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COMMENTS ON PUBLISHED ARTICLE
Year : 2016  |  Volume : 60  |  Issue : 11  |  Page : 876  

Incremental epidural anaesthesia for emergency caesarean section in a patient with ostium secundum atrial septal defect and severe pulmonary stenosis with right to left shunt


Department of Anesthesiology, Critical Care and Pain, Tata Memorial Centre, Mumbai 400 012, Maharashtra, India

Date of Web Publication9-Nov-2016

Correspondence Address:
Sohan Lal Solanki
Department of Anesthesiology, Critical Care and Pain, Tata Memorial Centre, Mumbai 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.193714

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How to cite this article:
Solanki SL, Parab SY. Incremental epidural anaesthesia for emergency caesarean section in a patient with ostium secundum atrial septal defect and severe pulmonary stenosis with right to left shunt. Indian J Anaesth 2016;60:876

How to cite this URL:
Solanki SL, Parab SY. Incremental epidural anaesthesia for emergency caesarean section in a patient with ostium secundum atrial septal defect and severe pulmonary stenosis with right to left shunt. Indian J Anaesth [serial online] 2016 [cited 2020 Nov 30];60:876. Available from: https://www.ijaweb.org/text.asp?2016/60/11/876/193714

Sir,

We read with interest the article by Saravana Babu et al. [1] on incremental epidural anaesthesia for emergency caesarean section in a patient with ostium secundum atrial septal defect and severe pulmonary stenosis with right to left shunt. The authors mentioned that this case was an emergency caesarean section in view of cephalopelvic disproportion (CPD) in labour. In CPD, once the baby's head engages into the pelvis, any delay in getting baby out of uterus results in traumatic brain injury of the baby. The authors proceeded with sequential epidural anaesthesia, which usually takes a very long time to achieve a reasonable anaesthetic band up to T4 level required for caesarean section. If this case had been an elective caesarean section, titrated epidural or very low-dose combined spinal-epidural anaesthesia could have been a better choice, [2] but if there is any evidence of foetal distress or chances of traumatic brain injury in CPD, general anaesthesia (GA) should be preferred. The authors mentioned that GA poses clear risk related to pulmonary vascular resistance and magnitude of shunt, but controlled ventilation with avoidance of hypoxia, hypercarbia and hyperinflation of lungs will not increase pulmonary vascular resistance. [3] In addition, the authors had supplemented epidural anaesthesia with ketamine and midazolam; however, it would carry the risk of respiratory depression in spontaneously breathing patient leading to hypoxia and hypercarbia (room air saturation of this patient was 90%-95%). Although hypotension during GA induction can decrease systemic vascular resistance (SVR) and increase the shunt magnitude, this can be prevented by the use of cardio-stable drugs for induction of anaesthesia such as ketamine or etomidate with judicious use of vasopressors (e.g., phenylephrine), or opioid during induction in a well-equipped hospital. [4] Invasive beat-to-beat arterial blood pressure monitoring would have been a better method to detect any decrease in SVR.

Hence, although the authors were fortunate in this case, GA is safer in view of emergency nature of the surgery.

 
   References Top

1.
Saravana Babu MS, Verma AK, Gupta BK, Jain V. Incremental epidural anaesthesia for emergency caesarean section in a patient with ostium secundum atrial septal defect and severe pulmonary stenosis with right to left shunt. Indian J Anaesth 2016;60:363-4.  Back to cited text no. 1
    
2.
Solanki SL, Jain A, Singh A, Sharma A. Low-dose sequential combined-spinal epidural anesthesia for cesarean section in patient with uncorrected Tetrology of Fallot. Saudi J Anaesth 2011;5:320-2.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Collis RE, Plaat F, Urquhart J. The obstetric patient with cardiac disease. In: Textbook of Obstetric Anaesthesia. New York: Cambridge University Press; 2002. p. 179-201.  Back to cited text no. 3
    
4.
Ngan Kee WD, Khaw KS, Ma KC, Wong AS, Lee BB, Ng FF. Maternal and neonatal effects of remifentanil at induction of general anesthesia for cesarean delivery: A randomized, double-blind, controlled trial. Anesthesiology 2006;104:14-20.  Back to cited text no. 4
    




 

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