Eisenmenger syndrome for urgent wrist fixation31-year-old woman, 54 kg, for urgent fixation of a displaced distal radius fracture

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A 31-year-old with Eisenmenger from an unrepaired VSD, for urgent wrist fixation. Patient
   • Her PVR is fixed, so any fall in systemic resistance sends more blood right to left. Disease
   • Her SpO2 of 84% is her baseline; I judge every change against that.
   • Haematocrit 62% means erythrocytosis, with hyperviscosity and thrombosis risk.
   • Hypoxaemia or high airway pressures would raise her PVR further.
   • Wrist surgery can be done under a plexus block, sparing her airway and ventilation. Surgery

2. Prepare

   Take me through her risk assessment and preparation.

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   • Urgency: urgent fracture, so hours for the right team, not weeks. Stem trigger
   • Active cardiac condition? Yes: Eisenmenger is severe pulmonary hypertension, and it can't be optimised. Disease
   • Risk score: no RCRI items, so RCRI 0.
   • Functional capacity: breathless after one flight, under 4 METs.
   • Decision: proceed, but in a pulmonary hypertension centre with her PH team.
   • Sildenafil continues; venesection only if she has hyperviscosity symptoms.
   • Air filters on every line; even small bubbles can reach her brain.

3. Plan

   What is your anaesthetic plan?

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   • Axillary block: it covers forearm and hand, and spares her phrenic nerve. Disease
   • Light sedation only, with capnography, so her CO2 doesn't climb.
   • Oxygen on throughout; it can help her hypoxaemia.
   • Arterial line; SVR kept at or just above her starting level.
   • Phenylephrine drawn up and noradrenaline ready before the block goes in. Crisis
   • Monitored bed overnight with her PH team; never a same-day discharge. After surgery

4. Crisis

   After midazolam and fentanyl, SpO2 falls to 68%, BP to 84/50, RR 10. What do you do?

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   • Two problems together: vasodilation widening her shunt, and hypoventilation raising her PVR. (Crisis)
   • Stop sedation, 100% oxygen, jaw thrust, and assist her breathing to clear CO2.
   • Phenylephrine 50–100 mcg IV to restore her systemic resistance.
   • Pressure still falling: start noradrenaline, 0.05–0.3 mcg/kg/min.
   • Fentanyl slowing her breathing: naloxone 40 mcg IV every 2 minutes.
   • My target is her baseline saturation of 84%, not 100%.

5. Crisis

   In recovery she cannot lift her left arm and her speech is slurred. What do you do?

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   • Stroke until proven otherwise: paradoxical embolism or a clot from thick blood. Crisis
   • Stroke team now, and emergent brain imaging.
   • Recent surgery doesn't absolutely bar thrombolysis; clot retrieval if bleeding risk is high.
   • Meanwhile keep her pressure and saturation at her baseline.
   • Stroke unit or ICU, with her PH team involved. After surgery