Spinal anesthesia for a rare case of Brugada syndrome undergoing cesarean section delivery

Anouar Jarraya | Imen Chayeb | Manel kammoun | Mohamed Derbel | Khanfir Fatma | Kamel Kolsi |

La tunisie chirurgicale - 2018 ; Vol 2018

Resumé

Brugada syndrome is an arrhythmogenic disease reported to be a cause of sudden cardiac death due to ventricular fibrillationin subjects under the age of 40 years. To date, there is no guidelines for anesthetic management, neither general, nor regional anesthesia,of patients suffering from this syndrome because of its rarity. We report the case of a young pregnant woman aged 34 years old who recently discovered the disease after her brother’s sudden death. Preoperative evaluation showed a well tolerated pregnancy with normal cardiac echography. Cesarean section delivery was done under spinal anesthesia with no complications. The aim of this article is to describe the perioperative management of our patient and to discuss the choice of regional anesthesia and enhanced recovery.

Mots Clés

Brugada syndrome,

Introduction :

Brugada syndrome is an arrhythmogenic disease reported to be a cause of sudden cardiac death due to ventricular fibrillation in subjects under the age of 40 years.

Peri-operative management of this kind of arrhythmogenic diseases is particular, especially when there are no guidelines for anesthetic management because of the absence of prospective studies and the presence of some anesthetics in the Contraindicated drugs’ list.

In this article, we showed that spinal anesthesia may be a safe alternative in Brugada syndrome and may be reasonable choice as it allowed us to avoid a risky   general anesthesia in pregnancy and to avoid the use of some forbidden anesthetics [1-3] (table1).

Article

Patient and observation

We report the case of a patient aged 34 years old with a personal past history of cesarean section delivery under spinal anesthesia with no complications, obesity (BMI=37 Kg/m2), Obstructive sleep apnoea syndrome and gestational diabetes  treated with diet alone, and family history of young brother’s death by sudden ventricular fibrillation and cardiac arrest.

The disease was discovered in our patient after systematic family investigation with positive intravenous flecaine test in the cardiology department of our institution. Cardiologists suggested an implantable cardioverter-defibrillator (ICD) meanwhile our patient was pregnant.

Preoperative evaluation showed a pregnant woman in the 36 weeks of pregnancy with normal somatic examination. Difficult intubation criteria were noted (limited mouth opening, class III Mallampati score). The electrocardiogram showed a discrete right bundle branch block and ST elevation in the right precordial leads.

A transthoracic echocardiogram has been requested and it has shown a dilated RV and reduced LVEF to 60%. Biological blood analyses (blood cell count, prothrombine ration and liver and kidney blood analyses) were correct.

At the end of the consultation, we explained the risk of surgeryand the risk of per operative cardiac rhythm disorders. We informed the patient about the spinal anesthesia and the enhanced recovery program after the operation.

The day of surgery, we verified the checklist of the operating  room and we verified the presence of the defibrillator. After the standard means of monitoring (Electrocardioscope, pSO2, noninvasive blood pressure and capnography), two peripheral venous lines of 18 G were taken. The patient was put in the left lateral decubitus position and then, she received 8 mg of dexamethasone to prevent postoperative nausea and vomiting  and 500 ml of Ringer lactate preload to prevent severe hypotension after the spinal anesthesia.

We performed a spinal anesthesia with a 27G needle in the L4-L5 space with 10 mg of hyperbaric bupivacaine 0.5% with 2.5 µg of sufentanil and 100 µg of morphine. Hypotension was prevented by titrated phenylephrine and ephedrine according to our protocol.

Intraoperative hemodynamic status was maintained stable with a systolic blood pressure of 125-135 mm Hg, diastolic blood pressure of 60-70 mm Hg and heart rate between 59 and 83 beats per minute. We used sulprostone (500µg/1hour) in place of oxytocin infusion. No cardiac rhythm disorders were noted.

The postoperative period was uneventful with no electric changes on ECG and no bleeding. The postoperative analgesia was provided by paracetamol (15 mg/kg/6 hours) and parecoxib (40 mg/12h) according to our enhanced recovery protocol. We noted no postoperative nausea and vomiting. The patient left the hospital 2 days after delivery.

 

Discussion

Brugada syndrome was reported for the first time in 1992[4]. It is an inherited channelopathy associated with increased risk of ventricular arrhythmias and sudden death, especially during anesthesia and surgery[5]

In this case report, we showed that spinal anesthesia may be safe in Brugada syndrome.Even if a general anesthesia is usually preferred in patients with cardiac rhythm disorders [6], we opted for spinal anesthesia.  General anesthesia in our case was highly risky for several reasons: first for the pregnancy itself, second for difficult airway management, Obstructive sleep apnoea syndrome,and also for contraindicated necessary drugs for crush induction like succinylcholine[3]

Many factors during general anesthetic management like certain drugs,medications, temperature changes, and heart rate variations, could precipitate lethal arrhythmias in this patient population [7, 8]

Local anesthetics may increase Electrocardiogram  changes due to a blockade of the sodium channels, mainly depending on the dose and the type of anesthetic [9]. Thus, there have been reported cardiac rhythm disorders consistent with Brugadasyndrome, triggered after epidural infusion of bupivacaine and ropivacaine. This may be explained by the higher dose and the longer duration of administration in epidural analgesia. However, the use of subarachnoid bupivacaine at low doses (10 mg) may be safer if we correct rapidly the hemodynamic changes after spinal anesthesia.

The implantable cardioverter-defibrillator (ICD) is the sole medical intervention that effectively protects patients with Brugada syndrome from sudden cardiac death [10]. It should be recommended at the consultation of anesthesia for scheduled operations. However, for our patient who was pregnant just after the diagnosis of the disease, the implantation of ICD needing X-Ray irradiation was not possible.

In the management of our patient, we opted for our enhanced recovery program based on mini-invasive surgery, early mobilization, early oral intake and a good analgesia [11]. In this patient, we avoided the TAP block that needs a local anesthetics injection and we opted for subarachnoid morphine which seems safer in our case [12].

Conclusion

The anesthesia   management of patients with Brugada syndrome is a so difficult, especially in patients with no ICD or pregnant patients or emergencies [13]. The use of anesthetic drug must be made after careful consideration (contraindicated drug‘s list),avoiding other factors that are known to have the potential to induce arrhythmias like temperature changes [14], and heart rate variations. In our case report, we showed that small dose of bupivacaine in spinal anesthesia may be safe and enhanced recovery strategy may be suitable for patients suffering from Brugada syndrome.

Competing interests

The authors declare no competing interest.

 

Authors’ contributions

AnouarJarraya is the writer of the article.  ImenChayeb collected data from the folder of the patient. Derbel Mohamed and KhanfirFatma were the surgeons who operated the cesarean section.  Manelkammoun  andkamelkolsi corrected the article.

Acknowledgements (if any)

We acknowledge the cardiology department of our institution for all explorations. 

 

Tables and figures

Table1:Acceptable and contraindicated drugs in Brugada syndrome that are frequently used during anesthesia for cesarean section delivery [1-3]

Drug list

Acceptable with precaution

Contraindicated

Anti arrhythmic drugs

  • Quinidine
  • Lidocaine
  • Amiodarone
  • Flecainide
  • procainamide

Autonomic nervous related drugs

  • atropine
  • ephedrine
  • phenylephrine
  • noradrenaline
  • atropine
  • neostigmine

General anesthetics

  • midazolam
  • propofol
  • fentanyl
  • myorelaxant
  • succinylcholineketamine

 

Local anesthetics

  • Ropivacaine
  • Bupivacaine (epiduralanesthesia)

Others

  • Ondansetron
  • dexamethasone

 

  • Ocytocine

 

 

 

 

Figure 1 : Electrocardiogram

 

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