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P-27 ANESTHETIC CONSIDERATIONS IN A PARTURIENT WITH MITRAL VALVE ATRESIA AND SINGLE VENTRICLE PHYSIOLOGY Haret, D.M.; Fragneto, R. Anesthesiology, University of Kentucky, Lexington, KY We report the anesthetic management of a patient with complex cyanotic congenital heart disease who underwent successful labor, vaginal delivery and PPBTL. A 30 y.o.WF at 33 weeks gestation was admitted in active labor. Her cardiac anomalies included: dextrocardia with atrial situs solitus, levo-ventricular looping, d-transposition of the great vessels, mitral atresia, large non-restrictive ASD and VSD, and moderate pulmonic stenosis. After the placement of standard ASA monitors and administration of supplemental O2, a left radial arterial line and right internal jugular CVP line were inserted using aseptic technique with meticulous removal of air bubbles. An epidural catheter was purposely placed intrathecally at the L23 space using a loss of resistance to saline technique. CSF was easily aspirated. Fentanyl 25 mcg was administered and prompt pain relief was achieved. During labor, the patient experienced 1 episode of mild hypotension that promptly resolved with a 500ml NS IV bolus. She remained pain-free and within 2 hr delivered a healthy baby. O2 sat. was 90 94% throughout labor and delivery. EBL was 600ml, and she received 2 units of PRBC to keep her Hct45%. The patient remained stable postpartum and underwent BTL 1 hour later. The spinal catheter was slowly and incrementally dosed with 1.5% hyperbaric spinal lidocaine fentanyl to achieve a T6 sensory level. She tolerated anesthesia and surgery well and remained stable during her PACU stay. She was sent to the ICU for 24 hr observation. Mother and baby were discharged on PPD 3. The patient developed no complications, including headache. Successful anesthetic management of a patient with cyanotic congenital heart disease requires an understanding of the pathophysiology of the intracardiac shunt. Our anesthetic goal in this patient was to provide reliable labor analgesia and anesthesia for BTL that would not significantly alter her hemodynamic state, thus allowing us to maintain an adequate pressure gradient across the stenotic pulmonic valve and keep the ratio of intracardiac shunt at the same level as prepartum. Using an intrathecal catheter and information from our invasive monitors to guide anesthetic dosing, we were able to accomplish this goal. We also maximized the oxygen supply demand ratio by increasing Hb to improve oxygen-carrying capacity and decreasing oxygen consumption by providing satisfactory analgesia. The patient's abnormal anatomy was a relative contraindication to the placement of a PA catheter. In addition, thermodilutional CO measurement is inaccurate in the setting of intracardiac shunt. Therefore, we chose not to place a PA catheter. Lockhart EM, et al. SvO2 Monitoring during Spinal anesthesia and Cesarean Section in a Parturient with Severe CCHDAnesthesiology1999; 90: 121315.
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