Epidural anaesthesia for bilateral inguinal herniorrhaphy in Eisenmenger's syndrome

Abstract

SummaryThe successful management of a patient with Eisenmenger 's syndrome undergoing bilateral herniorrhaphy is described, and some of the anaesthetic problems associated with this condition are considered. The case is reported because epidural anaesthesia is performed rarely in these patients. The use of subcutaneous heparin, the level of monitoring required, and the value of pulse oximetry are also discussed. Key wordsAnaesthetic techniques, regional; epidural. Complications; Eisenmenger's syndrome.In 1958 Wood' defined Eisenmenger's syndrome as 'pulmonary hypertension at or close to systemic level with reversed or bidirectional shunting at aortopulmonary, ventricular, or atrial level'. The condition is rare, but patients may survive into their 4th or 5th decadesZ and require anaesthetic management for incidental surgery. Patients have been managed successfully with general anaesthesia and several authors 3-5 have advocated this in preference to epidural blockade for lower abdominal or lower limb surgery. However, the peri-operative mortality rate remains high,4 and especially in labour with a maternal mortality of about 30% during vaginal delivery6-' and up to 75% after Caesarean section. ' Epidural anaesthesia has been employed in only a few cases8-10 because of the possible adverse effects on the systemic vascular resistance and hence the size of the shunt, but there were no significant complications in these patients. We report a further case managed successfully with epidural anaesthesia to highlight the problems associated with this condition and to discuss the level of monitoring required. Case historyA 43-year-old male patient was admitted for elective bilateral inguinal herniorrhaphy. Eisenmenger's syndrome had been confirmed at the age of 16 years by catheter studies which demonstrated a large ventricular septa1 defect (VSD) with equalisation of pressures between the pulmonary and systemic circulations. He was leading an active life at this time and complained of shortness of breath only when he walked up hills. He was reviewed in 1977 as a result of increasing dyspnoea when secondary polycythaemia with a packed cell volume of 0.65 was noted and treated by intermittent venesections. He was admitted with a chest infection and right-sided heart failure from which he made a good recovery in 1983. However, 2 days after discharge he was re-admitted with distended nonpulsatile right-sided neck veins and a swollen and discoloured right arm. Angiography demonstrated right subclavian and brachiocephalic vein thrombosis which was successfully treated with anticoagulant therapy. Warfarin was discontinued 3 months later and subsequently the patient remained well.He became breathless on walking upstairs or about 100 yards on the flat during his present admission. Examination showed he was cyanosed with finger clubbing and the jugular venous pulse was slightly elevated with a prominent 'a' wave, but there were no signs of peripheral oedema.Blood pressure was 160/90 mmHg, pulse rate 84 beats/ minute, in sinus rh...

Safety of regional anesthesia in Eisenmenger's syndrome☆

“…70 Traditionally, general anesthesia has been recommended for these patients because the relative sympathectomy that occurs with regional anesthesia would tend to decrease SVR and therefore promote increased right-to-left shunting. There are several case reports, 8,9,14,15,22 however, that document the relative safety of epidural anesthesia for ES patients. Epidural anesthesia is probably preferable to spinal anesthesia because the sudden sympathectomy which accompanies the latter could result in more difficult control of the shunt.…”

Low-dose combined spinal-epidural anaesthesia for caesarean section in a patient with Eisenmenger’s syndrome

“…17 Several case reports have documented the safe uses of epidural anaesthesia. 4,[17][18][19][20][21] Epidural anaesthesia is preferable to single-shot spinal anaesthesia because the rapid sympathectomy that accompanies the latter could result in more haemodynamic instability and worsening of the shunt. However, epidural anaesthesia can produce an incomplete sensory block, and may necessitate rapid conversion to general anaesthesia.…”

Continuous cervical plexus block for carotid body tumour excision in a patient with Eisenmenger's syndrome

“…The anaesthetic management of patients with Eisenmenger's syndrome or carotid body tumour resection are each associated with significant anaesthetic problems, which have been previously described [3–16]. Their coexistence represents a rare and potentially greater anaesthetic challenge, with only a single case report identified in which general anaesthesia was used [17].…”