Sectio caesarea in Katheter-Spinalanästhesie bei einer kardiopulmonalen Hochrisikopatientin

Zusammenfassung

Wir berichten über die Schnittentbindung in der 38. Schwangerschaftswoche bei einer 36jährigen Hochrisikopatientin in Spinalkathetertechnik. Eine schwere symptomatische koronare Herzerkrankung (Risikofaktoren: Hypercholesterinämie Typ II, Adipositas, Hypertonie, Nikotinabusus mit chronischer Bronchitis) der Patientin erfordert ab der 12. SSW therapeutische Maßnahmen und zwingt zur PTCA in der 15. und 19. Schwangerschaftswoche. Die geplante Sectio caesarea wird in Spinalkathetertechnik unter titrierender Gabe von insgesamt 2,2 ml isobarem Bupivacain 0,5% ausgeführt und gelingt problemlos; Herzfrequenz und Blutdruck bleiben stabil, es treten keine Angina-pectoris-Beschwerden auf. Der postoperative Verlauf ist unauffällig. Der Fallbericht soll zeigen, daß die kontinuierliche Spinalanästhesie die Möglichkeit sowohl der Aufrechterhaltung sehr stabiler Vitalfunktionen als auch einer eleganten postoperativen Analgesie bietet. Sie kommt daher als alternative Anästhesiemethode gerade bei Patientinnen mit schwerwiegenden mütterlichen oder kindlichen Risiken in Betracht, da mit dieser Methode spezifische Risiken anderer Anästhesieverfahren vermieden werden können. Diskutiert werden Vor- und Nachteile des Verfahrens.

Abstract

As a consequence of the progress in (perinatal) medicine the number of pregnant women with severe cardiopulmonal risk, who need caesarean delivery, is rising. The anaesthetic care of these patients requires optimal preparation and – as a prerequisite – constant intraoperative vitalfunctions (heartrate, bloodpressure, oxygensaturation). Typical risks like airway-problems, hypoxia, hyper- and hypotension and tachycardia must be strictly avoided. We report a case of successful caesarean delivery in a patient with severe coronary heart disease, using spinal catheter technique. Case report: The patient was a 36-year-old woman with a symptomatic coronary heart disease. Risk factors were hypercholesterinaemia, obesity (105 kg/168 cm), COPD consecutive to excessive nicotineabuse and hypertonia. Emergency admissions in the 12th and 14th gestation week led to the necessity of PTCA in the 15th and 19th gestation week in spite of pregnancy: coronary stenoses of 90% and 70% were dilated. Caesarean section was scheduled for 38 weeks’ gestation, however due to the high risk involved we decided to use a continuous spinal technique. There were no problems with introducing the catheter (28 gauge, L 3–4 interspace). Under careful titration a total of 2.2 ml plain bupivacaine 0.5% (spinal catheter) and 0.5 mg alfentanil (intravenously) were administered. This produced anaesthesia up to T 8 without any respiratory or cardiovascular embarrassment. A healthy male infant (Apgar score 9/10/10) was delivered. Postoperative analgesia was provided by intrathecal injections of bupivacaine and intravenous injections of piritramide. There were no intraoperative or postoperative problems. Discussion: By means of continuous spinal anaesthesia for caesarean section it is possible to avoid typical complications of general anaesthesia (hypoxia, airway management, aspiration, tachycardia), of single-shot spinal anaesthesia (hypotension, low or high block) and of epidural anaesthesia (high dose of local anaesthetics, danger of accidental intrathecal or intravenous injection). The possibility of postoperative analgesia is advantageous. Technical difficulties, postspinal headache and the high costs of the sets may be disadvantageous. Conclusion: This case demonstrates, that the use of a continuous spinal catheter technique for caesarean section anaesthesia is an alternative method, which should be considered especially in high risk patients, when meticulous care for constant vital functions is requested urgently.