Abstract
Purpose: To illustrate the clinical utility of a short acting opioid (remifentanil) based general anesthetic for Cesarean section in a parturient with compromised cardiac function.
Clinical Features: A 23-yr-old primigravida, complicated by a recurrent aortic coarctation with an approximate 50% narrowing of the aortic arch, presented for elective Cesarean section at 37 wk gestational age. Initially asymptomatic, her clinical condition had deteriorated as the pregnancy progressed, with worsening episodes of mild chest pain and shortness of breath. A semi-elective Cesarean section under general anesthesia was planned at 37 wk to minimize the potential for aortic complications associated with the hemodynamic stress of labour. Remifentanil was infused at 0.05 to 0.1 µg·kg−1·min−1 with good sedation and analgesia for the placement of invasive monitors. The infusion was increased to 0.2 µg·kg−1·min−1 for induction, and combined with isoflurane 0.4 to 0.6% for maintenance of anesthesia. The patient maintained stable hemodynamics throughout and her trachea was extubated without difficulty at the end of the procedure. The newborn did not require tracheal intubation, mask ventilation or naloxone and was in excellent condition upon transfer to the well baby nursery.
Conclusion: Remifentanil, when used as part of an opioid-based general anesthetic for Cesarean section, can provide maternal hemodynamic stability with minimal neonatal respiratory depression and should allow for immediate postoperative tracheal extubation of the mother.
Résumé
Objectif: Illustrer l’utilité dinique d’une anesthésie générale à base d’opioïde à action brève (rémifentanil) pour la césarienne chez une parturiente qui présente une dysfonction cardiaque.
Éléments cliniques: Une primigeste de 23 ans, qui présentait une coarctation aortique avec un rétrécissement d’environ 50 % de la crosse aortique, a été admise pour une césarienne planifiée à 37 sem de grossesse. D’abord asymptomatique, son état s’est détérioré graduellement pendant la grossesse et présentait des épisodes de douleurs thoraciques légères et d’essoufflement. Une césarienne sous anesthésie générale a été planifiée à 37 sem afin de réduire la possibilité de complications aortiques associées au stress hémodynamique du travail. Le rémifentanil a été administré en perfusion de 0,05 à 0,1 µg·kg−1·min−1 accompagnée d’une sédation et d’une analgésie efficaces pendant l’insertion effractive de moniteurs. La perfusion a été augmentée à 0,2 µg·kg−1·min−1 pendant l’induction et combinée à l’isoflurane de 0,4 à 0,6 % pour le maintien de l’anesthésie. Les paramètres hémodynamiques sont demeurés stables pendant l’intervention et l’extubation trachéale s’est bien déroulée à la fin de la césarienne. Le nouveau-né n’a pas eu besoin d’intubation trachéale, de ventilation au masque ou de naloxone et était en excellente condition lors de son transfert à la pouponnière.
Conclusion: Le rémifentanil qui fait partie d’une anesthésie générale à base d’opioïde pour la césarienne peut assurer la stabilité hémodynamique chez la mère et n’entraîner qu’une dépression respiratoire néonatale minimale. En outre, il permet l’extubation trachéale postopératoire immédiate de la mère.
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Manullang, T.R., Chun, K. & Egan, T.D. The use of remifentanil for cesarean section in a parturient with recurrent aortic coarctation. Can J Anaesth 47, 454–459 (2000). https://doi.org/10.1007/BF03018976
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DOI: https://doi.org/10.1007/BF03018976