Aspi Maria Teresita B, Ocsan Prince Mark F
Department of Anesthesiology, University of the Philippines - Philippine General Hospital, Taft Avenue, Manila, Philippines.
Int J Surg Case Rep. 2021 Dec;89:106601. doi: 10.1016/j.ijscr.2021.106601. Epub 2021 Nov 12.
Eisenmenger syndrome should be diagnosed before pregnancy and surgically corrected if possible. Cesarean section in a patient with Eisenmenger syndrome is high risk as morbidity and mortality are very high. Delivery in hospitals with intensive care units should be recommended. Use of point-of-care assessments and advanced monitors allow accurate management.
A primigravid with congestive heart failure from a patent ductus arteriosus in Eisenmenger syndrome, presented with threatened preterm labor and uncontrolled hypertension prompting cesarean delivery under epidural anesthesia. Pre-induction focused echocardiography revealed normal right ventricular function and severe pulmonary hypertension. Intraoperatively, hemodynamics became unstable. The decision to use fluids, vasopressor and inotrope was guided by analyses of arterial pulse contour, central venous pressure waveform and blood exams. Hemodynamics improved and a live baby was delivered. Postoperative course was unremarkable.
The cause of hemodynamic instability must be accurately determined as inappropriate use of fluid or medication may be detrimental to a patient with Eisenmenger syndrome. In this case, advanced hemodynamic monitoring showed changes in central venous pressure, cardiac output and systemic vascular resistance which differentiated the causes of hypotension and desaturation. Point-of-care blood analysis showed acidosis and hypoxia which may have worsened the right-to-left shunt, contributing to the desaturation. Fluid and drug infusions to address identified problems were then guided by advanced monitors.
The use of point-of-care assessments and advanced hemodynamic monitoring allowed accurate diagnoses and goal-directed therapies leading to improved patient safety and outcomes. The need for prolonged intensive care in this case was prevented.
艾森曼格综合征应在妊娠前诊断，如有可能应进行手术矫正。艾森曼格综合征患者行剖宫产风险很高，因为发病率和死亡率都非常高。建议在设有重症监护病房的医院分娩。使用即时检验评估和先进监测设备可实现精准管理。
一名初产妇，因艾森曼格综合征的动脉导管未闭导致充血性心力衰竭，出现先兆早产且高血压控制不佳，遂在硬膜外麻醉下行剖宫产。诱导前经胸超声心动图显示右心室功能正常但存在严重肺动脉高压。术中，血流动力学变得不稳定。通过对动脉脉搏轮廓、中心静脉压波形和血液检查的分析来指导使用液体、血管升压药和正性肌力药的决策。血流动力学得到改善，一名活婴顺利娩出。术后过程顺利。
必须准确确定血流动力学不稳定的原因，因为不恰当使用液体或药物可能对艾森曼格综合征患者有害。在本病例中，先进的血流动力学监测显示中心静脉压、心输出量和全身血管阻力发生变化，这些变化区分了低血压和血氧饱和度降低的原因。即时检验血液分析显示酸中毒和缺氧，这可能使右向左分流恶化，导致血氧饱和度降低。然后根据先进监测设备的结果指导输注液体和药物以解决已确定的问题。
使用即时检验评估和先进的血流动力学监测能够实现准确诊断和目标导向治疗，从而提高患者安全性并改善治疗结果。本病例避免了延长重症监护的需求。
