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Anesthesia & Co-existing Diseases in the Parturient. Joseph E Pellegrini, CRNA, PhD. 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 - PowerPoint PPT Presentation
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Anesthesia & Co-existing Diseases in the Parturient
Joseph E Pellegrini, CRNA, PhD
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
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 1:1200 deliveries
Systemic Lupus Erythematosus
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
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)
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 Reynaud’s phenomenon prior to ABG
EKG & PFT’s 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)
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 Reynaud’s phenomenon
Brachial artery catherization can be used
Systemic Sclerosis (Scleroderma)
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
Myasthenia Gravis (Contraindicated Drugs)
Antibiotics Gentamycin Kanamycin Steptomycin Plymyxin Colistin Tetracycline Lincomycin
Tocolytics
Magnesium Sulfate
Cardiac Meds
Quinidine Propanolol
Beta Mimetics
Ritrodrine Terbutaline
Others
Quinine Penicillamine Lithium Salts
Anesthetic Management Careful History and Physical Exam
Best if done before she presents for L&D 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 30:1 to oral dose Monitor fetal HR closely Observe for s/s of “cholinergic crisis”
Myasthenia Gravis
Myasthenia Gravis
Cholinergic Crisis Profound muscle weakness Respiratory failure Loss of bowel and bladder function Disorientation Diplopia
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
The Diabetic Parturient Diabetes Mellitus prevalence 6.8-8.2% in the general population
Most common medical problem of pregnancy Incidence 1:700 to 1:1000 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
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%
Prevalence Rates
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
>20 <10 - +
10-19 (or) 10-19 - +
<10 (or) >20 + +
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
Whites Classification
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
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%
The Diabetic Parturient
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
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
Measure of overall serum glucose
Gastroporesis with delayed emptying Sodium Citrate Consider metoclopramide and H2 antagonist premed
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 > 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 Obviously ensure strict aseptic technique during administration Poor wound healing noted in diabetic parturients
**Can see protamine sulfate anaphylaxis in patients taking NPH or protamine zinc insulin
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 Dec;64(12):1189-96
Diabetes Mellitus
Fetal Glucose Utilization
0
50
100
150
200
Dia
beti
c M
ate
rnal
Insu
lin
Req
(%
)
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
Obesity Study to determine the
minimum local anesthetic concentration (MLAC) of bupivacaine in women at term gestation
MLAC for obese women (> 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 Don’t standardize epidural dose
Panni MK, Columb MO. Obese parturients have lower epidural local anesthetic requirements foranalgesia in labour. Br J Anaesth 2006; 96: 106-10.
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
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
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
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
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 > 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
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
Multiple Sclerosis
Overview of Anesthetic Management for the pregnant MS patient 1. Most methods of analgesia will be beneficial because they will reduce stress2. Obtain careful history & note any neuromuscular anomalies and areas of weakness.3. Epidural analgesia (with local anesthetics) is particularly appealing because it is helpful in
relieving abdominal & pelvic spasticity that can interfere with spontaneous delivery.4. Research indicates that bupivacaine concentrations for continuous epidural infusions that exceed a
0.25% concentration can lead to exacerbation of neurological symptoms (when used for laboringanalgesia).
1. It is suggested that the lowest concentration of local anesthetic and volume that canachieve effective analgesia should be used.
a. Typically use concentrations of 0.0625% - 0.125% bupivacaine or 0.08% -0.125% ropivacaine with 1-2 ug/ml of fentanyl
b. Intrathecal opioids have not been investigated fully but anecdotal analysisshows that fentanyl, morphine and sufentanil have been successfully usedwithout causing exacerbation of symptoms
5. The use of intrathecal local anesthetics is controversial because of the potential highconcentrations of subarachnoid local anesthetic levels (research has shown that drugconcentrations of local anesthetics are 3-4 times higher in the CSF following subarachnoidadministration of a local anesthetic when compared to epidurally administered local anesthetics).
6. Epidural anesthesia is the preferred method for cesarean section.7. General anesthesia does not exacerbate the course of MS but succinylcholine should be avoided in
patients having severe musculoskeletal involvement. Particular attention must be directed towardsthe prevention of pulmonary complications and the maintenance of normal body temperature.
Questions??