49th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

•Supraventricular tachycardia (SVT) is a dysrhythmia characterized by a narrow QRS complex <120 milliseconds at a heart rate in excess of 100 BPM; it originates at or above the atrioventricular node. There have been documented cases of SVT being triggered following epidural placement.

•Here, we present a case of an SVT episode in a pregnant patient after epidural placement.

•Patients in SVT usually present with palpitations, lightheadedness, syncope, dyspnea, and anxiety, with symptom onset being sudden.

•The etiology of SVT is wide-ranging, with triggers including exercise, psychosocial stress, caffeine intake, cardiovascular disease, as well as prescription and recreational drugs.

•In the pregnant patient, physiologic changes of pregnancy predispose to SVT, including increased blood volume, decreased SVR, and vascular compression.

•A 25-year-old G7P1243 at 35 weeks and 2 days’ gestation with a history of SVT, chronic hypertension, and anxiety presented for right upper quadrant pain and nausea.

•Before this pregnancy she was scheduled for an ablation for SVT, but this was delayed until after delivery.

•Medications included acetaminophen, prenatal vitamins, aspirin, metformin, and metoprolol.

•Ruled in for preeclampsia with severe features two days after admission and was called for induction.

•A test dose of 1.5% lidocaine with epinephrine 1:200,000 was negative.

•Test dose included 15 mcg epinephrine total(5mcg/mL)

•Ten minutes after epidural placement the she developed an episode of tachycardia progressing to SVT; vagal maneuvers were initially attempted but provided no relief.

•She received a 3 mg bolus of adenosine with a concomitant decrease in heart rate, however, the patient was still symptomatic and continued to be in SVT.

•A subsequent 3 mg bolus of adenosine was delivered; the patient’s heart rate then decreased further and her rhythm converted from SVT to sinus tachycardia.

•The patient was given 2 mg metoprolol IV for persistent sinus tachycardia while waiting oral metoprolol.

•No other peripartum or postpartum complications arose during her hospital course.

•Roughly 6 weeks after delivery, she underwent successful ablation with cardiac electrophysiology.

•The most likely etiology of this patient's episode of SVT was a delay in receiving her home dose of metoprolol.

•Given the half-life of non-extended release formations of metoprolol, it is plausible that such an episode would present more than 24 hours since she took her last dose.

•There was concern that the epinephrine in the test dose triggered this episode of SVT, but was less likely given the duration between administration and onset of SVT.

•This episode of SVT was aborted using intravenous adenosine and metoprolol.

•Subsequent labs showed mild hypocalcemia and hypermagnesemia, which could have contributed; daytime telemetry showed no findings suggesting electrolyte abnormalities.

•Kuo, C. D., et al. (2000). Biphasic changes in autonomic nervous activity during pregnancy. British Journal of Anaesthesia, 84(3), 323–329. https://doi.org/10.1093/oxfordjournals.bja.a013433

•Page, R. L.,et al. (2016). 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Journal of the American College of Cardiology, 67(13), e27–e115. https://doi.org/10.1016/j.jacc.2015.08.856

49th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

SUPRAVENTRICULAR TACHYCARDIA AFTER EPIDURAL NEURAXIAL PLACEMENT FOR LABOR ANALGESIA

Poster Presenter

Authors

Part of Topic