Complicated Severe Pre-eclampsia General or regional anaesthesia for caesarean section. Jim Bamber Cambridge University Hospitals

Transcription

1 Complicated Severe Pre-eclampsia General or regional anaesthesia for caesarean section Jim Bamber Cambridge University Hospitals

2 This case presentation has the consent of the patient.

3 You have just finished the afternoon CS list You are on-call this evening You have been asked to review a patient on the Delivery Unit with the consultant obstetrician

4 Case History Part 1 Age early 30s, no co-morbidities. BMI 29. Primiparous IVF twin pregnancy. Gestational diabetes and pregnancy cholestasis. Weekly CTG at MFAU from 32 weeks. At 09:20 at 35 wk assessment c/o feeling unwell, headache, visual disturbance ( flashing lights Pulse 74bpm, BP 115/70, T.36, urine NAD.

5 Case History Part 2 12:10 - Headache better but vision poor. 13:00 Headache worse, vision worse (light perception only). BP 115/74. 13:35 Transfer to DU. BP 197/111. Severe Preeclampsia Protocol commenced. Magnesium and labetolol infusions started. 16:00 Joint obs/anaes consultant review BP /80, +++ proteinuria, headache 5/10, vision light only. 2 nd twin transverse, plan for CS.

6 Case History Part 3 18:00 Obstetric consultant handover. BP 148/82, good urine output, brisk reflexes and clonus 3 beats, vision can see fingers now. On magnesium and labetolol infusions. Good mouth opening. Mallampati 2. For emergency CS

7

8 ? WHAT CHOICE OF ANAESTHETIC

9 Caesarean Section Part 1 Transfer to theatre at 18:45 Self transfer from bed to table Infusions disconnected for transfer On reconnection IV cannulas not patent/dislodged Recannulation difficult, patient becomes distressed 19:05-19:10 c/o severe headache, blind, drowsy and confused. BP 151/102, 177/108 Magnesium and labetolol infusion rates increased temporarily 19:30 - Confusion resolves: orientated, obeys commands, unable to see, c/o severe headache. BP 110/56

10 ? WHAT CHOICE OF ANAESTHETIC

11 Caesarean Section Part 2 19:30 Spinal anaesthesia: Sitting position, 27G Whitacre, 2.3mls hyperbaric bupivacaine + 350mcg diamorphine. 19:41 KTS; Delivered at 19:45 and 19:46. Apgars: 9+10; 7+9. Placental abruption noted. Finished 20:11. Arterial line and transfer to Recovery at 20:45 20:50 Reviewed. BP 128/80, good urine output, feels unwell ( jittery ), severe headache behind eyes. ABG: ph 7.32, pco 2 3.9, po , HCO , BE :15 Transfer to NCCU HDU bed. CT scan. 09:10 No headache, vision almost normal. Platelets 65 Returned to Delivery Unit. Discharged 8 days later.

12

13 Occipital lobes Right parietal lobe AREAS OF SUBCORTICAL VASOGENIC OEDEMA

14 Posterior reversible encephalopathy syndrome (PRES) A clinicoradiological diagnosis Typically oedema of the posterior cerebral regions (especially of the parietooccipital lobes) in association with Acute encephalopathy (headache, altered mental status, vomiting), visual disturbances, and seizures. Occurs in endothelial disorders (hypertension, preeclampsia, autoimmune diseases, immunosuppressive and chemotherapy, sepsis)

15 PRES pathophysiology Theory 1: Evolving hypertension>intact autoregulation > vasoconstriction > hypoperfusion> ischaemia> vasogenic oedema Theory 2: Established hypertension> failed autoregulation > hyperperfusion > vasogenic oedema

16 Why posterior and is it always reversible Less dense sympathetic innervation of posterior circulation vs More dense sympathetic innervation of posterior circulation Usually reversible if timely treatment. 25% resolve in 24h, median resolution 2 days. Recurrance 4-8%.

17 Frequency (%) of posterior reversible encephalopathy syndrome signs and symptoms. Roth C and Ferbert A Pract Neurol 2011;11: by BMJ Publishing Group Ltd

18 Frequency (%) of posterior reversible encephalopathy syndrome signs and symptoms Roth C and Ferbert A Pract Neurol 2011;11: by BMJ Publishing Group Ltd

19 eceived Search 28 for September 2012; received in revised in form 4 January 2013; accepted 5 February published Advanced online Search 11 February ncorrected Proof Abstract «Back Full Text PDF Images References American Journal of Obstetrics & Gynecology Login Objective Articles & Issues Collections For Authors Journal Info Subscribe Society Information More Periodicals Article in Press Search for in All Fields Go Advanced Search We sought to investigate the concurrence of posterior reversible encephalopathy syndrome (PRES) with eclampsia and to describe the obstetric, radiological, and critical care correlates. Posterior reversible encephalopathy syndrome Print or Share This Page in 46 of 47 Access this article on patients with eclampsia SciVerse ScienceDirect Study Design This was a single-center, retrospective cohort study of all patients Article with Tools eclampsia who underwent neuroimaging via magnetic Justin Brewer, resonance MD, Michelle imaging Y. (MRI) Owens, or MD, computerized Kedra Wallace, tomography PhD, Amanda (CT) A. with Reeves, or without Download MD, Rachael contrast. Images* Morris, MD, Majid Khan, MD, Babbette LaMarca, PhD, James N. Martin Jr, MD Results Received 28 September 2012; received in revised form 4 January 2013; accepted 5 February Related Articles published online 11 February Forty-six Uncorrected of 47 of Proof eclamptic patients (97.9%) revealed PRES on neuroimaging using 1 or more modalities: MRI without contrast, (0) Cited in Scopus 41 (87.2%); MRI with contrast, 27 (57.4%); CT without contrast, 16 (34%); CT with contrast, 7 (14.8%); and/or magnetic Export Citation resonance A Abstract single angiography/magnetic centre Full Text ( ) PDFresonance Images retrospective venography, References 2 (4.3%). cohort PRES study was identified of all patients within the parietal, with eclampsia occipital, frontal, * Image Usage & Resolution temporal, and basal ganglia/brainstem/cerebellum areas of the brain. Eclampsia occurred antepartum in 23 patients and who had MRI or CT imaging. Presenting symptoms: headache (87%), altered mental postpartum in 24 patients. Headache was the most common presenting symptom (87.2%) followed by altered mental status (51.1%), status Objective visual (51%), disturbances visual (34%), disturbances and nausea/vomiting (34%), (19.1%). nausea Severe and systolic vomiting hypertension (19%) was and present severe in 22 patients (47%). systolic We sought hypertension to investigate the concurrence (47%) h or of without posterior contrast. reversible encephalopathy syndrome (PRES) with eclampsia and to describe the obstetric, radiological, and critical care correlates. Results Conclusion Study Design Forty-six of 47 of eclamptic patients (97.9%) revealed PRES on neuroimaging using 1 or more modalities: MRI without contrast, 41 (87.2%); MRI with contrast, 27 (57.4%); CT without contrast, 16 (34%); CT with contrast, 7 (14.8%); and/or magnetic resonance angiography/magnetic resonance venography, 2 (4.3%). PRES was identified within the parietal, occipital, frontal, The temporal, common and basal finding ganglia/brainstem/cerebellum of PRES in areas patients of the brain. with Eclampsia eclampsia occurred antepartum suggests in 23 patients that and PRES is a core component of the pathogenesis of postpartum in 24 patients. Headache was the most common presenting symptom (87.2%) followed by altered mental status eclampsia. (51.1%), This was visual Therapy disturbances a single-center, (34%), targeted and nausea/vomiting at prevention (19.1%). retrospective Severe or systolic reversal hypertension cohort of PRES was present study pathogenesis in 22 of patients all patients may with prevent eclampsia or facilitate who underwent recovery from neuroimaging eclampsia. via (47%). magnetic resonance imaging (MRI) or computerized tomography (CT) with or without contrast. Key words: cerebral imaging, eclampsia, posterior reversible encephalopathy syndrome Conclusion To Results access this article, please choose from the options below The common finding of PRES in patients with eclampsia suggests that PRES is a core component of the pathogenesis of eclampsia. Therapy targeted at prevention or reversal of PRES pathogenesis may prevent or facilitate recovery from eclampsia. Key words: cerebral imaging, eclampsia, posterior reversible encephalopathy syndrome Abstract Add to My Reading List RSS Feeds Register

20 Why spinal anaesthesia? Better cardiovascular stability with less risk of hypertension than GA Awake patient allows better assessment of neurological status

21 ANAESTHESIA AND PRE-ECLAMPSIA CARDIOVASCULAR STABILITY

22 Changes in mean blood pressure (BP) after spinal anesthesia in preeclamptic and healthy parturients. Aya A G M et al. Anesth Analg 2003;97:

23 Hemodynamic Changes Associated with Spinal Anesthesia for Cesarean Delivery in Severe Preeclampsia Fig. 1. (A) Cardiac output measurements for each patient at each time interval. Baseline = baseline measurements averaged after calibration of cardiac output monitor; sitting = time from sitting up for spinal anesthesia until induction of spinal anesthesia; spinal = time from induction of spinal anesthesia until patient supine; supine = time from adoption of supine position until left lateral tilt; L tilt = left lateral tilt (from tilt until skin incision); skin = time from skin incision until 30 s before uterine incision; uterine = 30-s time period before uterine incision; postdelivery = 30-s period from delivery until administration of oxytocin; oxytocin peak = time from administration of oxytocin until peak effect on cardiac output; end surg = 30-s time period before skin closure (end of surgery); recovery = 5-min time period before request for analgesia. (B) Percentage cardiac output (CO) change from baseline for individual patients, at defined time intervals, as ina. Reference lines have been drawn at + and -20%. Dyer, Robert A.; Piercy, Jenna L.; Reed, Anthony R.; Lombard, Carl J.; Schoeman, Leann K.; James, Michael F. Anesthesiology. 108(5): , May Copyright 2013 Anesthesiology. Published by Lippincott Williams & Wilkins. 23

24 Changes in the mean systolic arterial blood pressure (SAP) and diastolic arterial blood pressure (DAP) in the epidural group (n = 47) and the spinal group (n = 53) during the first 30 min of regional anesthesia. Visalyaputra S et al. Anesth Analg 2005;101:

25 Mean arterial pressure (MAP) in the study (preeclampsia N=8) and control groups (N=6) at baseline (Base); after the administration of labetalol and before induction in the study group (Labet); before induction in the control group (Preind); and 1 6 min after intubation. Labetolol, Thio, Sux Ramanathan J et al. Anesth Analg 1999;88:

26 Prospective, Randomized Trial Comparing General (N=35) with Spinal Anesthesia (N=35) for Cesarean Delivery in Preeclamptic Patients with a Nonreassuring Fetal Heart Trace Fig. 5. Changes in heart rate and mean arterial pressure in the general anesthesia (GA) and spinal anesthesia (SP) groups (mean ± SD). *Significant differences between groups; P < Time points refer to minutes after induction of anesthesia. End = immediate postsurgical measurement; PreAn = preanesthetic measurement. Thiopentone, Mg, Sux Dyer, Robert A.; Els, Ilse; Farbas, Josef; Torr, Gregory J.; Schoeman, Leann K.; James, Michael F. Anesthesiology. 99(3): , September Copyright 2013 Anesthesiology. Published by Lippincott Williams & Wilkins. 26

27 Fig. 2 A dose response study of remifentanil for attenuation of the hypertensive response to laryngoscopy and tracheal intubation in severely preeclamptic women undergoing caesarean delivery under general anaesthesia Yoo et al International Journal of Obstetric Anesthesia (2013) 22, 10 18

28 Risks of spinal anaesthesia? Thrombocytopenia. Risk of spinal haematoma? Adverse effect on cerebral circulation? Risk of intraoperative eclampsia? Risk of tonsillar herniation in presence of possible cerebral oedema?

29 In pre-eclampsia, a decreasing platelet count is accompanied by other coagulation abnormalities and this is assumed to be the case once the platelets drop to <100x10 9. If platelets are below this value, a coagulation screen should be performed if this is normal, it would be reasonable to perform a regional block down to a level of 75x10 9 depending on the rate of decrease of platelet numbers.

30 ANAESTHESIA AND PRE-ECLAMPSIA CEREBRAL BLOOD FLOW

31 The Effects of Spinal Anesthesia on Cerebral Blood Flow in the Very Elderly Minville et al. Anesth Analg 2009; 108:

32 Mean middle cerebral artery flow velocity (Vm) in the study (preeclampsia) and control groups at baseline (Base); after the administration of labetalol and before induction in the study group (Labet); before induction in the control group (Preind); and post intubation. Ramanathan J et al. Anesth Analg 1999;88:

33 Drummond J, Patel P. Chapter 19. Miller s Anesthesia 5 th Edition 2000

34 Neuroanaesthesia Spinal Anaesthesia Moderate reduction in MAP CBF stable Autoregulation preserved CMRO 2 unaffected General Anaesthesia May reduce MAP May reduce CBF May preserve autoregulation Reduce CMRO 2

35 Neuroanaesthesia Spinal Anaesthesia Moderate reduction in MAP CBF stable Autoregulation preserved CMRO 2 unaffected General Anaesthesia May reduce MAP May reduce CBF May preserve autoregulation Reduce CMRO 2 But not with thiopentone, suxamethonium, isoflurane, nitrous oxide

36 ANAESTHESIA AND PRE-ECLAMPSIA TONSILLAR HERNIATION

37 Cerebral herniation occurs in 5% of ABM and cause of 30% of mortality LP temporarily associated with herniation Herniation can occur despite normal CT scan Clinical signs are best predictor of impending herniation: GCS <12, brainstem signs, and very recent seizure

38 Risks of GA Risk of difficult intubation? Hypertension at intubation, skin incision and extubation? Assessing neurological status postoperatively? Other?

39 Stroke-free survival rate by different modes of anaesthesia as estimated by the Kaplan Meier method in the preeclamptic women undergoing CS. General anaesthesia vs epidural anaesthesia, P=0.008; general anaesthesia vs spinal anaesthesia, P<0.001 by the log-rank test.

40 ? WHAT CHOICE OF ANAESTHETIC

41 Complicated Severe Pre-eclampsia General or regional anaesthesia for caesarean section

42 Anaesthetic Chart

43 Proposed Neurovascular Cascade for Neuronal Injury during PRES MAP Treatment is to MAP CPP CMRO 2 >> CBF Ischaemia O vgn >> O cyx ICP Oedema Ischaemia Early Timeline Late CBF CVR Increased CBF CBV With thanks to Dr Derek Duane Autoregulatory threshold for hyperperfusion