P006: ANESTHETIC MANAGEMENT OF A PRETERM PARTURIENT WITH INFECTIOUS ENDOCARDITIS
Kyle H Chan, MD; Adam Wendling, MD; Matthew Andoniadis, MD
University of Florida College of Medicine
Introduction: Infectious endocarditis affects 3-5 per 100,000 people yearly, with in-hospital mortality of 20% and 1-year mortality of 30%. Treatment typically involves antibiotics, with surgery for indications such as heart failure, uncontrolled infection, and prevention of systemic embolic events. However, the timing of valvular placement surgery can be challenging in the setting of pregnancy and active bacteremia. At the same time, progressive valvular disease in the parturient can pose unique challenges that could endanger both mother and baby, and warrant evaluation for the risks and benefits of cesarean section.
Methods: 24-year-old G2P1001 at 26w3d with a history of IV drug use and chronic hepatitis C, admitted for treatment of acute-on-chronic tricuspid endocarditis, aortic endocarditis, MRSA bacteremia with septic arthritis, and septic pulmonary emboli. An Angio-Vac was performed 2 weeks before to debulk the potentially infectious right atrial lesion. However, a follow-up transthoracic echocardiogram raised concerns for progressive tricuspid, aortic, and mitral valve endocarditis, leading to the decision to proceed with cesarean section and a plan for valvular replacement surgery the following week.
Results: For cesarean delivery, spinal anesthesia was considered to improve analgesia and reduce bleeding, aspiration risk, and thromboembolic events. However, the patient declined and opted for general anesthesia. After rapid sequence induction, a radial arterial line was placed for hemodynamic monitoring. For large-bore venous access, we inserted an external jugular venous catheter rather than a central venous catheter, as the patient was not on any vasoactive infusions and had an active systemic infection. Bradycardia, hypervolemia, hypertension, and decreased contractility were avoided in the setting of aortic regurgitation.
The patient was at increased risk of postpartum hemorrhage due to thrombocytopenia and pre-existing coagulopathy. Intraoperative viscoelastic testing confirmed hypercoagulability secondary to hyperfibrinogenemia. Due to uterine atony, multiple uterotonic agents were given after delivery (oxytocin, calcium chloride, methylergonovine, carboprost). We also converted from a volatile anesthetic to TIVA with propofol and fentanyl to increase uterine tone. The surgeons also placed a B-Lynch suture.
Quantitative blood loss was 300 cc. The patient remained hemodynamically stable with minimal pressor requirements and 1 unit of packed red blood cells transfused for an intraoperative hemoglobin of 7.7. The patient received dexmedetomidine, opioids, and bilateral TAP blocks for multimodal post-operative pain control. The patient was then extubated uneventfully and transported to MICU with nasal cannula oxygen, oxytocin infusion, and no vasoactive infusions.
Conclusion: In this case, we explore various anesthetic considerations to safely perform a cesarean section in the setting of infectious endocarditis.
Unfortunately, despite clinical improvement in the first three post-operative days, the patient’s clinical status later deteriorated in the MICU due to worsening sepsis and multi-organ failure. The patient ultimately expired before she was able to undergo valvular replacement surgery safely.
The child spent nearly four months in the NICU, initially due to apnea of prematurity, but with a hospital course later complicated by Klebsiella pneumoniae pneumonia and COVID-19 infection. The child was ultimately able to be discharged home with a foster family and presently remains on home oxygen due to bronchopulmonary dysplasia.