Journal of clinical anesthesia
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Pregnancy carries substantial maternal and fetal risks in patients with uncorrected or palliatively corrected cyanotic congenital heart disease (CHD). In tricuspid valve Ebstein's anomaly, pregnancy is well tolerated. Maternal mortality in tetralogy of Fallot seems to be less than 10%, but it exceeds 50% in Eisenmenger's syndrome and primary pulmonary hypertension (PPH). ⋯ Prevention of excessive erythrocytosis, volume and blood loss substitution, cardiocirculatory pharmacologic support, prophylaxis of infective endocarditis, and judicious use of anticoagulant drugs should be applied as indicated by the type and presentation of CHD. Poor outcome of pregnancy in PPH requires an early consideration of heart-lung or lung transplantation. Multidisciplinary team effort and prolonged monitoring in the intensive care unit are mandatory to ensure a favorable outcome for cyanotic CHD and PPH parturients.
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Regional anesthetic techniques for children have recently enjoyed a justified resurgence in popularity. Intraoperative blockade of the neuraxis, whether by the spinal or epidural route, provides excellent analgesia with minimal physiologic alteration and, with an indwelling catheter, can provide continuous pain relief for many days postoperatively. ⋯ Although some practitioners contend that a regional block on an already anesthetized child adds to the risk of the general anesthetic itself, in experienced hands the risks are negligible and the benefits dramatic. In this review of caudal and lumbar epidural and subarachnoid blockade in infants and children, anatomy, physiologic alterations, and pharmacology pertinent to the three types of neuraxial blockade are described, with the aim of providing the practicing anesthesiologist with the foundation needed to perform these blocks with relative confidence.