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Anesthesia

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Title: Anesthesia


1
Anesthesia Co-existing Diseases in the
Parturient
  • Joseph E Pellegrini, CRNA, PhD

2
Co-existing Disease
  • Estimated that approximately 10-15 of all
    parturients have some co-existing disease
  • Most benign
  • Discussion for all diseases beyond scope of this
    discussion
  • Autoimmune Diseases
  • Effects 1-2 of all pregnancies
  • Systemic Lupus Erythematosus
  • Systemic Sclerosis (Scleroderma)
  • Myasthenia Gravis
  • Diabetes Mellitus
  • Obesity
  • Neurological and Neuromuscular Disease
  • Multiple Sclerosis

3
Systemic Lupus Erythematosus
  • Multisystem inflammatory disease of unknown
    etiology that is characterized by the production
    of autoantibodies against cell membrane antigens
  • Most common in women in childbearing years
  • Overall see more prevalence in African Americans,
    Asians Native Americans than Caucasians
  • Occurs in 11200 deliveries

4
Systemic Lupus Erythematosus
5
Systemic Lupus Erythematosus
  • Anesthetic Management
  • Coordinated effort between OB, Rheumatology
    Anesthesia
  • Evaluate for organ involvement
  • Periocarditis
  • Typically asymptomatic
  • Evaluate EKG for prolongation of PR interval or
    non-specific T wave changes
  • Evaluate exercise tolerance
  • Valvular Disorders
  • More prone to Valvular thickening (51),
    Vegetations (43), Regurgitation (25) and
    Stenosis (4)
  • Prophylactic antibiotics only required if patient
    at high risk for endocarditis (previous infective
    carditis, unrepaired cyanotic heart disease,
    implanted prosthetic devices, cardiac
    transplantation with cardiac valvulopathy). Not
    recommended for women with common valvular
    lesions undergoing GU procedures (which includes
    vaginal delivery)
  • Neuropathies
  • Central Peripheral neuropathaties noted in
    approximately 25 of all SLE patients
  • Vocal Cord palsy evaluate all SLE prior to
    implementation of GA/CLE etc
  • Note any area of sensory deficit prior to
    implementation of any neuraxial
    anesthesia/analgesia
  • Early implementation of Regional Anesthesia
    recommended

6
Systemic Sclerosis (Scleroderma)
  • Scleroderma is a chronic progressive disease
    characterized by deposition of fibrous connective
    tissue in the skin and other tissues
  • 240 million Americans have Scleroderma
  • No proven treatment exists for the arrest of
    scleroderma
  • Therapy geared towards improving existing
    symptoms and preventing end organ damage
  • Five times more prevalent in women than men
  • Occurs between the ages of 30-50
  • Death is usually 15-20 years after diagnosis from
    renal failure malignant hypertension
  • Becoming more of a problem with recent trend
    towards first time pregnancies at 30 years of
    age
  • Effect on Pregnancy
  • Typically symptoms unchanged with pregnancy
  • Approximately 20 will have worsening of symptoms
    with significant esophageal reflux, cardiac
    arrhythmias, arthritis, renal crisis
  • ACE inhibitors are treatment of choice for
    scleroderma associated renal crisis
  • However ACE inhibitors are typically not
    administered during pregnancy secondary to high
    incidence of teratogenicity however they should
    be given at the first indication of maternal
    hypertension
  • Evaluate parturient for evidence of renal,
    pulmonary cardiac dysfunction
  • Work in collaboration with specialists
  • Some obstetricians recommend termination of
    pregnancy in advanced disease
  • Prone to pulmonary HTN, cardiac dysfunction,
    obstructive uropathy (from enlarged uterus)
  • No increased frequency of miscarriage
  • Preterm labor occurs in 25 of pregnancies (as
    compared to a 5 national average)

7
Systemic Sclerosis (Scleroderma)
  • Anesthetic Management
  • Requires a multi-disciplinary approach
  • Evaluation of patient should be done prior to
    labor and delivery
  • History Physical directed toward detection of
    underlying systemic dysfunction
  • Lab tests
  • CBC, Coagulation profile, Full Chemistry Panel
    with creatinine clearance, ABG, Urinalysis with
    protein
  • Evaluate for presence of Reynauds phenomenon
    prior to ABG
  • EKG PFTs
  • Should be performed in all patients
  • Echocardiography useful to evaluate ventricular
    dysfunction, pericardial and pleural effusions
    and pulmonary HTN
  • Very thorough examination of upper airway
  • Can have severe limitation of oral opening
  • Evaluate maximal oral opening, ability to sublux
    the mandible, visualization of oropharyngeal
    structures, degree of atlanto-occipital joint
    extension and presence of nasal or oral
    telangiectasias
  • Prepare for possibility of awake intubation
    (equipment for fiberoptic and emergency
    cricothyrotomy should be available in labor and
    delivery suite)

8
Systemic Sclerosis (Scleroderma)
  • Anesthetic Implications
  • Epidural anesthesia can be used
  • Can see severe prolongation of motor and sensory
    blockade
  • Initiate analgesia/anesthesia using small
    incremental doses
  • Incremental doses preferable over continuous
    infusion for laboring analgesia
  • Decision to use epidural or GETA dependent on
    urgency for cesarean section
  • Spinal anesthesia has been used but difficulty
    treatment of hypotension
  • Epidural anesthesia preferable over Spinal
    anesthesia
  • General Anesthesia most frequently used in severe
    cases
  • Awake versus RSI??
  • CVP cannulation may be required in patients with
    diffuse cutaneous involvement
  • Extensive skin involvement may lead to inaccurate
    non-invasive blood pressure readings
  • Arterial blood pressure measurements preferable
    in severe cases
  • Radial artery catheterization contraindicated in
    patients with Reynauds phenomenon
  • Brachial artery catherization can be used

9
Myasthenia Gravis
  • Rare Autoimmune Disorder
  • Progressive muscle weakness
  • Destruction of ACTH receptors
  • Typically treated with anticholinergic agents
    such as neostigmine or edrophonium
  • Women 3 times more likely to develop
  • Typically manifests before age 40
  • Pregnancy can exacerbate symptoms (cholinergic
    crisis)
  • Usually requires adjustment of neostigmine doses

10
Myasthenia Gravis (Contraindicated Drugs)
11
Myasthenia Gravis
  • Anesthetic Management
  • Careful History and Physical Exam
  • Best if done before she presents for LD
  • Document all medications dose frequency
  • Look for possible interactions between drugs
  • Most commonly on neostigmine
  • Maintain on normal regimen
  • IV dose is given in ratio of 301 to oral dose
  • Monitor fetal HR closely
  • Observe for s/s of cholinergic crisis

12
Myasthenia Gravis
  • Cholinergic Crisis
  • Profound muscle weakness
  • Respiratory failure
  • Loss of bowel and bladder function
  • Disorientation
  • Diplopia

13
Myasthenia Gravis
  • Anesthetic Management
  • Regional Anesthesia preferable to General
    Anesthesia
  • If GETA is required keep to absolute minimum
  • 1/2 MAC usually adequate
  • Highly sensitive to both depolarizing and
    non-depolarizing neuromuscular blocking agents
  • Intubation doses are typically 1/2 to 1/3 normal
  • More receptive to effects of opioids and local
    anesthetic agents

14
The Diabetic Parturient
  • Diabetes Mellitus prevalence 6.8-8.2 in the
    general population
  • Most common medical problem of pregnancy
  • Incidence 1700 to 11000 gestations
  • Hyperplasia of ?-cells of maternal islets of
    Langerhans
  • Pregnancy produces higher levels of insulin
  • Altered insulin requirements throughout pregnancy
  • Two types
  • Type 1 Decrease in insulin secretion
  • Primarily an autoimmune disorder
  • Type 2- Resistance to insulin in target tissues
  • Accounts for 90-95 of the cases of DM in U.S.
  • Gestational Diabetes
  • Refers to DM that is first diagnosed in pregnancy
  • Present in 4 of all pregnancies in U.S.
  • Insulin requirements
  • Diet Control

15
Gestational Diabetes
  • Associated with
  • Advanced maternal age
  • Obesity
  • Family history of DM
  • History of stillbirth, neonatal death, or fetal
    malformation or macrosomia
  • Presents when patients cannot mount a sufficient
    compensatory insulin response during pregnancy
  • More prevalent in 2nd and 3rd trimesters
  • After delivery most parturients return to normal
    glucose tolerance
  • Recurrence rate with subsequent pregnancies
    52-68

16
Prevalence Rates
17
Whites Classification
Modified White Classification of Diabetes Mellitus During Pregnancy Modified White Classification of Diabetes Mellitus During Pregnancy Modified White Classification of Diabetes Mellitus During Pregnancy Modified White Classification of Diabetes Mellitus During Pregnancy Modified White Classification of Diabetes Mellitus During Pregnancy
Class Age of onset (yrs) Duration of diabetes (yrs) Vascular Disease Insulin Required
Gestational Diabetes A1 A2 Any Any Any Any - - -
Pregestational Diabetes B C D F R T H gt20 lt10 - 10-19 (or) 10-19 - lt10 (or) gt20 Any Any Any Any Any Any Any Any gt20 lt10 - 10-19 (or) 10-19 - lt10 (or) gt20 Any Any Any Any Any Any Any Any gt20 lt10 - 10-19 (or) 10-19 - lt10 (or) gt20 Any Any Any Any Any Any Any Any gt20 lt10 - 10-19 (or) 10-19 - lt10 (or) gt20 Any Any Any Any Any Any Any Any
Vascular Disease in D is hypertension or benign retinopathy F, Nephropathy R, proliferative retinopathy T, status-post renal transplant H, ischemic heart disease Vascular Disease in D is hypertension or benign retinopathy F, Nephropathy R, proliferative retinopathy T, status-post renal transplant H, ischemic heart disease Vascular Disease in D is hypertension or benign retinopathy F, Nephropathy R, proliferative retinopathy T, status-post renal transplant H, ischemic heart disease Vascular Disease in D is hypertension or benign retinopathy F, Nephropathy R, proliferative retinopathy T, status-post renal transplant H, ischemic heart disease Vascular Disease in D is hypertension or benign retinopathy F, Nephropathy R, proliferative retinopathy T, status-post renal transplant H, ischemic heart disease
18
Major Complications
  • Acute Complications
  • Diabetic Ketoacidosis
  • Hyperglycemic nonketotic state
  • Primarily occurs in Type II diabetes
  • Hypoglycemia
  • Chronic Complications
  • Macrovascular
  • Coronary
  • Cerebrovascular
  • Peripheral Vascular
  • Microvascular
  • Retinopathy
  • Nephropathy
  • Neuropathy
  • Autonomic
  • Somatic

19
The Diabetic Parturient
  • Pregnancy associated with a progressive
    peripheral resistance to insulin in 2nd 3rd
    trimester
  • Diabetes associated with higher incidence of
    gestational HTN, polyhydramnios and cesarean
    delivery
  • Initiation of early glycemic control is the best
    way to prevent fetal structural abnormalities
  • Determination of hemoglobin A1C concentrations
    help determine adequacy of glycemic control
  • Normal range is 4-6
  • Increased risk of microvascular and macrovascular
    disease begins at 6.5

20
Stiff Joint Syndrome
  • 30-40 in Type 1 Diabetics
  • Occurs in patients with long-standing type 1
    diabetes and is associated with nonfamilial short
    stature, joint contractures and tight skin
  • Direct laryngoscopy can be difficult in 30 of
    all parturients with DM
  • C-spine rigidity (atlanto-occipital joint)
  • Ensure plan for emergency airway in place
  • Planned general anesthesia
  • Awake intubation?
  • Fiberoptic intubation
  • Preanesthestic management
  • Controversial
  • Some recommend pre-anesthetic flexion-extension
    cervical spine x-rays
  • No evidence to indicate that having
    pre-anesthetic cervical spine series makes a
    difference

21
Anesthetic Management
  • Maternal insulin requirements increase
    progressively during the 2nd and 3rd trimester
    decrease at the onset of labor and continue to
    decrease following delivery
  • Preanesthestic Evaluation
  • Absorption of SQ insulin is unpredictable
  • IV insulin therapy more flexible
  • Obtain Preoperative or pre-anesthesia
    intervention serum glucose levels
  • Controversy regarding use of insulin infusion
    during labor and delivery
  • Tighter controls recommended if patient is going
    to cesarean section
  • Evaluate End Organ Damage
  • Diabetic Autonomic Neuropathy
  • HTN
  • Orthostatic Hypotension
  • Painless MI
  • Decreased HR variability
  • Decreased response to medications
  • Atropine and propanolol
  • Resting tachycardia
  • Neurogenic atonic bladder
  • Hemoglobin A1C

22
Management in Operating Room
  • Intraoperative
  • Ensure good intravenous line in place
  • Evaluate preoperative serum glucose levels with
    IV start
  • Begin D5W 1-1.5 ml/kg/hr as an IV piggy back into
    crystalloid solution
  • Administer insulin
  • Either
  • One-half of total daily dose as intermediate form
    (NPH) plus an intraoperative sliding scale
  • Continuous infusion of regular insulin
  • Start infusion based on serum glucose using
    formula
  • Units/hr Plasma glucose/150 (desired range of
    150 etc)
  • i.e. plasma glucose of 220/150 1.4 units/hr
    (usually delivered in 250 units regular
    insulin/250 ml 09 NaCl solution
  • Monitor Blood Glucose
  • Maintain serum glucose gt 100 mg/dl
  • Avoid hypoglycemia and hyperglycemia
  • Infection
  • Important cause of morbidity in pregnant women
  • No data regarding incidence of CNS infection
    after administration of neuraxial anesthesia

23
Clearance of Local Anesthetic
  • One study showed delayed clearance and higher
    serum levels following epidural lidocaine
    administration in diabetic groups
  • Study used 20 ml
  • Possible toxicity if large volumes used
  • Caudal anesthesia etc

Moises EC et al. Eur J Clin Pharmacol.
Pharmacokinetics of lidocaine and its metabolite
in peridural anesthesia administered to pregnant
women with gestational diabetes mellitus. 2008
Dec64(12)1189-96
24
Diabetes Mellitus
25
Obesity
  • Obesity is a public health issue in most
    developed countries
  • Obese parturients at risk for medical
    obstetrical (and anesthesia) complications during
    pregnancy
  • Difficulty with intubation
  • All know difficulties with intubation and GETA
  • Problems with placement of neuraxial anesthesia
  • Significant differences in anesthetic
    requirements during labor delivery and at
    cesarean section

26
Obesity
  • Study to determine the minimum local anesthetic
    concentration (MLAC) of bupivacaine in women at
    term gestation
  • MLAC for obese women (gt 30kg/m2) was 41 lower
    than non-obese women
  • Despite lower anesthetic concentrations
    administered to obese women they achieved higher
    sensory blockade with no differences in pain
    scores
  • Greater distribution of epidural local
    anesthestic within epidural space in obese women
  • Dont standardize epidural dose

Panni MK, Columb MO. Obese parturients have lower
epidural local anesthetic requirements
for analgesia in labour. Br J Anaesth 2006 96
106-10.
27
Multiple Sclerosis
  • Major cause of neurological disability in young
    adults
  • incidence of 0.3-0.8 of population
  • Presents over a period of several years as two
    general patterns
  • Exacerbating remitting- attacks appear abruptly
    resolve over several months
  • Chronic progressive
  • Manifest as neurological defects that present as
    pyramidal, cerebellar or brainstem symptoms

28
Multiple Sclerosis
  • Etiology is unclear
  • ? Link to previous exposure to viral agent that
    may trigger autoimmune response
  • Loss of myelin in CNS
  • Most common Symptoms
  • Motor weakness, impaired vision, ataxia, bladder
    bowel dysfunction and emotional lability
  • No curative treatment
  • Treat symptomatically by immunosuppression
  • Often tx is marked by relapses regression of Sx

29
Multiple Sclerosis
  • Interaction with pregnancy
  • No effect on progression of MS
  • Slight increased risk for relapse during
    pregnancy
  • Stress, exhaustion, infection and hyperpyrexia
    may contribute to relapse (most often in the
    postpartum period)
  • Pregnancy does not have an overall negative
    effect on the long-term outcome of MS

30
Multiple Sclerosis
  • Anesthetic Management
  • Careful assessment of neurological and
    respiratory compromise (if any)
  • Note any areas of motor weakness, visual
    disturbances or bowel and bladder disorders
  • Auscultate all lung fields
  • Assess any anomalous finding with AP Lateral
    Chest X-ray and pulmonary function test before
    analgesic intervention initiated

31
Multiple Sclerosis
  • Concerns w/ neuraxial anesthesia
  • exposures of de-mylinated areas of spinal cord to
    potential neurotoxic effects
  • concerns over relapse of symptoms
  • Recommended
  • Do not exceed concentrations gt 0.25 bupivacaine
    in CLE infusions
  • Epidural anesthesia better tolerated than SAB
  • SAB has been successfully employed
  • CSF concentrations 4 fold higher with SAB than
    CLE
  • CSE technique well tolerated with IT opioids

32
Multiple Sclerosis
  • General Anesthesia
  • Not contraindicated
  • Succinylcholine should be avoided with severe
    musculoskeletal involvement
  • Remain cognizant of pulmonary complications and
    maintenance of normal body temperature

33
Multiple Sclerosis
34
Questions??Pellegrini_at_son.umaryland.edu
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