Graded Epidural Block: A Safer Anesthesia Technique in Patients with Eisenmenger Syndrome

Pulmonary hypertension and right-to-left or bidirectional shunting are the hallmarks of Eisenmenger’s syndrome. It is associated with a most severe form of pulmonary artery hypertension, particularly in people with uncorrected shunts. The mainstay of management is preserving the output by the heart. The present article reports the case of a 42-year-old male, who was a known case of ventricular septal defect Eisenmenger, which was diagnosed at 8 years of age with pulmonary hypertension and bidirectional shunt predominantly right to left, and was scheduled for open inguinal hernia repair. The plan of anesthesia was graded epidural anesthesia with continuous invasive blood pressure monitoring. The test dose with 2% lignocaine with 1/2,00,000 adrenaline 3 mL was given, followed by 10 mL bupivacaine 0.5%, followed by additional 2 mL. The block was provided till the T8 dermatome level. Noradrenalin infusion was started soon after administration of the epidural block and was titrated to maintain a mean arterial pressure of >60 mm Hg. The surgery concluded uneventfully, and the patient was discharged. This case demonstrates the safe management of a patient with Eisenmenger syndrome undergoing surgery under titrated epidural anesthesia, inotropic support, and continuous intra-arterial blood pressure monitoring. A multidisciplinary approach and tailored anesthetic strategy can minimize risks and optimize outcomes in this high-risk population.