued)
Complete Blood count:
• Platelets : 294.00×109/L
• ESR (Westergren) : 26 mm in 1st hour
Coagulation profile:
Prothrombin Time (PT):
• Patient : 17 second
• Control : 12 second
• INR : 1.44
Activated Partial thromboplastin time (APTT):
• Patient : 36 second
• Control : 31 second
Physical and Chemical
examination
Microscopic
Examination
Appearance:
Sp. Gravity:
Reaction:
Protein:
Glucose:
Bile salt:
Bile
pigments:
Light amber
Not done
Acidic
Nil
Nil
Not done
Not done
WBCs:
RBCs:
Epithelial
cells:
Casts:
Crystals:
Others:
2-3/HPF
Nil/HPF
4-6/HPF
Nil
Nil
Nil
Urine routine & microscopic examination:
Investigations (Continued)
Blood Sugar:
• Plasma Glucose Fasting : 5.0 mmol/L
• Plasma Glucose 2 hrs after
75 mg oral Glucose : 6.0 mmol/L
Blood group (ABO and Rh):
• B (BEE) +ve (positive)
VDRL (Qualitative):
• Non-reactive
HbsAg
• Negative
Investigations (Continued)
Ultrasonogram of Pregnancy profile:
Investigations (Continued)
 Uterus is gravid containing single living foetus with
regular cardiac pulsations and normal foetal movement
 Foetal presentation: Cephalic
 EDD: 4 Dec 2016 ± 1 week
 Placenta: Anterior, away from os
 Gestational age: 35 wks & 2 days
Figure: ECG tracing showing P mitralae with Tacycardia
Electrocardiogram:
Investigations (Continued)
 Sinus tachycardia
 P mitralae
 Rheumatic heart disease
 Moderate mitral stenosis (MS)
 Mitral vulve area: 1.2 cm2
 Moderate mitral regurgitation (MR)
 Mild to moderate aortic regurgitation (AR)
 Severe pulmonary hypertension (PASP: 68 cm of H2O)
 Good left ventricular function (LVEF: 60%)
Echocardiogram (bed-side):
Investigations (Continued)
Confirmatory diagnosis
Primi gravida with 35+ weeks pregnancy with
PROM with preterm labour with moderate MS
and MR with mild to moderate AR with severe
pulmonary hypertension
Decision of Emergency Surgery
Immediately after confirmation of the
diagnosis, decision of performing the
emergency Cesarean section was taken
Anaesthetic management
Anaesthetic considerations
 Anaesthetic management for an emergency
Caesarean section with double valve heart disease
which was diagnosed just prior to the operation.
 Administering anaesthesia in a compromised
patient with respiratory distress and basal
crepitations due to valvular heart disease and
pulmonary hypertension which were not
optimised by preoperative treatment.
 Prevention and management of intra-operative
complications due to pulmonary hypertension.
 As the mother was on preterm labour with
PROM, so there were great concerns of safety of
two lives on distress.
Anaesthetic considerations
(Continued)
Pre-anaesthetic assessment
 Pre-anaesthetic check-up was done with detailed
history, proper clinical examination and
assessment of the investigation reports.
 Immediately after the check-up in PACU patient
was shifted to Operation Theatre.
Pre-anaesthetic assessment
(Continued)
 Considering her preterm labour with PROM and
stat diagnosis of moderately advanced valvular
heart disease and severe pulmonary hypertension,
the patient was assessed as:
 NYHA classification : NYHA class - IV
 Airway assessment : Mallampati class - II
 ASA Grading : ASA Grade - IV (E)
 Patient was planned for emergency Caesarean
section.
 Propped up position
 O2 inhalation @ 2-4 l/min
 Airway management eqpt
 Different sized ET tube
 Gum elastic bougie
 Breathing circuits
 Drugs for GA and
emergency carts
Preparation for Anaesthesia
 Defibrillator
 Syringe pumps
 Large-bore 16 gauze I/V line was
established through left cephalic
vein
 Inj. Frusemide 20 mg I/V stat given
 Urinary catheterization was done
 Paediatric team was brought in the
OT.
Preparation for Anaesthesia
(Continued)
 A central venous catheter line was established
through the right internal jugular vein (IJV) with 7
Fr, 20 cm central venous catheter.
Preparation for Anaesthesia
(Continued)
 An intra-arterial line was established in the right
radial artery to monitor the continuous invasive
blood pressure.
Preparation for Anaesthesia
(Continued)
 Inj. Metoclopramide (10 mg)
 Inj. Ranitidine (50 mg)
 Inj. Ceftriaxone (1 gm)
 Inj. Fentanyl (100 mcg)
Premedication
 Medications given on the OT table before operation
 Induction was done by Inj.
Thiopentone Sodium
(300mg)
 Intubation was done after
adequate muscle relaxation
with Inj. Suxamethonium
(100mg)
Induction and Intubation
 The patient was reassured with compassion to allay
her fear and anxiety
 Anaesthesia was maintained with O2 and
intermittent Midazolam.
 Adequate analgesia was ensured with intravenous
Fentanyl (150 mcg)
 Adequate muscle relaxation was provided with
intermittent NMBA (Inj. Vecuronium Bromide)
 Intravascular volume was kept optimised by Inj.
Frusemide.
 Per-operatively, only 200 ml of Hartmann solution
was given.
Maintenance
 Control of HR & rhythm: By Inj Esmolol
 Maintaining CVP within 5-6 cmH2O by optimum
volume of IV Fluids (only 200 ml) and judicious use of
diuretics (Inj Frusemide 20 mg)
 Emergency medicines were kept ready to combat any
unforeseen complications which include - Inj GTN,
Adrenaline, Noradrenaline, etc.
Measures to overcome
Anesthetic challenges
Further deterioration of PAH was
managed by:
 100% O2 (to prevent hypoxia)
 Avoidance of Halothane and N2O
 Adequate analgesia by Inj. Fentanyl (150 mcg)
 Moderate hyperventilation (to prevent of acidosis)
 Low-dose infusion of Inj. Dobutamin to reduce
Pulmonary vascular resistance
Measures to overcome Anesthetic
challenges (Continued)
 Routine monitoring of
ECG and SpO2.
 Continuous ETCO2 was
monitored and kept below
30 mmHg to prevent
further deterioration of
pulmonary hypertension.
 CVP was monitored to
restore normal volume
status.
Intra-operative monitoring
 Beat-to-beat IBP was monitored through arterial line.
 Urine output was monitored (50 ml in 45 minutes).
 Per-operative ABG analysis was done and kept within
normal ranges.
Intra-op monitoring (Continued)
A male baby with 2 kg body weight was delivered per-
abdominally and after immediate resuscitation at the OT
by the attending Paediatric Team, the baby was shifted
to NICU for further evaluation and management.
Baby resuscitation
The conventional reversal and emergence usually
provokes tachycardia and agitation which are
considered as the detrimental factors for the patients
with VHD and PAH. Moreover, this patient needed a
less stress and pain free reversal. So, she was not
reversed on the OT table and kept on elective
mechanical ventilation, then shifted to CCC, with an
endotracheal tube in situ.
Issue of Reversal
Postoperative Management
 In the CCC, all invasive and non-invasive monitoring
were continued.
 MAP was kept within 70-90 mmHg.
 Cardiac output was monitored by flow trac module.
 Analgesia & sedation was provided with Inj Fentanyl
and Inj Midazolam.
 Fluid maintenance was ensured by 0.45% DNS @ 70
ml/hr
 The patient was on pressure-supported ventilation for
48 hours in the CCC with measured VT of 7 ml/kg.
Postoperative Management
(Continued)
 On 2nd POD, she was
extubated and shifted to Post-
Anaesthesia CU from CCC.
 On 5th POD, a follow-up
Echo was done & her cardiac
status was found comparable
with the pre-existing
condition.
 On 6th POD, the patient was
shifted from Post-Anaes CU
to Gynae ward.
Postoperative Management
(Continued)
 On 7th POD, the stitches of the surgical wound were
removed.
 On the same day, Cardiologist visited the patient and
prescribed Tab. Furosemide+Spironolactone, Tab.
Metoprolol, Tab. Bosentan & Tab. Phenoxymethyl
Penicillin and she was advised to come for follow-up
after 4 weeks.
 On the same day, the patient was discharged from CMH
Dhaka.
Discussion
Parameter
Average changes from
non-pregnant values (%)
Plasma volume +45
Cardiac output +40
Heart rate +15
Stroke volume + 30
Systemic vascular resistance -15
Oxygen consumption +20
Renal blood flow and GFR -50
Haemodynamic changes in
normal pregnancy
 Increases significantly by 5 weeks gestation.
 At the end of 1st trimester : CO increases by 40%
 At the end of 2nd trimester : Increases by 50%
 Immediately postpartum : Increases by 75%
 Overall, cardiac output get increased by 40% during
pregnancy period from non-pregnant values.
 It has a significant effect on maternal physiology and
pharmacology during anaesthetic procedure.
Critical periods
Cardiac output
 Incidence of valvular heart disease in developed
country is 2.5%, amongst all valvular heart
disease.
 Mitral valve prolapse is most common affecting
1% to 2.5% of all population of developed
countries.
 Most commonly women of child bearing ages are
affected.
Incidence of Valvular Heart
Disease
Pregnancy can cause following cardiac complication
in a patient with valvular heart disease:
 Atrial fibrillation
 Pulmonary oedema
 Pulmonary hypertension
 Right ventricular failure
 Congestive cardiac failure
 Bacterial endocarditis.
Effect of Pregnancy on
Valvular heart disease
Effect of Valvular heart disease
on Pregnancy
Valvular heart disease has some detrimental effect on
pregnancy it includes:
 Abortion
 Preterm labour
 Intra uterine growth retardation
 Congenital heart disease in baby – 5%
 Intrauterine fetal death
Anaesthetic challenges
(Mitral stenosis)
Challenges Management
Sinus tachycardia, atrial fibrillation
Cardioversion or IV administration
of Beta blockers, Ca++ channel
blockers, digoxin
Marked increase in central blood
volume
Judicious use of IV fluid
Drug induced decrease in systemic
vascular resistance
Use of sympathomimetic drug
(Phenylephrine)
Pulmonary Hypertension and right
heart failure
Avoidance of hypoxaemia and
hypercarbia, Ionotropes,
Pulmonary vasodilating drugs.
Anaesthetic challenges
(Mitral & Aortic regurgitation)
Challenges Management
Bradycardia Avoid volume overload
Increased systemic
vascular resistance
After load reduction with a
vasodilator(Nitroprusside)with or
without inotropes, maintenance of
cardiac output by modest increase in
heart rate.
Myocardial depression Judicious use of drugs.
Anaesthetic challenges
(Pulmonary Hypertension)
Challenges Management
Right heart
failure
• Reduce RV after load
• Avoid hypoxemia, hypotension and
inadequate RV preload
• Continuous use of pulmonary
vasodilator s (Ca channel blockers,
Inhaled NO, GTN)
Pulmonary
Oedema
Use of diuretics.
Hypoxia,
Hypercarbia,
acidosis
Use of 100% oxygen and judicious use of
inhalation anesthetics and sedatives
Choice of Anaesthesia
Condition Choice of Anaesthesia
NYHA class 1 & 2
Normal vaginal delivery, forceps
delivery with epidural analgesia
NYHA class 3 & 4 LUCS under G/A
It is better to avoid spinal anaesthesia except MR
Postoperative Care
Risk of:
 Sudden death in early postoperative period due to
worsening of pulmonary hypertension
 Pulmonary oedema and Right heart failure
 Pulmonary thromboembolism and Dysrhythmias
 Hypoxaemia, hypercarbia and respiratory acidosis due
to pain & hypoventilation
Postoperative Care (Continued)
These can be managed by:
 Intense cardiovascular monitoring
 Proper oxygenation, mechanical ventilation (if
necessary).
 Maintenance of hemodynamic variables at acceptable
levels
 Optimal pain control
Surgical and Anaesthetic management of a patient with
diseased heart is always challenging. Specially it sweats
more when the issue is PREGNANCY.
It demands skillful and sophisticated handling of the
patient. Moreover, when the finding is incidental, a
single break of concentration can be fatal.
Conclusion
Preoperative Incidental Detection & Anaesthetic Management of Valvular Heart Disease in Emergency LUCS

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Preoperative Incidental Detection & Anaesthetic Management of Valvular Heart Disease in Emergency LUCS

  • 1. Department of Anaesthesiology Combined Military Hospital Dhaka, Bangladesh22 Apr 2017
  • 2. • Name : Buly Akhter • Spouse : Snk Shamim Mollah • Age : 21 years • Gender : Female • Religion : Islam • Marital Status : Married • Hailing from : Borogoni, Chitolmari, Bagerhat • Date of Admission : 4th November 2016 Particulars of the Patient
  • 3. • Amenorrhea due to pregnancy for 35+ weeks • Lower abdominal pain for 3 days • Watery vaginal discharge for 2 days Chief complaints
  • 4. The patient had been amenorrhoic due to pregnancy for 35+ weeks. She had complaints of lower abdominal pain for last 3 days which was initially dull and intermittent in nature, radiated towards back and groins, not associated with hardening of uterus. She also complained about per-vaginal discharge for last 2 days, which was initially whitish and foul- smelling then gradually watery in nature. H/O Present illness
  • 5. With these complaints, she got admitted to this CMH in ORs’ Family Gynae ward. After 2 days of her admission, she developed severe respiratory difficulties in the ward which was treated by O2 inhalation, nebulisation and diuretics, but did not improve significantly. Then, she was shifted to PACU from the Gynae ward immediately. H/O Present illness (Continued)
  • 6. There was NO history of - • Diabetes Mellitus • Systemic Hypertension • Bronchial asthma • Pregnancy Induced Hypertension • Gestational Diabetes Mellitus • Tuberculosis • Rheumatic fever H/O Past illness
  • 7. Nothing contributory Drug History The patient was on Iron, Vitamin B complex & Calcium supplementation during her pregnancy. She was on irregular antenatal check up. Treatment History Nothing contributory Family History Low middle class Socio-economic History
  • 8. Married for : Two and half years Para : 0 Gravida : Primi Obstetric History Menstrual period : 5 days Menstrual cycle : 28 days Menstrual flow : Regular LMP : 3 Mar 2016 EDD : 10 Dec 2016 Menstrual History
  • 9. • Appearance : Anxious • Built : Average • Nutritional status : Average • Decubitus : Propped up • Anaemia : Mild • Cyanosis : Absent • Jaundice : Absent • Clubbing : Absent General Examination
  • 10. • Koilonychias : Absent • Leukonychia : Absent • Oedema : Absent • Dehydration : Absent • Pulse : 120 b/min • BP : 130/80 mm of Hg • Temperature : 98.4˚F • Lymph node : Not palpable • Thyroid gland : Not enlarged General Examination (Continued)
  • 11. Systemic Examination Respiratory system: Inspection Palpation Percussion Auscultation • Shape: Normal • Chest movement: symmetrical on both side • No visible scar mark • No visible engorged vein • Respiratory rate: 28/min • Trachea: centrally placed • Apex beat: normal • Chest expansibility: symmetrical on both side • Vocal fremitus: normal • Percussion: Resonant • Cardiac dullness: Normal • Vesicular breath sound with Bilateral basal crepitation on both lung
  • 12. Systemic Examination (Continued) Cardiovascular system: Inspection Palpation Auscultation • Not done • Apex Beat: Left 5th inter costal space • Thrill: Present in apical & left parasternal area • 1st & 2nd heart sound: Normal in all areas • Murmur: Mid diastolic murmur in mitral area and Early diastolic murmur in left lower parasternal area
  • 13. Per-abdominal Examination: Inspection Palpation Percussion Auscultation • Normal in shape • Umbilicus: Centrally placed • Relaxed • Symphysio fundal height: Reveals 36 weeks of pregnancy • Abdominal girth: 115 cm • Fetal movement: present • Normal • Fetal heart rate: 148 beat/min Systemic Examination (Continued)
  • 14. Per-vaginal Examination: • Cervix : Soft • OS : 1.5 cm dilated • Presentation : Cephalic • Station : 0 • Movement : Regular Systemic Examination (Continued)
  • 15. Salient Features A 21-years-old primi reported to Gynae OPD of CMH Dhaka with the complaints of amenorrhea due to pregnancy for 35+ weeks. She had complaints of lower abdominal pain for last 3 days which was initially dull and intermittent in nature, radiated towards back and groins, not associated with hardening of uterus. She also noticed per-vaginal discharge for last 2 days, which was initially whitish and foul-smelling, then watery in nature.
  • 16. With those complaints, she got admitted in the ORs’ Family Gynae ward. After 2 days of her admission, she developed severe respiratory distress in the ward which was treated by O2 inhalation, nebulisation and diuretics; but did not improve significantly. Then, she was shifted from ward to PACU immediately. The patient was thoroughly examined in PACU and was found to have tachycardia and tachypnoea. Salient Features (Continued)
  • 17. Her CVS examination revealed thrill and mid-diastolic murmur on apical area and early diastolic murmur on parasternal area. On respiratory system examination, there were basal crepitations on both lungs fields. Her per-abdominal and per-vaginal examination revealed 36 wks of pregnancy with labour. Her other systems shown no abnormality. Then, the patient was referred to Cardiologist for further cardiac evaluation. Salient Features (Continued)
  • 18. Provisional diagnosis Primi gravida with 35+ weeks of pregnancy with PROM with preterm labour with Valvular heart disease
  • 19. Differential diagnosis  Primi gravida with 35+ weeks of pregnancy with PROM with preterm labour with Fluid over load  Primi gravida with 35+ weeks of pregnancy with PROM with preterm labour with Pneumonia
  • 20. Investigations Complete Blood count: • Hb conc. : 11.00 gm/dl • Total Red Blood cells : 3.75×1012/L • Hct : 34.10% • Total White blood cells : 13×109/L • Differential Leucocyte count : • Neutrophils - 80% • Eosinophils - 01% • Basophils - 00% • Lymphocytes - 15% • Monocytes - 04% • Others - 00%
  • 21. Investigations (Continued) Complete Blood count: • Platelets : 294.00×109/L • ESR (Westergren) : 26 mm in 1st hour Coagulation profile: Prothrombin Time (PT): • Patient : 17 second • Control : 12 second • INR : 1.44 Activated Partial thromboplastin time (APTT): • Patient : 36 second • Control : 31 second
  • 22. Physical and Chemical examination Microscopic Examination Appearance: Sp. Gravity: Reaction: Protein: Glucose: Bile salt: Bile pigments: Light amber Not done Acidic Nil Nil Not done Not done WBCs: RBCs: Epithelial cells: Casts: Crystals: Others: 2-3/HPF Nil/HPF 4-6/HPF Nil Nil Nil Urine routine & microscopic examination: Investigations (Continued)
  • 23. Blood Sugar: • Plasma Glucose Fasting : 5.0 mmol/L • Plasma Glucose 2 hrs after 75 mg oral Glucose : 6.0 mmol/L Blood group (ABO and Rh): • B (BEE) +ve (positive) VDRL (Qualitative): • Non-reactive HbsAg • Negative Investigations (Continued)
  • 24. Ultrasonogram of Pregnancy profile: Investigations (Continued)  Uterus is gravid containing single living foetus with regular cardiac pulsations and normal foetal movement  Foetal presentation: Cephalic  EDD: 4 Dec 2016 ± 1 week  Placenta: Anterior, away from os  Gestational age: 35 wks & 2 days
  • 25. Figure: ECG tracing showing P mitralae with Tacycardia Electrocardiogram: Investigations (Continued)  Sinus tachycardia  P mitralae
  • 26.  Rheumatic heart disease  Moderate mitral stenosis (MS)  Mitral vulve area: 1.2 cm2  Moderate mitral regurgitation (MR)  Mild to moderate aortic regurgitation (AR)  Severe pulmonary hypertension (PASP: 68 cm of H2O)  Good left ventricular function (LVEF: 60%) Echocardiogram (bed-side): Investigations (Continued)
  • 27. Confirmatory diagnosis Primi gravida with 35+ weeks pregnancy with PROM with preterm labour with moderate MS and MR with mild to moderate AR with severe pulmonary hypertension
  • 28. Decision of Emergency Surgery Immediately after confirmation of the diagnosis, decision of performing the emergency Cesarean section was taken
  • 30. Anaesthetic considerations  Anaesthetic management for an emergency Caesarean section with double valve heart disease which was diagnosed just prior to the operation.  Administering anaesthesia in a compromised patient with respiratory distress and basal crepitations due to valvular heart disease and pulmonary hypertension which were not optimised by preoperative treatment.
  • 31.  Prevention and management of intra-operative complications due to pulmonary hypertension.  As the mother was on preterm labour with PROM, so there were great concerns of safety of two lives on distress. Anaesthetic considerations (Continued)
  • 32. Pre-anaesthetic assessment  Pre-anaesthetic check-up was done with detailed history, proper clinical examination and assessment of the investigation reports.  Immediately after the check-up in PACU patient was shifted to Operation Theatre.
  • 33. Pre-anaesthetic assessment (Continued)  Considering her preterm labour with PROM and stat diagnosis of moderately advanced valvular heart disease and severe pulmonary hypertension, the patient was assessed as:  NYHA classification : NYHA class - IV  Airway assessment : Mallampati class - II  ASA Grading : ASA Grade - IV (E)  Patient was planned for emergency Caesarean section.
  • 34.  Propped up position  O2 inhalation @ 2-4 l/min  Airway management eqpt  Different sized ET tube  Gum elastic bougie  Breathing circuits  Drugs for GA and emergency carts Preparation for Anaesthesia
  • 35.  Defibrillator  Syringe pumps  Large-bore 16 gauze I/V line was established through left cephalic vein  Inj. Frusemide 20 mg I/V stat given  Urinary catheterization was done  Paediatric team was brought in the OT. Preparation for Anaesthesia (Continued)
  • 36.  A central venous catheter line was established through the right internal jugular vein (IJV) with 7 Fr, 20 cm central venous catheter. Preparation for Anaesthesia (Continued)
  • 37.  An intra-arterial line was established in the right radial artery to monitor the continuous invasive blood pressure. Preparation for Anaesthesia (Continued)
  • 38.  Inj. Metoclopramide (10 mg)  Inj. Ranitidine (50 mg)  Inj. Ceftriaxone (1 gm)  Inj. Fentanyl (100 mcg) Premedication  Medications given on the OT table before operation
  • 39.  Induction was done by Inj. Thiopentone Sodium (300mg)  Intubation was done after adequate muscle relaxation with Inj. Suxamethonium (100mg) Induction and Intubation  The patient was reassured with compassion to allay her fear and anxiety
  • 40.  Anaesthesia was maintained with O2 and intermittent Midazolam.  Adequate analgesia was ensured with intravenous Fentanyl (150 mcg)  Adequate muscle relaxation was provided with intermittent NMBA (Inj. Vecuronium Bromide)  Intravascular volume was kept optimised by Inj. Frusemide.  Per-operatively, only 200 ml of Hartmann solution was given. Maintenance
  • 41.  Control of HR & rhythm: By Inj Esmolol  Maintaining CVP within 5-6 cmH2O by optimum volume of IV Fluids (only 200 ml) and judicious use of diuretics (Inj Frusemide 20 mg)  Emergency medicines were kept ready to combat any unforeseen complications which include - Inj GTN, Adrenaline, Noradrenaline, etc. Measures to overcome Anesthetic challenges
  • 42. Further deterioration of PAH was managed by:  100% O2 (to prevent hypoxia)  Avoidance of Halothane and N2O  Adequate analgesia by Inj. Fentanyl (150 mcg)  Moderate hyperventilation (to prevent of acidosis)  Low-dose infusion of Inj. Dobutamin to reduce Pulmonary vascular resistance Measures to overcome Anesthetic challenges (Continued)
  • 43.  Routine monitoring of ECG and SpO2.  Continuous ETCO2 was monitored and kept below 30 mmHg to prevent further deterioration of pulmonary hypertension.  CVP was monitored to restore normal volume status. Intra-operative monitoring
  • 44.  Beat-to-beat IBP was monitored through arterial line.  Urine output was monitored (50 ml in 45 minutes).  Per-operative ABG analysis was done and kept within normal ranges. Intra-op monitoring (Continued)
  • 45. A male baby with 2 kg body weight was delivered per- abdominally and after immediate resuscitation at the OT by the attending Paediatric Team, the baby was shifted to NICU for further evaluation and management. Baby resuscitation
  • 46. The conventional reversal and emergence usually provokes tachycardia and agitation which are considered as the detrimental factors for the patients with VHD and PAH. Moreover, this patient needed a less stress and pain free reversal. So, she was not reversed on the OT table and kept on elective mechanical ventilation, then shifted to CCC, with an endotracheal tube in situ. Issue of Reversal
  • 47. Postoperative Management  In the CCC, all invasive and non-invasive monitoring were continued.  MAP was kept within 70-90 mmHg.  Cardiac output was monitored by flow trac module.  Analgesia & sedation was provided with Inj Fentanyl and Inj Midazolam.  Fluid maintenance was ensured by 0.45% DNS @ 70 ml/hr  The patient was on pressure-supported ventilation for 48 hours in the CCC with measured VT of 7 ml/kg.
  • 48. Postoperative Management (Continued)  On 2nd POD, she was extubated and shifted to Post- Anaesthesia CU from CCC.  On 5th POD, a follow-up Echo was done & her cardiac status was found comparable with the pre-existing condition.  On 6th POD, the patient was shifted from Post-Anaes CU to Gynae ward.
  • 49. Postoperative Management (Continued)  On 7th POD, the stitches of the surgical wound were removed.  On the same day, Cardiologist visited the patient and prescribed Tab. Furosemide+Spironolactone, Tab. Metoprolol, Tab. Bosentan & Tab. Phenoxymethyl Penicillin and she was advised to come for follow-up after 4 weeks.  On the same day, the patient was discharged from CMH Dhaka.
  • 51. Parameter Average changes from non-pregnant values (%) Plasma volume +45 Cardiac output +40 Heart rate +15 Stroke volume + 30 Systemic vascular resistance -15 Oxygen consumption +20 Renal blood flow and GFR -50 Haemodynamic changes in normal pregnancy
  • 52.  Increases significantly by 5 weeks gestation.  At the end of 1st trimester : CO increases by 40%  At the end of 2nd trimester : Increases by 50%  Immediately postpartum : Increases by 75%  Overall, cardiac output get increased by 40% during pregnancy period from non-pregnant values.  It has a significant effect on maternal physiology and pharmacology during anaesthetic procedure. Critical periods Cardiac output
  • 53.  Incidence of valvular heart disease in developed country is 2.5%, amongst all valvular heart disease.  Mitral valve prolapse is most common affecting 1% to 2.5% of all population of developed countries.  Most commonly women of child bearing ages are affected. Incidence of Valvular Heart Disease
  • 54. Pregnancy can cause following cardiac complication in a patient with valvular heart disease:  Atrial fibrillation  Pulmonary oedema  Pulmonary hypertension  Right ventricular failure  Congestive cardiac failure  Bacterial endocarditis. Effect of Pregnancy on Valvular heart disease
  • 55. Effect of Valvular heart disease on Pregnancy Valvular heart disease has some detrimental effect on pregnancy it includes:  Abortion  Preterm labour  Intra uterine growth retardation  Congenital heart disease in baby – 5%  Intrauterine fetal death
  • 56. Anaesthetic challenges (Mitral stenosis) Challenges Management Sinus tachycardia, atrial fibrillation Cardioversion or IV administration of Beta blockers, Ca++ channel blockers, digoxin Marked increase in central blood volume Judicious use of IV fluid Drug induced decrease in systemic vascular resistance Use of sympathomimetic drug (Phenylephrine) Pulmonary Hypertension and right heart failure Avoidance of hypoxaemia and hypercarbia, Ionotropes, Pulmonary vasodilating drugs.
  • 57. Anaesthetic challenges (Mitral & Aortic regurgitation) Challenges Management Bradycardia Avoid volume overload Increased systemic vascular resistance After load reduction with a vasodilator(Nitroprusside)with or without inotropes, maintenance of cardiac output by modest increase in heart rate. Myocardial depression Judicious use of drugs.
  • 58. Anaesthetic challenges (Pulmonary Hypertension) Challenges Management Right heart failure • Reduce RV after load • Avoid hypoxemia, hypotension and inadequate RV preload • Continuous use of pulmonary vasodilator s (Ca channel blockers, Inhaled NO, GTN) Pulmonary Oedema Use of diuretics. Hypoxia, Hypercarbia, acidosis Use of 100% oxygen and judicious use of inhalation anesthetics and sedatives
  • 59. Choice of Anaesthesia Condition Choice of Anaesthesia NYHA class 1 & 2 Normal vaginal delivery, forceps delivery with epidural analgesia NYHA class 3 & 4 LUCS under G/A It is better to avoid spinal anaesthesia except MR
  • 60. Postoperative Care Risk of:  Sudden death in early postoperative period due to worsening of pulmonary hypertension  Pulmonary oedema and Right heart failure  Pulmonary thromboembolism and Dysrhythmias  Hypoxaemia, hypercarbia and respiratory acidosis due to pain & hypoventilation
  • 61. Postoperative Care (Continued) These can be managed by:  Intense cardiovascular monitoring  Proper oxygenation, mechanical ventilation (if necessary).  Maintenance of hemodynamic variables at acceptable levels  Optimal pain control
  • 62. Surgical and Anaesthetic management of a patient with diseased heart is always challenging. Specially it sweats more when the issue is PREGNANCY. It demands skillful and sophisticated handling of the patient. Moreover, when the finding is incidental, a single break of concentration can be fatal. Conclusion