CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 6, November/December 2011
AFRICA
339
volaemia and prevention of increased ventricular afterload.
26
These were factors that guided our choice of regional anaesthesia
in this patient. Epidural anaesthesia produces changes in preload
and afterload that mimic pharmacological goals in the treatment
of patients with cardiomyopathy.
With this in mind and the need to urgently deliver the baby, we
opted for a CSE and, considering the fact that spinal anaesthesia
may lead to a sudden and rapid reduction in systemic vascular
resistance and thereby preload, which might be disastrous in a
low-cardiac output condition, we used a low dose of fentanyl as
the spinal anesthetic. With this technique, the patient was ready
for surgery in five minutes and we had stable cardiovascular
haemodynamics. Usually volume preloading with 500 ml to one
litre of crystalloid or colloid is employed to minimise the hypo-
tension that follows sympathetic blockade. However, preloading
in this patient was restricted to 250 ml of 0.9% saline to prevent
worsening of the cardiac symptoms.
Indira
et al
.,
18
in a similar case report, employed CSE in a
patient with ejection fraction less than 25%. They injected 5 mg
of 0.5% hyperbaric bupivacaine with 20
m
g fentanyl intrathecally
and fractionated doses of 5 ml of 2% lidocaine into the epidural
space. They reported no hypotension intra-operatively. Similarly,
Shnaider
et al
.
23
reported a case of peripartum dilated cardio-
myopathy presenting for CS who was successfully managed with
CSE. They injected 6 mg of hyperbaric bupivacaine (0.8% ml
of 0.75%) together with 15
m
g of fentanyl in the subarachnoid
space. Supplementation of the subarachnoid block was done
with epidural bupivaicane 5 ml of 0.5 and 0.25% at 60 and 105
minutes, respectively. Their patient had stable haemodynamics
throughout the procedure. Epidural lidocaine, titrated in small
aliquots together with fentanyl, has been successfully employed
in a patient with pulmonary hypertension and cardiomyopathy.
27
Oxytocin has been known to decrease mean arterial pressure
by 30% and systemic vascular resistance by 50%, and increase
cardiac output by 50% and heart rate and stroke volume by 20
to 30%.
28
These effects may worsen the condition of a patient
with cardiac failure. However, this creates a dilemma since with-
holding oxytocin may lead to haemorrhage, which may also be
dangerous in these patients. We slowly administered the oxytocin
following the delivery of the placenta to reduce these effects,
and subsequently commenced an infusion using a reduced dose.
Dob and Yentis
29
recommended giving 5 units of oxytocin in 20
ml saline over five to 10 minutes, followed by 40 units in 500 ml
saline to run for four to five hours.
Several authors
19,25
have used invasive monitoring to manage
more symptomatic cases, while others
27,30
have used a non-inva-
sive monitoring technique for asymptomatic and haemodynami-
cally stable patients. Elective use of invasive monitoring (arterial
and central venous) is justified in a symptomatic patient with an
elevated jugular venous pressure, third and fourth heart sounds,
orthopnoea, paroxysmal nocturnal dyspnoea or shortness of
breath at rest, with clinical evidence of a low cardiac output or
echocardiographic evidence of significant myocardial depression
(poor contractility, left ventricular wall motion abnormalities).
30
Although our patient had some significant symptoms, she did
not have any form of invasive monitoring before presenting for
anaesthesia and we were unable to provide one because of the
urgency required to deliver the baby. Colloid was employed to
restrict intra-operative fluid therapy, and supplemental oxygenwas
administered to ensure that oxygen saturation remained between
98 and 100%. Non-invasive cardiac monitors such as Doppler
ultrasound and impedance cardiography have been usedwith good
results in patients with PPCM, although limitations include cost
and technical difficulties, especially in low-resource countries.
Conclusion
Our opinion is that combined spinal–epidural, employing low-
dose fentanyl for the spinal anaesthesia is a suitable option for
patients with PPCM scheduled for emergency Caesarean section.
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