REGIONAL ANESTHESIA USING EPIDURAL BLOCK TECHNIQUE IN PATIENTS WITH

CHF NYHA III - IV, MS SEVERE, MR MODERATE, PH SEVERE WHICH UNDERGOING

C-SECTION
Erwin Kresnoadi
Faculty of Medicine Mataram University
BACKGROUND

In women who have heart disease, pregnancy would pose a severe risk to the mother and fetus.
Valve disorders are accompanied by changes in the cardiovascular system that occurs during
pregnancy and childbirth would facilitate the development of heart failure and pulmonary edema.
One of the things that affect the morbidity and mortality of pregnant women with heart defects
are the labor pain. Regional analgesia (epidural and spinal) is the most effective method for pain
relief during labor.

CASE

A 28 years old patient with 36 weeks of gestation with CHF NYHA III-IV, MS severe, MR
moderate, PH severe was planned for elective caesarean section after optimization of condition
by a cardiologist.

Vital sign : BP : 85/58 mmHg, heart rate 130x/menit, respiratory rate 26x/menit, afebris. SaO2
monitor: 8894%,

Pulmonal: weakened vesicular sound , ronchi+/+, wheezing -/-.

LAB : Hb 10,3 g/dL Ht 33% Leukosit 8000/L Trombosit 283.000/L Bt/Ct : 310/12
Ureum/ Creatnin : 19/0,5 mg/dL SGOT/SGPT : 18/14 mg/dL Albumin : 3,0 mg/dL GDS : 89
mg/dL

Echo :
Dilated RV RA LA, AR mild,
TR moderate, PR moderate,
severe PH (PAP 60.9)
calcification MV, MR moderate,
MS severe, decreased systolic
RV function, systolic LV
function EF 59 %.
ASSESMENT

Patient ASA III with CHF NYHA III - IV, MS SEVERE, MR MODERATE, PH SEVERE
hipoalbumin 3,0. We performed regional anesthesia with epidural block technique using plain
bupivacaine 0.5 %, incremental dose 65 mg and fentanyl 75 mcg. Intraoperative we use
dobutamine titration until 15mcg/kgBB/menit, furosemide, no vasoconstrictor and restrict
fluid.duration of operation was about 1 hour. Urin output 125cc,blood loss was about 750cc,
colloid intake was 250cc. fluid balance (-) 500cc. After operation, the patient was admitted in
ICU.

DISCUSSION

Patients were categorized as mitral stenosis late stage because it found signs of right heart
failure. pulmonary hypertension cause mitral stenosis leads to right heart failure due to right
ventricular failure in the pump all the blood against the pulmonary vascular resistance. This
explains why patients have low blood pressure (85/58 mmHg) and edema in the extremities. In
Chest radiogram found that heart is enlarged to the left and right. Dimensional echocardiogram
obtained the right heart chamber dilatation (ventricle and right atrium) and the reduction in right
ventricular systolic function. Mitral regurgitation is classified as moderate (30% -60
regurgitation). Physical examination found the patients rate 130x / min. This is happening
because of (1) an increase in cardiac output during pregnancy; (2) compensation of heart to
maintain cardiac output through the activation of sympathetic; (3) activation of sympathetic due
to pain and crowded. Tachycardia in these patients would limit left ventricular filling time, so it
will aggravate edema and pulmonary hypertension. This condition explains why patients with
tachypnea and 88-94% saturation, heart rate irregular (finding VES), murmur (+), weakened
vesicular sound, crackles +/+. Atrial contraction required for adequate ventricular filling which
requires serial ECG monitoring. Although ECG atrial fibrillation early is not found in these
patients, but in patients with mitral stenosis accompanied atrial possibility of a large atrial
fibrillation. Atrial fibrillation that arise can lead to increased mortality and morbidity of these
patients, due to loss of atrial systole and increased frequency of ventricular rate would cause a
decrease in cardiac output and increase the risk of pulmonic edema. CVP required for assessing
intravascular volume is adequate or not. Hypervolemia and hypovolemia conditions would
endanger the patient. Hypovolemia will cause tachycardia and hypervolemia will aggravate
pulmonary edema both of which will cause a worsening of the condition. In these patients the
adequacy of body fluids is calculated by monitoring fluid. The body fluids are considered
inadequate because of sympathetic stimulation which happen due to vasopressin (antidiuretic
hormone) secretion, causing fluid retention by the kidneys. These patients also receive diuretics
which can reduce right ventricular preload, and if it is not well managed it can worsen heart
failure. When mounting CVC must pay attention to the placement of the catheter tip as changes
in sinus rhythm in these patients may result in deterioration. Examination of blood gases and
electrolytes should be done serially, because we need to aggressively treat the condition of
hypoxia, hypercarbia and acidosis to prevent the improvement of pulmonary vascular resistance.
Examination of serial electrolytes should be performed for these patients obtain Furosemide can
cause hypokalemia. Hypokalemia conditions cause cardiac arrhythmias and aggravate digitalis
toxicity. Hypoxia occurs in chronic patients; it is seen from increased level of hematocrit, which
should have been occur in pregnant women as well due to hemodilution.

CONCLUSION

After the epidural block saturation of the patient is

gradually increased, the tightness is reduced and wet
crackles reduced. This happens because; (1) flow of oxygen
enhanced and using a simple mask, (2) with analgesia
neuraxial blood flow to the kidneys will be better, so that
urine output increased, and a decrease of systemic vascular
resistance that causes a decrease in pressure in the
pulmonary artery so that the pressure in the capillaries of
the pulmonary also decreased (3) in addition, the pain will
also disappear. Benefit of CVC beside to assess
intravascular volume is adequate or not, can be used as a
central line when vasopressor drugs needed. Invasive
hemodynamic monitoring is required for patient with heart
failure to determine blood pressure in real time.
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