Transcript Anesthesia & Co-existing Diseases in the Parturient Joseph E Pellegrini, CRNA, PhD

Anesthesia & Co-existing
Diseases in the Parturient
Joseph E Pellegrini, CRNA, PhD
Co-existing Disease
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Estimated that approximately 10-15% of all
parturients have some co-existing disease
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Most benign
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Autoimmune Diseases
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Discussion for all diseases beyond scope of this discussion
Effects 1-2 % of all pregnancies
 Systemic Lupus Erythematosus
 Systemic Sclerosis (Scleroderma)
 Myasthenia Gravis
 Diabetes Mellitus
Obesity
Neurological and Neuromuscular Disease
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Multiple Sclerosis
Systemic Lupus Erythematosus
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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
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Overall see more prevalence in African
Americans, Asians & Native Americans than
Caucasians
Occurs in 1:1200 deliveries
Systemic Lupus Erythematosus
Systemic Lupus Erythematosus
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Anesthetic Management
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Coordinated effort between OB, Rheumatology & Anesthesia
Evaluate for organ involvement
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Periocarditis
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Valvular Disorders
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More prone to Valvular thickening (51%), Vegetations (43%), Regurgitation (25%) and
Stenosis (4%)
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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
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Typically asymptomatic
Evaluate EKG for prolongation of PR interval or non-specific T wave changes
Evaluate exercise tolerance
Central & Peripheral neuropathaties noted in approximately 25% of all SLE patients
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Vocal Cord palsy – evaluate all SLE prior to implementation of GA/CLE etc
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Note any area of sensory deficit prior to implementation of any neuraxial
anesthesia/analgesia
Early implementation of Regional Anesthesia recommended
Systemic Sclerosis (Scleroderma)
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Scleroderma is a chronic progressive disease characterized by deposition of
fibrous connective tissue in the skin and other tissues
240 million Americans have Scleroderma
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No proven treatment exists for the arrest of scleroderma
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Therapy geared towards improving existing symptoms and preventing end organ damage
Five times more prevalent in women than men
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Occurs between the ages of 30-50
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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
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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
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Evaluate parturient for evidence of renal, pulmonary & cardiac dysfunction
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Work in collaboration with specialists
Some obstetricians recommend termination of pregnancy in advanced disease
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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
Prone to pulmonary HTN, cardiac dysfunction, obstructive uropathy (from enlarged uterus)
No increased frequency of miscarriage
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Preterm labor occurs in 25% of pregnancies (as compared to a 5% national average)
Systemic Sclerosis (Scleroderma)
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Anesthetic Management
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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
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Lab tests
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EKG & PFT’s
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CBC, Coagulation profile, Full Chemistry Panel with creatinine clearance, ABG,
Urinalysis with protein
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Evaluate for presence of Reynaud’s phenomenon prior to ABG
Should be performed in all patients
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Echocardiography useful to evaluate ventricular dysfunction, pericardial and
pleural effusions and pulmonary HTN
Very thorough examination of upper airway
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Can have severe limitation of oral opening
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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
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Prepare for possibility of awake intubation (equipment for fiberoptic and
emergency cricothyrotomy should be available in labor and delivery suite)
Systemic Sclerosis (Scleroderma)
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Anesthetic Implications
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Epidural anesthesia can be used
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Can see severe prolongation of motor and sensory blockade
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Decision to use epidural or GETA dependent on urgency for cesarean section
Spinal anesthesia has been used but difficulty treatment of hypotension
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Initiate analgesia/anesthesia using small incremental doses
Incremental doses preferable over continuous infusion for laboring analgesia
Epidural anesthesia preferable over Spinal anesthesia
General Anesthesia most frequently used in severe cases
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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
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Arterial blood pressure measurements preferable in severe cases
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Radial artery catheterization contraindicated in patients with Reynaud’s
phenomenon
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Brachial artery catherization can be used
Myasthenia Gravis
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Rare Autoimmune Disorder
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Progressive muscle weakness
 Destruction of ACTH receptors
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Typically treated with anticholinergic agents such as
neostigmine or edrophonium
Women 3 times more likely to develop
Typically manifests before age 40
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Pregnancy can exacerbate symptoms
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(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
Myasthenia Gravis
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Anesthetic Management
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Careful History and Physical Exam
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Best if done before she presents for L&D
Document all medications dose & frequency
Look for possible interactions between drugs
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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
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Cholinergic Crisis
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Profound muscle weakness
Respiratory failure
Loss of bowel and bladder function
Disorientation
Diplopia
Myasthenia Gravis
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Anesthetic Management
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Regional Anesthesia preferable to General
Anesthesia
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If GETA is required keep to absolute minimum
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1/2 MAC usually adequate
Highly sensitive to both depolarizing and nondepolarizing neuromuscular blocking agents
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Intubation doses are typically 1/2 to 1/3 normal
More receptive to effects of opioids and local anesthetic
agents
The Diabetic Parturient
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Diabetes Mellitus prevalence 6.8-8.2% in the general population
 Most common medical problem of pregnancy
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Incidence 1:700 to 1:1000 gestations
Hyperplasia of -cells of maternal islets of Langerhans
Pregnancy produces higher levels of insulin
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Two types
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Type 1 – Decrease in insulin secretion
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Primarily an autoimmune disorder
Type 2- Resistance to insulin in target tissues
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Altered insulin requirements throughout pregnancy
Accounts for 90-95% of the cases of DM in U.S.
Gestational Diabetes
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Refers to DM that is first diagnosed in pregnancy
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Present in 4% of all pregnancies in U.S.
 Insulin requirements
 Diet Control
Gestational Diabetes
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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
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Recurrence rate with subsequent pregnancies 52-68%
Prevalence Rates
Whites Classification
Modified White Classification of Diabetes Mellitus During Pregnancy
Class
Gestational Diabetes
A1
A2
Pregestational Diabetes
B
C
D*
F
R
T
H
Age of onset (yrs)
Duration of
diabetes (yrs)
Vascular
Disease
Insulin
Required
Any
Any
Any
Any
-
+
>20
10-19
<10
Any
Any
Any
Any
(or)
(or)
<10
10-19
>20
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
Major Complications
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Acute Complications
 Diabetic Ketoacidosis
 Hyperglycemic nonketotic state
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Primarily occurs in Type II diabetes
Hypoglycemia
Chronic Complications
 Macrovascular
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Microvascular
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Coronary
Cerebrovascular
Peripheral Vascular
Retinopathy
Nephropathy
Neuropathy
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Autonomic
Somatic
The Diabetic Parturient
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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
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Determination of hemoglobin A1C concentrations help
determine adequacy of glycemic control
 Normal range is 4-6%
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Increased risk of microvascular and macrovascular disease begins
at 6.5%
Stiff Joint Syndrome
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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
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C-spine rigidity (atlanto-occipital joint)
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Ensure plan for emergency airway in place
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Planned general anesthesia
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Awake intubation?
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Fiberoptic intubation
Preanesthestic management
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Controversial
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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
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Maternal insulin requirements increase progressively during the 2 nd and 3rd trimester
& decrease at the onset of labor and continue to decrease following delivery
Preanesthestic Evaluation
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Absorption of SQ insulin is unpredictable
IV insulin therapy more flexible
Obtain Preoperative or pre-anesthesia intervention serum glucose levels
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Controversy regarding use of insulin infusion during labor and delivery
Tighter controls recommended if patient is going to cesarean section
Evaluate End Organ Damage
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Diabetic Autonomic Neuropathy
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HTN
Orthostatic Hypotension
Painless MI
Decreased HR variability
Decreased response to medications
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Atropine and propanolol
Resting tachycardia
Neurogenic atonic bladder
Hemoglobin A1C
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Measure of overall serum glucose
Gastroporesis with delayed emptying
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Sodium Citrate
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Consider metoclopramide and H2 antagonist premed
Management in Operating Room
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Intraoperative
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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
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Either
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One-half of total daily dose as intermediate form (NPH) plus an intraoperative “sliding scale
Continuous infusion of regular insulin
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Start infusion based on serum glucose using formula:
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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
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Monitor Blood Glucose
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Maintain serum glucose > 100 mg/dl
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Infection
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Avoid hypoglycemia and hyperglycemia
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
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One study showed delayed
clearance and higher serum
levels following epidural
lidocaine administration in
diabetic groups
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Study used 20 ml
Possible toxicity if large
volumes used
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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
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Diabetic Maternal Insulin
Req (%)
Diabetes Mellitus
Fetal Glucose Utilization
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150
100
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0
Obesity
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Obesity is a public health issue in
most developed countries
Obese parturients at risk for medical
& obstetrical (and anesthesia)
complications during pregnancy
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Difficulty with intubation
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All know difficulties with intubation
and GETA
Problems with placement of neuraxial
anesthesia
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Significant differences in anesthetic
requirements during labor & delivery
and at cesarean section
Obesity
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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
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Despite lower anesthetic
concentrations administered to
obese women they achieved
higher sensory blockade with
no differences in pain scores
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Greater distribution of
epidural local anesthestic
within epidural space in
obese women
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Don’t 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.
Multiple Sclerosis
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Major cause of neurological disability in
young adults
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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
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Multiple Sclerosis
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Etiology is unclear
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? Link to previous exposure to viral agent that
may trigger autoimmune response
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Most common Symptoms
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Loss of myelin in CNS
Motor weakness, impaired vision, ataxia, bladder & bowel
dysfunction and emotional lability
No curative treatment
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Treat symptomatically & by immunosuppression
 Often tx is marked by relapses & regression of Sx
Multiple Sclerosis
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Interaction with pregnancy
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No effect on progression of MS
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Slight increased risk for relapse during pregnancy
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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
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Anesthetic Management
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Careful assessment of neurological and
respiratory compromise (if any)
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Note any areas of motor weakness, visual
disturbances or bowel and bladder disorders
Auscultate all lung fields
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Assess any anomalous finding with AP & Lateral Chest Xray and pulmonary function test before analgesic
intervention initiated
Multiple Sclerosis
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Concerns w/ neuraxial anesthesia
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exposures of de-mylinated areas of spinal cord to
potential neurotoxic effects
concerns over relapse of symptoms
Recommended
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Do not exceed concentrations > 0.25% bupivacaine in
CLE infusions
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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
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General Anesthesia
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Not contraindicated
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Succinylcholine should be avoided with severe
musculoskeletal involvement
Remain cognizant of pulmonary complications and
maintenance of normal body temperature
Multiple Sclerosis
1.
2.
3.
4.
5.
6.
7.
Overview of Anesthetic Management for the pregnant MS patient
Most methods of analgesia will be beneficial because they will reduce stress
Obtain careful history & note any neuromuscular anomalies and areas of weakness.
Epidural analgesia (with local anesthetics) is particularly appealing because it is helpful in
relieving abdominal & pelvic spasticity that can interfere with spontaneous delivery.
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 laboring
analgesia).
1. It is suggested that the lowest concentration of local anesthetic and volume that can
achieve 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 analysis
shows that fentanyl, morphine and sufentanil have been successfully used
without causing exacerbation of symptoms
The use of intrathecal local anesthetics is controversial because of the potential high
concentrations of subarachnoid local anesthetic levels (research has shown that drug
concentrations of local anesthetics are 3-4 times higher in the CSF following subarachnoid
administration of a local anesthetic when compared to epidurally administered local anesthetics).
Epidural anesthesia is the preferred method for cesarean section.
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 towards
the prevention of pulmonary complications and the maintenance of normal body temperature.
Questions??
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