Anesthesia

1
Anesthesia Co-existing Diseases in the
Parturient

• Joseph E Pellegrini, CRNA, PhD

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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

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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

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Systemic Lupus Erythematosus
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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

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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)

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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)

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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

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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

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Myasthenia Gravis (Contraindicated Drugs)
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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

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Myasthenia Gravis

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

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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

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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

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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

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Prevalence Rates
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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
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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

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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

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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

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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

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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

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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
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Diabetes Mellitus
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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

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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.
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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

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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

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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

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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

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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

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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

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Multiple Sclerosis
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Questions??Pellegrini_at_son.umaryland.edu