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MIDDLE EAST JOURNAL OF ANESTHESIOLOGY
Department of Anesthesiology
American University of Beirut Medical Center
P.O. Box 11-0236. Beirut 1107-2020, Lebanon
Editorial Executive Board
Consultant Editors
Editor-In-Chief:
Ghassan Kanazi
Assem Abdel-Razik
(Egypt)
Executive Editors
Fouad Salim Haddad
[email protected]
Maurice A. Baroody
Bassam Barzangi
(Iraq)
Izdiyad Bedran
(Jordan)
Chakib Ayoub
Marie Aouad
Sahar Siddik-Sayyid
Dhafir Al-Khudhairi
(Saudi Arabia)
Mohammad Seraj
(Saudi Arabia)
Managing Editor
Mohamad El-Khatib
[email protected]
Abdul-Hamid Samarkandi
(Saudi Arabia)
Mohamad Takrouri
(Saudi Arabia)
Founding Editor
Bernard Brandstater
Bourhan E. Abed
(Syria)
Mohamed Salah Ben Ammar
(Tunis)
Ramiz M. Salem
(USA)
Elizabeth A.M. Frost
(USA)
Halim Habr
(USA)
Editors
Emeritus Editor-In-Chief Anis Baraka
Honorary Editors
Nicholas Greene
Musa Muallem
Webmaster
Rabi Moukalled
Secretary
Alice Demirdjian
[email protected]
The Middle East Journal of Anesthesiology is a
publication of the Department of Anesthesiology of
the American University of Beirut, founded in 1966 by
Dr. Bernard Brandstater who coined its famous motto:
“For some must watch, while some must sleep”
(Hamlet-Act. III, Sc. ii).
and gave it the symbol of the poppy flower (Papaver
somniferum), it being the first cultivated flower in
the Middle East which has given unique service to
the suffering humanity for thousands of years. The
Journal’s cover design depicts The Lebanese Cedar
Tree, with’s Lebanon unique geographical location
between East and West. Graphic designer Rabi
Moukalled
The Journal is published three times a year (February,
June and October) The volume consists of a two year
indexed six issues. The Journal has also an electronic
issue accessed at www.aub.edu.lb/meja
The Journal is indexed in the Index Medicus and
MEDLARS SYSTEM.
E-mail: [email protected]
Fax: +961 - (0)1-754249
All accepted articles will be subject to a US $ 100.00
(net) fee that should be paid prior to publishing the
accepted manuscript
Please send dues via:
WESTERN UNION
To Mrs. Alice Artin Demirjian
Secretary, Middle East Journal of Anesthesiology
OR TO
Credit Libanaise SAL
AG: Gefinor.Ras.Beyrouth
Swift: CLIBLBBX
Name of Beneficent
Middle East Journal of Anesthesiology
Acc. No. 017.001.190 0005320 00 2
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- Name and Code of article
- Transfer No. and date (WESTERN UNION)
- Receipt of transfer to (Credit Libanaise SAL)
Personal checks, credit cards and cash, are not
acceptable
“For some must watch, while some must sleep”
(Hamlet-Act. III, Sc. ii)
SYMPOSIUM ANNOUNCEMENT
29th Annual Symposium
Clinical Update in Anesthesiology, Surgery and Perioperative Medicine
January 16-21, 2011
St. Martin, French West Indies
BROCHURE, ABSTRACT, POSTER AND PAPERS INFORMATION:
(Deadline – October 25, 2010)
Helen Philips
Mount Sinai Medical Center
1 Gustave L. Levy Place
Box 1010, Dept. of Anesthesiology
New York, NY 10029-6574
Phone: 212 – 241 – 7467
Fax: 212 – 426 – 2009
Email: [email protected]
134
Kingdom of Saudi Arabia, Riyadh
King Abdulaziz Medical City
National Guard Health Affairs,
DEPARTMENT OF INTENSIVE CARE
King Abdul-Aziz Medical City - Riyadh is considered a flagship facility in the Middle East,
JCI accredited hospital, providing primary and tertiary healthcare services to the National
Guard forces, their dependents and civilian employees. As a Center Of Excellence, it
performs all major surgeries-including cardiac surgery, liver transplants and conjoined
twin separation.
We are currently inviting applications for the following posts:
Assistant Consultants ICU – Riyadh
Our requirements in terms of academics and experience are
as follows:
• Arab Board in Intensive Care coupled with 3 years critical
care / trauma training within a recognized Gulf Region or
Western healthcare facility.
The Adult Intensive Care Department in KAMC-Riyadh is a Center of Excellence in the
Middle East, run at North American standards, staffed with North American Critical
Care Board Certified consultants. It has very strong clinical research in affiliation with
international centers to conduct randomized controlled trials. The Department has
an outstanding achievement profile leading to an excellent international professional
reputation. Working at KAMC ICU provides a great opportunity for professional growth.
We in turn can offer a generous tax-free salary, 50 days holidays, and educational support
for your children, free flights at start and end of your contract, and of course high quality
accommodation.
The consultant will do 18 shifts per month with flexible scheduling.
If you are interested please e-mail your CV indicating which journal advert you are
responding to, along with copies of your certificates to the recruitment office of
the NGHA for the attention of Mr. John Quinn at Email: [email protected], or
fax# +966-1-2520056.
For more information please visit our website at:
http://www.ngha.med.sa/English/MedicalCities/AlRiyadh/Centers/Pages/
ICUextended.aspx
Middle East Journal of Anesthesiology
Vol. 20, No. 4, February 2010
CONTENTS
editorials
Top 10 Cited Paper 2006-2008: International Journal Of Obstetric Anesthesia
.............................................................................................................................. Anis Baraka
481
review articles
Update On Anesthesia Considerations For Electroconvulsive Therapy
...............................................................Cody Mayo, Alan Kaye, Erich Conrad, Amir Baluch
and Elizabeth Frost
Management Of Obstetric Hemorrhage
................................................................ A. Rudra, S. Chatterjee, S. Sengupta, R. Wankhede,
B. Nandi, G. Maitra and J. Mitra
493
499
scientific articles
Comparing Two Methods Of LMA Insertion: Classic Versus Simplified Airway
........................................................................ M. Haghighi, A. Mohammadzadeh, B. Naderi,
A. Seddighinejad and H. Movahedi
Pretreatment With Remifentanil Is Associated With Less Succinylcholine-Induced
Fasciculation
....................................................................................Karim Nasseri, Mehdi Tayebi Arastheh
and Shoaleh Shami
Epidural Analgesia During Labor – 0.5% Lidocaine With Fentanyl Versus 0.08% Ropivacaine
With Fentanyl
............................................................... Wesam Mousa, R. Al-Metwalli and Maanal Mostafa
Occupational Fatigue Of The Anesthesiologist: Illusion Or Real?
...................................................................... Afaf Mansour, Waleed Riad and Ashraf Moussa
The Effect Of Addition Of Low Dose Atracurium To Local Anesthetic In Retrobulbar Block
For Cataract Surgery
............................................. Mohamad Hossein Eghbal, Hesam Tabei, Shoja Alhagh Taregh
and Mohammad Reza Razeghinejad
Labor Analgesia In Preeclampsia: Remifentanil Patient Controlled Intravenous Analgesia
Versus Epidural Analgesia
................................................................................................ Hala El-Kerdawy, Adel Farouk
Spinal Anesthesia For Transurethral Resection: Levobupivacaine With Or Without Fentanyl
................................................... Ozgun Cuvas, Hulya Basar, aydan Yeygel, Esra Turkyilmaz
and Mehmet M. Sunay
Association Between Factors Predicting And Assessing The Airway And Use Of Intubating
Laryngeal Mask Airway
............................................... Chryssoula Staikou, Athanassia Tsaroucha, Anteia Paraskeva
and Argyro Fassoulaki
Preoperative Oral Dextromethorphan Does Not Reduce Pain Or Morphine Consumption
After Open Cholesyctectomy
................................................................................... Hossein Mahmoodzadeh, Ali Movafegh
and Nooshin Moosavi Beigi
479
509
515
521
529
535
539
547
553
559
M.E.J. ANESTH 20 (4), 2010
Dexamethasone With Either Granisetron Or Ondansetron For Postoperative Nausea And
Vomiting In Laparoscopic Surgery
........................................................... Aliya Dabbous, Samar Jabbour-Khoury, Viviane Nasr,
Adib Moussa,, Reine Zbeidy, Nabil Khouzam, Mohamad El-Khatib,
Frederic Gerges and Anis Baraka
case reports
Persistent Postoperative Hypertension Following Posterior Fossa Surgery
- A Case Report ................................................................Zulfiqar Ali, Hemanshu Prabhakar and Girija Rath
Granular Cell Myoblastoma Of Tongue: A Rare Case Of Unanticipated Difficult Intubation
................................................... Lenin Babu Elakkumanan, Anjolie Chhabra, Somnath Bose
and Kiran Sharma
Use Of Remifentanil In A Patient With Eisenmenger Syndrome Requiring Urgent Cesarean
Section
..................................................................Ates Duman, Gamze Sarkilar, Mürüvvet Dayioglu,
Mine Özden and Niyazi Görmüs
Combined Spinal Epidural Anesthesia For Cesarean Section In A Pregnant Patient With Rare
Intracranial Neoplasm
................................................................... Anjolie Chhabra, Neeraj Kumar, Ashwini Kumar,
Neena Singh and B.S. Sharma
The Use Of Remifentanil In General Anesthesia For Cesarean Section In a Parturient With
Severe Mitral Stenosis And Pulmonary Edema
.......................................................................................Shahram Amini and Ninoo Yaghmaei
Intravenous Regional Analgesia In A Patient With Glanzmann Thrombastenia
.............................................................. Sitki Goksu, Rauf Gul, Onder Ozen, Mehmet Yilmaz,
Orhan Buyukbebeci and Unsal Onerl
Anesthetic Management Of A 29 Week Pregnant Patient Undergoing Craniotomy For
Pituitary Macroadenoma
.........................................................Oya Yalcin Cok, Sule Akin, Anis Aribogan, Meltem Acil,
Bulent Erdogan and Tayfun Bagis
Iatrogenic Postoperative Seizure After Mastoid Surgery
- A Case Report ............................................................. Erkalp Kerem, Basaranoglu Gokcen, Kokten Numan,
Ilhan Emre, Egeli Unal, Ozdemir Haluk and Saidoglu Leyla
Psycho-Mimetic Manifestations Following Use Of Propofol In Day Case Surgery
- Two Case Reports ................................................................................... Pragnyadipta Mishra, Pradipta Bhakta
and Qutaiba Tawfic
Use Of Dexmedetomidine As The Main Anesthetic Agent In patients With LarungoTracheomalacia
- Three Case Reports ..................................................Khalid Al-Zaben, Ibraheem Qudaisat, Bassam Al-Barazangi
and Izdiad Badran
Primary Malignant Melanoma Of The Trachea
..... Mohamad Nattout, Nabil Fuleihan, Omar Sabra, Ibrahim Aburizk, Abdul-Latif Hamdan
Tracheal Schwannoma: A Misleading Entity
....................................................... Abdul Latif Hamdan, Roger V. Moukarbel, Ayman Tawil,
Mohamad El-Khatib, Ussama Hadi
480
565
571
573
577
581
585
589
593
597
599
603
607
611
Editorial
TOP 10 CITED PAPER 2006-2008
International Journal of
Obstetric Anesthesia
On behalf of the Editorial Board of the Middle East Journal of Anesthesiology (MEJA),
I would like to congratulate Drs. A. Zeidan, O. Farhat, H. Maaliki, and Dr. A. Baraka from the
Departments of Anesthesiology and Neurosurgery, Sahel General Hospital, and the Department
of Anesthesiology of the American University of Beirut, Beirut, Lebanon for ranking their paper
entitled “Does postdural puncture headache left untreated lead to subdural hematoma?”* which was
published in the “International Journal of Obstetric Anesthesia”, Volume 15, Issue 1, 2006, pages
50-58” among the top 10 cited reports between 2006 and 2008. Also, I sincerely thank the Editorial
Board of the International Journal of Obstetric Anesthesia for awarding certificates of recognition
to the authors of the paper, and for permitting the MEJA to republish the report.
The paper reports a 39-year-old pregnant woman who developed cranial subdural hematoma
following spinal anesthesia for Cesarean section using a 26­gauge spinal needle with an atraumatic
bevel. In addition, the paper reviews the literature on 46 patients who developed a postdural
puncture headache complicated by subdural hematoma following spinal or epidural anesthesia.
The report concluded that postdural puncture headache left untreated may be complicated by
the development of subdural hematoma. Also, patients developing a postdural puncture headache
unrelieved by conservative measures, as well as the change from postdural to non-postdural
headache, require careful follow-up for early recognition and management of possible subdural
hematoma.
Anis Baraka, MD,FRCA(Hon)
Emeritus Editor-in-Chief MEJA
Department of Anesthesiology
American University of Beirut
*
Reprinted with permission from International Journal of Obstetric Anesthesia.
481
M.E.J. ANESTH 20 (4), 2010
482
Anis Baraka
TOP 10 CITED PAPER 2006-2008 International Journal of Obstetric anesthesia
483
International Journal of Obstetric Anesthesia (2006) 15, 50–58
� 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijoa.2005.07.001
CASE REPORT AND REVIEW
Does postdural puncture headache left untreated lead to
subdural hematoma? Case report and review of the literature
A. Zeidan, O. Farhat, H. Maaliki, A. Baraka
Departments of Anesthesiology and Neurosurgery, Sahel General Hospital, and Department of Anesthesiology,
American University of Beirut Medical Center, Beirut, Lebanon
SUMMARY. The patient was a 39-year-old pregnant woman who was scheduled for cesarean section. Spinal anesthesia was induced using a 26-gauge needle with an atraumatic bevel. Postoperatively, the patient developed cranial
subdural hematoma manifesting as severe non-postural headache, associated with right eye tearing, fifth cranial nerve
palsy and left hemiparesis. The diagnosis was confirmed by computed tomography scan. The patient was managed by
careful neurological follow-up associated with conservative treatment and recovered fully after 12 weeks. Our report
reviews the literature on 46 patients who developed a postdural puncture headache complicated by subdural hematoma following spinal or epidural anesthesia. It is possible that postdural puncture headache left untreated may be
complicated by the development of subdural hematoma. Patients developing a postdural puncture headache unrelieved by conservative measures, as well as the change from postural to non-postural, require careful follow-up
for early diagnosis and management of possible subdural hematoma.
� 2005 Elsevier Ltd. All rights reserved.
Keywords: Subdural hematoma; Dural puncture; Spinal, epidural; Anesthesia; Parturient
INTRODUCTION
general anesthesia) was scheduled for elective cesarean
section under spinal anesthesia. She had no history of
trauma, headache or coagulation abnormalities. Preoperative laboratory blood tests, including platelet count,
prothrombin time and activated prothromboplastin time,
were normal. The patient received no anticoagulants.
Before spinal anesthesia, lactated Ringer’s solution
1500 mL was administered. With the patient in the sitting position, spinal anesthesia was performed at the
L3-4 interspace using a 26-gauge needle with an atraumatic bevel (Atraucan�, B-Braun, Germany). Subarachnoid puncture was successful on the first attempt and
0.5% plain bupivacaine 12 mg was administered, which
led to a sensory block up to T6. The intraoperative
course was uneventful except for a decrease in systolic
blood pressure from 143 to 110 mmHg, which was treated with i.v. ephedrine 10 mg; the systolic blood pressure remained >110 mmHg throughout the remainder
of the operative period.
Three days postoperatively, the patient experienced a
mild occipital headache, which was assumed to be a
PDPH because it was more intense in the sitting position. Over the next two days, the headache improved
rapidly following hydration and bed rest. The patient
was discharged on the fifth postoperative day. On postoperative day six, the patient suffered from headache
Spinal anesthesia can be followed by postdural puncture
headache (PDPH), and even cerebral hemorrhage.1–4
This report describes the occurrence of cerebral subdural
hemorrhage in a 39-year-old patient undergoing cesarean section under spinal anesthesia, and reviews the literature of 46 patients who developed subdural
hematoma following spinal and epidural anesthesia.
CASE REPORT
A 39-year-old woman, gravida 5 para 4 (three normal
deliveries and one uneventful cesarean section under
Accepted June 2005
A. Zeidan MD, Staff anesthesiologist, Sahel General Hospital,
O. Farhat MD, Staff neurosurgiologist, Sahel General Hospital,
H. Maaliki MD, Staff anesthesiologist, Sahel General Hospital,
A. Baraka MD, FRCA, Professor and Chairman, Department of
Anesthesiology, American University of Beirut Medical Center;
Beirut, Lebanon.
Correspondence to: Anis Baraka MD FRCA, Professor & Chairman,
Department of Anesthesiology, American University of Beirut Medical
Center, Beirut, Lebanon.
E-mail: [email protected]
50
M.E.J. ANESTH 20 (4), 2010
484
Anis Baraka
Postdural puncture subdural hematoma 51
Fig. 1 Cranial CT scan 30 days after spinal anesthesia showing rightsided subdural hematoma.
associated with right eye tearing and fifth nerve palsy.
On the 15th day, the patient developed diplopia and severe right orbital pain. On the 30th day she came to
the hospital when she developed a mild left hemibody
weakness. Neurological examination demonstrated mild
upper and lower left limb weakness, non-postural severe
headache and right eye pain associated with the disappearance of the diplopia and fifth nerve palsy. A computed tomography (CT) scan on the day of admission
to the hospital revealed a 1.8-cm thick chronic cerebral
subdural hematoma (>2 weeks old) overlying the right
fronto-parietal lobe causing compression of the underlying brain and obliteration of the sulci (Fig. 1).
The patient was admitted to the department of neurosurgery and surgical versus conservative management
was discussed with the patient. She refused the surgical
option, and accordingly close regular follow-up of neurological symptoms (lower left limb weakness, headache, and right eye pain), was chosen. The patient
showed a marked clinical improvement. Eleven days
later, a follow-up CT scan showed good resolution of
the hematoma (Fig. 2). Cerebral angiography through
the right femoral artery did not reveal an associated
aneurysm or arteriovenous malformation. The patient
was discharged on the 12th day and recovered fully 12
weeks after dural puncture.
DISCUSSION
Postdural puncture headache is the most frequent major
complication after spinal anesthesia. In the majority of
cases the symptoms subside within a few days when
treated with analgesics and bed rest. Intracranial sub-
Fig. 2 Cranial CT scan 41 days after spinal anesthesia showing
decreasing size of subdural hematoma.
dural hematoma is rare, but could be a lethal complication that can occur after epidural or spinal anesthesia, as
well as following myelography.1–3 The same mechanism
has been postulated for both PDPH and subdural hematoma.4 The leakage of cerebrospinal fluid (CSF) from
the dural hole causes reduction in CSF volume, which
lowers first the intraspinal pressure, and more dangerously, the intracranial pressure. This alteration in cerebrospinal dynamics results in a caudally-directed
movement of the spinal cord and brain, which in turn
stretches the pain-sensitive structures, dura, cranial
nerves and bridging veins.
Cerebral veins empty into dural sinuses that are
adherent to the inner table of the skull. These veins form
short trunks passing directly from the brain to the dura
mater. Between these two points, bridging veins take a
straight course with no tortuosity to allow for any possible displacement of the brain. The thinnest parts of the
bridging veins’ walls are in the subdural space and the
thickest are in the subarachnoid portion. This implies
that bridging veins are more fragile in the subdural portion than in the subarachnoid space.5 Anteroposterior
acceleration or deceleration and/or traction exerted on
the bridging veins, may cause a rupture at their weakest
point in the subdural space. Cerebral atrophy and low
CSF pressure (low CSF volume) will accentuate this
mechanism.
Following spinal anesthesia, a dural fistula can remain open for many weeks, and the volume of CSF lost
may be over 200 mL per day, which can exceed normal
CSF production.6 In these circumstances, the rupture of
TOP 10 CITED PAPER 2006-2008 International Journal of Obstetric anesthesia
52 International Journal of Obstetric Anesthesia
a subdural vein is certainly conceivable. Research on
weakness of the dura and abnormalities of connective
tissue, particularly abnormality of fibrillin and elastin,
is gaining momentum as one of the etiological factors
for delayed healing of a dural tear.7 The incidence of
PDPH is reduced following dural puncture using a small
needle (26-gauge spinal). In contrast, PDPH occurs in up
to 80% of parturients who experience inadvertent dural
puncture with a large bore needle.8 Nevertheless, the
use of a 26-gauge spinal needle in our patient was complicated by PDPH and subsequent subdural hematoma.
Thus, once PDPH develops, it should be treated as such
irrespective of needle size.
The concurrence of neurological symptoms with
PDPH does not mean certainty of the formation of intracranial hemorrhage. Continuous loss of CSF leads to
intracranial hypotension. Intracranial hypotension is an
increasingly recognized neurologic syndrome characterized by postural headache that occurs or worsens shortly
after assuming the upright position and disappears or improves after resuming the recumbent position. Additional symptoms may include neck pain, nausea,
emesis, interscapular pain, photophobia, diplopia, dizziness, change in hearing, visual blurring, cranial nerve
palsies and radicular upper extremity symptoms.7 The
occurrence of subdural hematoma increases the intracranial pressure which can be associated with non-postural
headache, convulsions, hemiplegia, disorientation and
more serious neurological symptoms. Differentiation between the neurological symptoms of intracranial hypotension and subdural hematoma can be difficult. A
change in headache characteristics from postural to
non-postural should be a warning sign. CT scan of the
skull usually gives the correct diagnosis. However, intracranial hematoma 7–21 days old may have the same
radiological density as the brain, so magnetic resonance
imaging (MRI) or CT scan with contrast may be more
reliable.1
The delayed diagnosis, in many cases, implies that
subdural hematoma wasn’t taken into consideration as
a complication of spinal anesthesia. In our case, there
was a major delay between the onset of symptoms and
diagnosis. The patient considered the prolonged postoperative headache as a benign complication of spinal
anesthesia and she didn’t consult us until the appearance
of the hemiparesis. Our patient developed an intracranial
hypotension syndrome (eye tearing and fifth nerve
palsy) on the sixth postoperative day. The time of formation of the subdural hematoma, although unknown, was
most probably on the second or third week after dural
puncture. We concur that intracranial hypotension syndrome might be a prodrome of subdural hematoma after
dural puncture.
Cerebral atrophy, dehydration, anticoagulant, arteriovenous malformations and excessive CSF leakage (mul-
485
tiple dural puncture, large dural hole) are thought to be
contributing factors in the pathogenesis of subdural
hematoma. In our patient, the angiography of cerebral
vessels revealed no associated aneurysm or arteriovenous abnormalities. Furthermore, our patient received
no anticoagulants.
Review of the literature disclosed 25 cases of subdural hematoma following spinal anesthesia (Table
1).1,4,9–31 Among these 25 cases, the age of patients ranged between 20 to 88 years. The earliest diagnosis of
subdural hematoma was six hours after spinal anesthesia
and the latest was 29 weeks. Subdural hematoma after
spinal anesthesia occurred most frequently on the left
side of the brain (13 cases were left-sided, six rightsided, four bilateral and two were intracerebral). The
largest spinal needle used was 19 gauge and the narrowest one was a 27-gauge Whitacre needle. Three cases of
multiple puncture were noted. Surgery was performed in
20 of these 25 patients, and was followed by postoperative mortality of four patients. Mortality was not related
to the age of the patient or the size of the spinal needle
used.
Also, review of the literature disclosed 21 cases of
subdural hematoma after unintentional dural puncture
following epidural anesthesia (Table 2),2,10,12,32–49 the
most recent being reported by Kayacan et al.49 Nineteen
of these 21 cases were obstetric patients. The earliest
diagnosis of subdural hematoma was two days after epidural anesthesia and the latest was 20 weeks. Almost
half of the patients developed bilateral subdural hematoma (11 cases were bilateral, six left-sided and four
right-sided). Surgery was performed in 15 of these 21
patients and two died. In both groups, (spinal and epidural), the size of the hematoma, severity of symptoms, delayed diagnosis and/or interventions did not apparently
affect mortality rate.
It is possible that parturients are at high risk of developing post dural puncture headache.50–53 The increased
incidence of post-dural puncture headache in parturients
may be attributed to numerous factors including peripartum dehydration, which could reduce the production of
CSF, postpartum diuresis, abrupt release of intra-abdominal pressure and venacaval compression at delivery,
which reduces epidural venous pressures. Maternal bearing-down efforts that could increase CSF leakage
through the dural hole could also be a factor, as well
as early ambulation, anxiety about delivery and hormonally-induced ligamentous changes.54 In addition, it is
widely believed that pregnancy increases the risk of
stroke; reports showed that the incidence of intracerebral
hemorrhage is increased in the six weeks after delivery.55 Furthermore, there was an association between
post-partum hemorrhagic stroke and cesarean delivery.56,57 It seems that venous congestion during pregnancy can make bridging veins more susceptible to
M.E.J. ANESTH 20 (4), 2010
67/M
33/F
70/M
63/M
50/M
67/M
67/M
68/M
63/F
68/M
71/M
71/M
31/F
42/M
20/M
Newrick12
Miyazaki13
Rudehill14
Jonsson15
Giamundo16
Blake17
Beal18
Macon4
Ortiz19
Van de Kelft20
Baldwin21
Bj�rnhall1
Akpek22
Cantais23
Acharya24
Eggert
29/F
27/F
Mantia11
25
37/M
Pavlin10
Welch
69/M
Age/Sex
9
References
1 day, CT scan: left SDH
1 week, MRI: right SDH
10 days, CT scan: left SDH
14 days; MRI: Bilat. SDH,
basal ganglia and
thalamus hemorrhage
5 days, CT scan: right SDH
29 weeks, CT scan: Bilat. SDH
30 days; CT scan: right SDH
11 days, CT scan: left SDH
2 weeks; CT scan: left SDH
6 days, CT scan: left SDH
3 weeks, CT scan: left SDH
30 days, CT scan: left SDH
On 12th day scan was normal,
29 days by angiography: left SDH
21 days, CT scan: right SDH
26 days, CT scan: left SDH
10 days, CT scan: left SDH
5 days, CT scan: right SDH
6 days, angiography: right SDH
48 days, clinical
diagnosis: Bilat. SDH
Diagnosis time/PDP/ Methods/
Localization of hematoma
Pregnancy?
None
Anticoagulants
Pregnancy?
None
None
Previous dural
puncture
with 22-G
one month ago
Anticoagulants
Multiple puncture
None
Multiple puncture
attempts
None
None
None
Pregnancy?
None
Pregnancy?
Multiple puncture
attempts with 22-G
None
Predisposing
factors
Table 1. Reported cases of subdural hematoma after spinal anesthesia
Removal of
retained placenta
Appendectomy
Achilles tendon repair
Cesarean section
Cystoscopy
TURP
Urethral dilatation
Vaginal hysterectomy
Inguinal
herniorraphy
TURP
TURP
Inguinal herniorraphy
Inguinal herniorraphy
Inguinal herniorraphy
Cesarean section
Inguinal herniorraphy
Normal delivery
Perirectal abscess
Retropubic prostatectomy
Procedure
24-G Sprotte
23-G Quincke
27-G Whitacre
22-G
22-G Quincke
22-G
22-G
22-G
25-G Quincke
22-G Quincke
25-G
?
24-G
22-G
21-G
22-G
26-G
25-G
22-G
Needle size for
spinal anesthesia
Fronto-occipital NPH,
photophobia and vomiting
Severe NPH, vomiting
Severe frontal NPH,
vomiting and coma
Absent mindedness;
drowsiness and
right hemiparesis
NPH and vomiting
Headache, vomiting and
personality changes
NPH, confusion and dizziness
Severe headache, left
hemiparesis and photophobia
NPH, left orbit pain and left
hemicranial pain
Coma
Right frontal pain, confusion
and clumsy gait
Severe headache, memory
deficit and confusion
Right orbit pain, dysphasia
and right arm weakness
Severe headache, vomiting,
confusion and drowsiness
Severe headache, vomiting
and confusion
Disorientation and general
hyperreflexia
Left hemiplegia and aphasia
Coma
Frontal headache, diplopia
and confusion
Warning sign
(continued on next page)
Medical/recovered
Medical/recovered
Surgical/death
Surgical/recovered
Surgical/recovered
Surgical/recovered
Surgical/recovered
Surgical/?
Surgical/recovered
Surgical/death
Surgical/recovered
Surgical/recovered
Surgical/recovered
Surgical/recovered
Surgical/recovered
Surgical/death
Medical/neurological
deficit?
Surgical/neurological
deficit
Surgical/death
Treatment/Outcome
486
Postdural puncture subdural hematoma 53
Anis Baraka
TOP 10 CITED PAPER 2006-2008 International Journal of Obstetric anesthesia
Slowinski
SDH: subdural hematoma; NPH: non-postural headache; PDP: post-dural puncture.
Surgical/recovered
Medical/recovered
NPH and left hemiparesis
Confusion and drowsiness
25-G Quincke
26-G Atraucan
Cesarean section
Right femoral herniorraphy
Brain atrophy
Pregnancy?
Our case
3 days, CT scan: left SDH
88/F
39/F
Tan31
30 days, CT scan: left SDH
Surgical/recovered
Severe headache, six nerve
palsy and diplopia
19-G
Tubal ligation
None
25 days, CT scan: left SDH
41/F
Alilou30
Surgical/recovered
NPH,diplopia and bilateral
abducent nerve palsy
25-G Quincke
Saphenous vein ligation
None
6 weeks, MRI: bilat. SDH
38/F
Surgical/recovered
Severe frontal NPH
22-G Quincke
Inguinal herniorrhaphy
None
38/M
29
Kelsaka28
40 days, CT scan: left SDH
Surgical/recovered
NPH and confusion
27-G Whitacre
Prostate surgery
Cerebral aneurysms
59/M
Wells27
2 days, CT scan:
left intracranial hemorrhage
Surgical/neurological
deficit?
Severe headache,
vomiting and left hemiparesis
24-G
Cesarean section
Pregnancy?
28/F
Sharma26
6 h, CT scan: right
intracerebral hematoma
Age/Sex
References
Diagnosis time/PDP/Methods/
Localization of hematoma
Predisposing
factors
Procedure
Needle size for
spinal anesthesia
Warning sign
Treatment/Outcome
International Journal of Obstetric Anesthesia
Table 1. continued
54
487
rupture. Also, sudden increases in venous pressure of
these dilated veins by coughing, stressing or abdominal
compression during labor and delivery (Valsalva maneuver) can lead to an augmentation of tension, especially at
the subdural portion of bridging veins.5
The true incidence of subdural hematoma after dural
puncture is unknown. In most cases, non postural headache and vomiting are the warning signs. In addition,
changes in headache characteristics (intractable headache associated with retro-orbital and frontal pains) were
observed in most cases. Most patients with headaches
are probably treated without further investigation.
Therefore, the true incidence of subdural hematoma
after spinal anesthesia may be greater than the published
case reports suggest. Suess et al. found that headache
lasting >5 days was the chief complaint in 17 reported
cases of intracranial hemorrhage after myelography.3
The management of subdural hematoma is either conservative or surgical. Small hematomas often resolve
spontaneously. Early blood patching may decrease the
risk of subdural bleeding by preventing a fall in CSF
volume and subsequent intracranial hypotension. Reynolds and Salvin recommend that “headache after dural
puncture with a large needle should be treated promptly
with an epidural blood patch.”58 However, when epidural blood patch is performed in the presence of intracranial hemorrhage, rebound intracranial hypertension and
neurological deterioration can result.14,47
The practice of administering a prophylactic epidural
blood patch to obstetric patients after inadvertent dural
puncture with an epidural needle has been controversial.
When a large dural hole is known to exist and a functioning epidural catheter is in place, a prophylactic epidural blood patch through the catheter might be tried.
Some authors have suggested that prophylactic epidural
blood patch may reduce the incidence of subsequent
PDPH to 5%–21%.59–61 However, Scavone et al.62
showed recently that prophylactic epidural blood patch
after inadvertent dural puncture in parturients did not decrease the incidence of PDPH to the magnitude predicted; the length and severity of PDPH symptoms,
however, were decreased. Loeser et al.63 have shown
that therapeutic epidural blood patch is not as effective
when performed within the first 24–48 h after dural
puncture. Also, Safa-Tisseront et al.64 showed recently
that the percentage of failure of epidural blood patch
was significantly increased when epidural blood patch
was performed within three days after dural puncture.
Epidural blood patch essentially has two effects.
The immediate effect is simply related to volume
replacement by compression of the dura that will restore CSF pressure and relieve the headache. The
second latent effect is related to sealing of a dura
defect. The time interval between these two effects
varies considerably. Beards et al.65 demonstrated no
M.E.J. ANESTH 20 (4), 2010
488
11. Mantia A M. Clinical report of the occurrence of an intracerebral
hemorrhage following post-lumbar puncture headache.
Anesthesiology 1981; 55: 684–685.
12. Newrick P, Read D. Subdural haematoma as a complication of
spinal anaesthetic. Br Med J 1982; 285: 341–342.
13. Miyazaki S, Fukushima H, Kamata K, Ishii S. Chronic subdural
hematoma after lumbar-subarachnoid analgesia for a cesarean
section. Surg Neurol 1983; 19: 459–460.
14. Rudehill A, Gordon E, Rahn T. Subdural haematoma. A rare but
life-threatening complication after spinal anaesthesia. Acta
Anaesthesiol Scand 1983; 27: 376–377.
15. Jonsson L O, Einarsson P, Olsson G L. Subdural haematoma and
spinal anaesthesia. A case report and an incidence study.
Anaesthesia 1983; 38: 144–146.
16. Giamundo A, Benvenuti D, Lavano A, D’Andrea F. Chronic
subdural haematoma after spinal anaesthesia. Case report.
J Neurosurg Sci 1985; 29: 153–155.
17. Blake D W, Donnan G, Jensen D. Intracranial subdural haematoma
after spinal anaesthesia. Anaesth Intensive Care 1987; 15:
341–342.
18. Beal J L, Royer J M, Freysz M, Poli L, Wilkening M. Acute
intracranial subdural hematoma of arterial origin after spinal
anesthesia. Ann Fr Anesth Reanim 1989; 8: 143–145.
19. Ortiz M, Aliaga L, Baturell C, Preciado M J, Aguilar J, Vidal F.
Intracranial subdural haematoma - a rare complication after spinal
anaesthesia. Eur J Anaesthesiol 1991; 8: 245–248.
20. Van de Kelft E, De la Porte C, Meese G, Adriaensen H.
Intracranial subdural hematoma after spinal anesthesia. Acta
Anaesthesiol Belg 1991; 42: 177–180.
21. Baldwin L N, Galizia E J. Bilateral subdural haematomas: a rare
diagnostic dilemma following spinal anaesthesia. Anaesth
Intensive Care 1993; 21: 120–121.
22. Akpek E A, Karaaslan D, Erol E, Caner H, Kayhan Z. Chronic
subdural haematoma following caesarean section under
spinal anaesthesia. Anaesth Intensive Care 1999; 27:
206–208.
23. Cantais E, Behnamou D, Petit D, Palmier B. Acute subdural
hematoma following spinal anesthesia with a very small spinal
needle. Anesthesiology 2000; 93: 1354–1356.
24. Acharya R, Chhabra S S, Ratra M, Sehgal A D. Cranial subdural
haematoma after spinal anaesthesia. Br J Anaesth 2001; 86:
893–895.
25. Eggert S M, Eggers K A. Subarachnoid haemorrhage following
spinal anaesthesia in an obstetric patient. Br J Anaesth 2001; 86:
442–444.
26. Sharma K. Intracerebral hemorrhage after spinal anesthesia.
J Neurosurg Anesthesiol 2002; 14: 234–237.
27. Wells J B, Sampson I H. Subarachnoid hemorrhage presenting as
post-dural puncture headache: a case report. Mt Sinai J Med 2002;
69: 109–110.
28. Kelsaka E, Sarihasan B, Baris S, Tur A. Subdural hematoma as a
late complication of spinal anesthesia. J Neurosurg Anesthesiol
2003; 15: 47–49.
29. Slowinski J, Szydlik W, Sanetra A, Kaminska I, Mrowka R.
Bilateral chronic subdural hematomas with neurologic symptoms
complicating spinal anesthesia. Reg Anesth Pain Med 2003; 28:
347–350.
30. Alilou M, Halelfadl S, Caidi A, Kabbaj S, Ismaili H, Maazouzi W.
Cranial subdural haematoma following spinal anaesthesia. Ann Fr
Anesth Reanim 2003; 22: 560–561.
31. Tan S T, Hung C T. Acute-on-chronic subdural haematoma: a rare
complication after spinal anaesthesia. Hong Kong Med J 2003; 9:
384–386.
32. Jack T M. Post-partum intracranial subdural haematoma. A
possible complication of epidural analgesia. Anaesthesia 1979; 34:
176–180.
33. Edelman J D, Wingard D W. Subdural hematomas after lumbar
dural puncture. Anesthesiology 1980; 52: 166–167.
34. Reinhold P, Lindau B, Bohm P. Chronic subdural haematoma
following epidural anaesthesia. Anasth Intensivther Notfallmed
1980; 15: 428–431.
35. Deglaire B, Duverger P, Muckensturm B, Maissin F, Desbordes
J M. Acute intracranial subdural hematoma after accidental dural
Anis Baraka
Postdural puncture subdural hematoma 57
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
puncture in epidural anesthesia. Ann Fr Anesth Reanim 1988; 7:
156–158.
Scott D B, Hibbard B M. Serious non-fatal complications
associated with extradural block in obstetric practice. Br J Anaesth
1990; 64: 537–541.
Wyble S W, Bayhi D, Webre D, Viswanathan S. Bilateral subdural
hematomas after dural puncture: delayed diagnosis after false
negative computed tomography scan without contrast. Reg Anesth
1992; 17: 52–53.
Campbell D A, Varma T R. Chronic subdural haematoma
following epidural anaesthesia, presenting as puerperal psychosis.
Br J Obstet Gynaecol 1993; 100: 782–7844.
Thons M, Neveling D, Hatzmann W. Intracerebral subdural
hematoma after delivery with peridural catheter anesthesia. Z
Geburtshilfe Perinatol 1993; 197: 235–237.
Garcia-Sanchez M J, Prieto-Cuellar M, Sanchez-Carrion J M,
Galdo-Abadin J R, Martin-Linares J M, Horcajadas-Almansa A.
Chronic subdural hematoma secondary to an accidental dural
puncture during lumbar epidural anesthesia. Rev Esp Anestesiol
Reanim 1996; 43: 327–329.
Cohen J E, Godes J, Morales B. Postpartum bilateral subdural
hematomas following spinal anesthesia: case report. Surg Neurol
1997; 47: 6–8.
Skoldefors E K, Olofsson C I. Intracranial subdural haematoma
complicates accidental dural tap during labour. Eur J Obstet
Gynecol Reprod Biol 1998; 81: 119–121.
Diemunsch P, Balabaud V P, Petiau C, et al. Bilateral subdural
hematoma following epidural anesthesia. Can J Anaesth 1998; 45:
328–331.
Davies J M, Murphy A, Smith M, O’Sullivan G. Subdural
haematoma after dural puncture headache treated by epidural
blood patch. Br J Anaesth 2001; 86: 720–723.
Ferrari L, De Sevin F, Vigue J P, Granry J C, Preckel M P.
Intracranial subdural hematoma after obstetric dural puncture. Ann
Fr Anesth Reanim 2001; 20: 563–566.
Ezri T, Abouleish E, Lee C, Evron S. Intracranial subdural
hematoma following dural puncture in a parturient with HELLP
syndrome. Can J Anaesth 2002; 49: 820–823.
Kardash K, Morrow F, Beique F. Seizures after epidural blood
patch with undiagnosed subdural hematoma. Reg Anesth Pain Med
2002; 27: 433–436.
Nolte C H, Lehmann T N. Postpartum headache resulting from
bilateral chronic subdural hematoma after dural puncture. Am J
Emerg Med 2004; 22: 241–242.
Kayacan N, Arici G, Karsli B, Erman M. Acute subdural
haematoma after accidental dural puncture during epidural
anaesthesia. Int J Obstet Anesth 2004; 13: 47–49.
Barash P, Cullen B, Stoelting R. Clinical Anesthesia. 4th
ed. Philadelphia: Lippincott Williams & Wilkins, 2001:
1152.
Angle P, Thompson D, Halpern S, Wilson D B. Second stage
pushing correlates with headache after unintentional dural
puncture in parturients. Can J Anaesth 1999; 46: 861: 861–866.
Vandam L D, Dripps R D. Long-term follow-up of patients who
received 10,098 spinal anesthetics; syndrome of decreased
intracranial pressure (headache and ocular and auditory
difficulties). JAMA 1956; 161: 586–591.
Loo C C, Dahlgren G, Irestedt L. Neurological complications
in obstetric regional anaesthesia. Int J Obstet Anesth 2000; 9:
99–124.
Ravindran R S, Viegas O J, Tasch M D, Cline P J, Deaton R L,
Brown T R. Bearing down at the time of delivery and the incidence
of spinal headache in parturients. Anesth Analg 1981; 60:
524–526.
Sharshar T, Lamy C, Mas J L. Incidence and causes of strokes
associated with pregnancy and puerperium. Stroke 1995; 26:
930–936.
Witlin A G, Mattar F, Sibai B M. Postpartum stroke: A
twenty-year experience. Am J Obstet Gynecol 2000; 183:
83–88.
Lanska D J, Kryscio R J. Risk factors for peripartum and
postpartum stroke and intracranial venous thrombosis. Stroke
2000; 31: 1274–1282.
36/F
29/F
70/M
(?)
15/F
21/F
19/F
Reinhold34
Newrick12
Deglaire35
Scott36
Wyble37
Campbell38
Thons39
29/F
23/F
Vaughan2
Ferrari45
27
Diemunsch43
39/F
19/F
Skoldefors42
Davies44
18/F
Cohen41
54/F
27/F
Edelman33
Garcia-Sanchez
23/F
Pavlin10
40
29/F
Age/Sex
Jack32
References
9 days, CT scan
with contrast: left SDH
16 days, MRI: left SDH
4 days, CT scan: left SDH
30 days, CT scan: bilat SDH
23 days, CT scan: left SDH
42 days, CT scan: bilat SDH
5 months, CT scan: right SDH
26 days, CT scan: right SDH
6 weeks, CT scan: bilat SDH
On 17th day CT scan normal;
19 days CT scan: bilat SDH
Some weeks? -CT
scan: bilat SDH
2 days, CT scan:
right SDH.
4 weeks, angiography:
bilat SDH
21 days, CT scan: left SDH
40 days, autopsy: bilat SDH
8 days, angiography:
bilat SDH
28 days, angiography:
bilat SDH
Diagnosis time/PDP/Methods/
Localization of hematoma
Pregnancy?
Pregnancy?
Pregnancy? A-V
malformations
Pregnancy?
Pregnancy?
Pregnancy?
None
Pregnancy?
Pregnancy?
Pregnancy?
Pregnancy?
Anticoagulants
Pregnancy?
Pregnancy?
Pregnancy?
Pregnancy?
Pregnancy? Preeclampsia?
Predisposing factors
Table 2. Reported cases of subdural hematoma after epidural anesthesia
Normal delivery
Labor and then
cesarean section
Normal delivery
Normal delivery
Normal delivery
Normal delivery
For bilateral
saphenectomy
Normal delivery
Cesarean-section
Normal delivery
Normal delivery
TUR-P
Normal delivery
Normal delivery
Normal delivery
Normal delivery
Normal delivery
Procedure
Tuohy 18-G
Tuohy 16-G
Tuohy ?-G
Tuohy needle
18-G. Dural puncture
by the catheter?
Tuohy 16-G
Tuohy ?-G
Tuohy ?-G
Tuohy ?-G
Tuohy 16-G?
No obvious
dural puncture?
Tuohy 17-G
Tuohy? -G
Tuohy 17-G
Tuohy 18-G
Tuohy 18-G
Tuohy 16-G
Crawford 18 -G
Tuohy ?-G No
obvious dural
puncture?
Needle and size
NPH, nausea and vomiting
Severe headache, dysphasia,
right arm sensory loss
Convulsion and coma
NPH, left hemiparesis
and aphasia
Severe headache and
drowsiness
NPH; photophobia vomiting
and right Babinski’s sign
Persistent NPH
Persistent headache
Persistent headache,
blurred vision, vomiting.
Suicidal attempts and
puerperal psychosis
Medical/recovered
Surgical/recovered
Medical/recovered?
Surgical/recovered
Surgical/recovered
Surgical/recovered
Surgical/recovered
Surgical/recovered
Surgical/recovered
Surgical/recovered
Surgical/recovered
Surgical/death
Surgical/permanent
visual defect
Surgical/recovered
Death
Surgical/recovered
Surgical/recovered
Treatment/
Outcome
(continued on next page)
NPH, blurred vision,
vomiting. Then confusion
and paresis after blood patch
Prolonged severe headache
Coma
Headache; drowsiness,
vision loss and right
limb weakness
Headache; blurred vision;
dysphasia and memory deficit
Apnea and cardiac arrest
Headache; dysarthria
and right vision loss
Headache; disorientation
and muscle weakness
Warning sign
TOP 10 CITED PAPER 2006-2008 International Journal of Obstetric anesthesia
Postdural puncture subdural hematoma 55
489
M.E.J. ANESTH 20 (4), 2010
490
Anis Baraka
Medical/recovered
residual dural compression after seven hours after
epidural blood patch, indicating that the sustained
therapeutic response to blood patches reflects sealing
of the thecal tear by clot. Blood could persist for
more than 18 h after epidural blood patch.65
Other modalities of treatment for PDPH have been
proposed. Ayad et al.66 showed that an epidural catheter
left in the subarachnoid space for 24 h after a dural
puncture significantly reduced both PDPH and the need
of epidural blood patch. The mechanism for subarachnoid catheter prevention of PDPH is speculative. The
large-bore intrathecal catheter may act as a barrier to
CSF leakage by plugging the dural tear, decreasing the
CSF efflux from the subarachnoid space to the epidural
compartment. Furthermore, the effect of leaving the
catheter in place for 24 h may provoke an inflammatory
process that facilitates closure of the dural puncture after
catheter removal. Also, Charsley et al.67 showed that the
intrathecal injection of normal saline (10 mL) was associated with a significantly reduced incidence of PDPH
and a reduced need for epidural blood patch. One explanation for the beneficial effect of intrathecal saline is
that the increased CSF pressure may result in approximation of the dura and arachnoid at the puncture site,
thus sealing the defect.
In conclusion, our patient developed a cranial subdural hematoma following untreated PDPH. Patients
developing PDPH unrelieved by conservative measures,
as well as the change of PDPH from postural to non-postural, require careful follow-up for early diagnosis and
management of possible subdural hematoma.
SDH: subdural hematoma; NPH: non-postural headache; PDP: post-dural puncture.
Tuohy 18-G
36/F
Kayacan49
On 7th day scan was normal;
11 days by MRI: right SDH
Pregnancy?
Normal delivery
Persistent severe
headache and convulsion
Surgical/recovered
Tuohy 17-G
31/F
Nolte48
20 days, CT scan: bilat SDH
Pregnancy?
Normal delivery of twins
NPH, vomiting,
drowsiness
Medical/recovered
Tuohy ?-G
33/F
Kardash47
3 days, CT scan
with contrast: left SDH
Pregnancy?
Normal delivery
Headache, seizure
Medical/recovered
Severe NPH
Tuohy 18-G
Labor and then
cesarean section
Preeclampsia
and HELLP
syndrome
(thrombocytopenia)
4 days, MRI: bilat SDH
19/F
Ezri46
References
Age/Sex
Diagnosis time/PDP/Methods/
Localization of hematoma
Predisposing factors
Procedure
Needle and size
Warning sign
Treatment/
Outcome
International Journal of Obstetric Anesthesia
Table 2. continued
56
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491
Postdural puncture subdural hematoma 57
11. Mantia A M. Clinical report of the occurrence of an intracerebral
hemorrhage following post-lumbar puncture headache.
Anesthesiology 1981; 55: 684–685.
12. Newrick P, Read D. Subdural haematoma as a complication of
spinal anaesthetic. Br Med J 1982; 285: 341–342.
13. Miyazaki S, Fukushima H, Kamata K, Ishii S. Chronic subdural
hematoma after lumbar-subarachnoid analgesia for a cesarean
section. Surg Neurol 1983; 19: 459–460.
14. Rudehill A, Gordon E, Rahn T. Subdural haematoma. A rare but
life-threatening complication after spinal anaesthesia. Acta
Anaesthesiol Scand 1983; 27: 376–377.
15. Jonsson L O, Einarsson P, Olsson G L. Subdural haematoma and
spinal anaesthesia. A case report and an incidence study.
Anaesthesia 1983; 38: 144–146.
16. Giamundo A, Benvenuti D, Lavano A, D’Andrea F. Chronic
subdural haematoma after spinal anaesthesia. Case report.
J Neurosurg Sci 1985; 29: 153–155.
17. Blake D W, Donnan G, Jensen D. Intracranial subdural haematoma
after spinal anaesthesia. Anaesth Intensive Care 1987; 15:
341–342.
18. Beal J L, Royer J M, Freysz M, Poli L, Wilkening M. Acute
intracranial subdural hematoma of arterial origin after spinal
anesthesia. Ann Fr Anesth Reanim 1989; 8: 143–145.
19. Ortiz M, Aliaga L, Baturell C, Preciado M J, Aguilar J, Vidal F.
Intracranial subdural haematoma - a rare complication after spinal
anaesthesia. Eur J Anaesthesiol 1991; 8: 245–248.
20. Van de Kelft E, De la Porte C, Meese G, Adriaensen H.
Intracranial subdural hematoma after spinal anesthesia. Acta
Anaesthesiol Belg 1991; 42: 177–180.
21. Baldwin L N, Galizia E J. Bilateral subdural haematomas: a rare
diagnostic dilemma following spinal anaesthesia. Anaesth
Intensive Care 1993; 21: 120–121.
22. Akpek E A, Karaaslan D, Erol E, Caner H, Kayhan Z. Chronic
subdural haematoma following caesarean section under
spinal anaesthesia. Anaesth Intensive Care 1999; 27:
206–208.
23. Cantais E, Behnamou D, Petit D, Palmier B. Acute subdural
hematoma following spinal anesthesia with a very small spinal
needle. Anesthesiology 2000; 93: 1354–1356.
24. Acharya R, Chhabra S S, Ratra M, Sehgal A D. Cranial subdural
haematoma after spinal anaesthesia. Br J Anaesth 2001; 86:
893–895.
25. Eggert S M, Eggers K A. Subarachnoid haemorrhage following
spinal anaesthesia in an obstetric patient. Br J Anaesth 2001; 86:
442–444.
26. Sharma K. Intracerebral hemorrhage after spinal anesthesia.
J Neurosurg Anesthesiol 2002; 14: 234–237.
27. Wells J B, Sampson I H. Subarachnoid hemorrhage presenting as
post-dural puncture headache: a case report. Mt Sinai J Med 2002;
69: 109–110.
28. Kelsaka E, Sarihasan B, Baris S, Tur A. Subdural hematoma as a
late complication of spinal anesthesia. J Neurosurg Anesthesiol
2003; 15: 47–49.
29. Slowinski J, Szydlik W, Sanetra A, Kaminska I, Mrowka R.
Bilateral chronic subdural hematomas with neurologic symptoms
complicating spinal anesthesia. Reg Anesth Pain Med 2003; 28:
347–350.
30. Alilou M, Halelfadl S, Caidi A, Kabbaj S, Ismaili H, Maazouzi W.
Cranial subdural haematoma following spinal anaesthesia. Ann Fr
Anesth Reanim 2003; 22: 560–561.
31. Tan S T, Hung C T. Acute-on-chronic subdural haematoma: a rare
complication after spinal anaesthesia. Hong Kong Med J 2003; 9:
384–386.
32. Jack T M. Post-partum intracranial subdural haematoma. A
possible complication of epidural analgesia. Anaesthesia 1979; 34:
176–180.
33. Edelman J D, Wingard D W. Subdural hematomas after lumbar
dural puncture. Anesthesiology 1980; 52: 166–167.
34. Reinhold P, Lindau B, Bohm P. Chronic subdural haematoma
following epidural anaesthesia. Anasth Intensivther Notfallmed
1980; 15: 428–431.
35. Deglaire B, Duverger P, Muckensturm B, Maissin F, Desbordes
J M. Acute intracranial subdural hematoma after accidental dural
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37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
puncture in epidural anesthesia. Ann Fr Anesth Reanim 1988; 7:
156–158.
Scott D B, Hibbard B M. Serious non-fatal complications
associated with extradural block in obstetric practice. Br J Anaesth
1990; 64: 537–541.
Wyble S W, Bayhi D, Webre D, Viswanathan S. Bilateral subdural
hematomas after dural puncture: delayed diagnosis after false
negative computed tomography scan without contrast. Reg Anesth
1992; 17: 52–53.
Campbell D A, Varma T R. Chronic subdural haematoma
following epidural anaesthesia, presenting as puerperal psychosis.
Br J Obstet Gynaecol 1993; 100: 782–7844.
Thons M, Neveling D, Hatzmann W. Intracerebral subdural
hematoma after delivery with peridural catheter anesthesia. Z
Geburtshilfe Perinatol 1993; 197: 235–237.
Garcia-Sanchez M J, Prieto-Cuellar M, Sanchez-Carrion J M,
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review articles
UPDATE ON ANESTHESIA CONSIDERATIONS FOR
ELECTROCONVULSIVE THERAPY
Cody Mayo*, Alan D. Kaye**, Erich Conrad***, Amir Baluch****
and E lizabeth F rost *****
Abstract
Depression is diagnosed in 14 million Americans every year, and pharmacotherapy is the
standard treatment. However, in approximately 50% of patients, pharmacology intervention does
not resolve depression. Electroconvulsive therapy (ECT) has been a mainstay as a treatment option
for treatment-resistant major depression since its inception in the 1930s. It has also been shown
to be effective in treatment-resistant mania and catatonic schizophrenia. The complication rate
of ECT has improved from 50% in the 1960’s to almost anecdotal adverse events, similar to the
morbidity and mortality seen in minor surgery and childbirth. Although anesthetic agents are
administered briefly, many patients experience significant fluctuations in physiologic parameters.
The clinical anesthesiologist must be aware of these changes as well as have an understanding
of perioperative pharmacological interventions. ECT is a proven therapy for select psychiatric
patients, and appropriate anesthesia is a critical part of successful ECT. Careful review of the
patient’s medical history may reveal pertinent anesthetic considerations.
Introduction
Electroconvulsive therapy has earned an evidence based niche in modern day psychiatry as
a treatment for refractory major depression, mania and catatonic schizophrenia1,2. Traditionally, it
was reserved primarily for the most gravely disabled patients who had failed numerous treatment
options. However, ECT is a popular treatment option, and it is estimated that over 50,000 procedures
take place annually3.
Depression is diagnosed in 14 million Americans every year, and pharmacotherapy is
the standard treatment. However, up to 50% of patients do not respond to the initial round of
pharmacologic treatment4. Unfortunately, studies have shown that subsequent medication trials
have decreasing rates of successful remission5. A meta analysis has shown ECT to be more effective
than single or combination pharmacotherapy in achieving remission of major depression6. Elderly
patients are also known to be more refractory to pharmacotherapy, but it is estimated that up to 50%
will improve with ECT7.
*
**
Intern, Department of Internal Medicine, Methodist Hospital, Houston, Texas.
Professor and Chairman, Department of Anesthesiology, Louisiana State University Health Science Center, New Orleans,
Louisiana.
*** Department of Psychiatry, Louisiana State University Health Science Center, New Orleans, Louisiana.
**** Department of Anesthesiology, Jackson Memorial Hospital/University of Miami, Miami, Florida.
***** Clinical Professor, Mt. Sinai Department of Anesthesiology, New York, New York.
Address Correspondence to: Alan D. Kaye, MD, PhD, DABPM, Professor and Chairman, Department of Anesthesiology,
Professor, Department of Pharmacology, Louisiana State University School of Medicine, 1542 Tulane Ave, 6th floorAnesthesia, New Orleans, LA 70112, Tel: (504) 568-2319, Fax: (504) 568-2317, E-mail: [email protected]
493
M.E.J. ANESTH 20 (4), 2010
494
Some patients may notice an improvement in their
symptoms after one or two sessions of ECT. However,
the current practice in the USA is to administer three
treatments weekly for two to four weeks. In Europe
treatments are administered twice weekly and remission
rates are lower2. The benefits of each individual
treatment are theorized to build on one another, and
response is usually attained between treatment 6 and
12. Some patients may require further treatment, or
begin bi-monthly or monthly maintenance treatment if
still symptomatic. To date, the exact mechanism of the
effectiveness of ECT is unknown.
In the earliest days of ECT, prior to proper
anesthetic and paralytic control, injuries such as
vertebral fractures and chipped teeth were common
in up to 50% of patients1. The challenge for the
anesthesiologist involves the complex effects,
electrical and chemical, converging on the patient’s
central nervous system (CNS) at the time of therapy.
The anesthesiologist must find the balance between
under-medicating, which risks physical injury from
convulsion, and over-sedation, which can raise the
seizure threshold, preventing a sufficient therapeutic
seizure. The complication rate of ECT has improved
from 50% in the 1960’s to almost anecdotal adverse
events, similar to the morbidity and mortality seen in
minor surgery and childbirth2.
Physiologic Changes
ECT involves placing electrodes on the head
and applying a current of electricity for 2-8 seconds
sufficient enough to induce a seizure lasting at least
30 seconds, which is considered to be the minimally
effective length of time for a therapeutic seizure8.
Typically, electrode placement is either bitemporal
or bifrontal9. Most treatment centers begin with right
unilateral placement in an effort to reduce the cognitive
side effects of treatment. Subjective impairment of
memory is the most common disturbing adverse event
associated with treatment, which usually fully recovers
in the weeks to months following treatment8.
Understanding the physiologic changes that occur
during the procedure allows the anesthesiologist to
anticipate and limit complications. Most ECT morbidity
results from adverse cardiovascular events10. As the
electrical current is delivered, the parasympathetic
Cody Mayo et. al
nervous system is stimulated, primarily through direct
neuronal stimulation of the hypothalamus to the vagal
nerve8 resulting in transient sinus bradycardia, or rarely,
asystole. Shortly thereafter, the sympathetic nervous
system is stimulated, releasing catecholamines, which
usually causes tachycardia, hypertension, and may
lead to arrhythmias.
ECT exerts several other effects on the central
nervous system. When a seizure is induced, the
metabolic demands of the brain are increased, doubling
blood flow velocity through the middle cerebral artery
in order to provide enough oxygen to the brain1. There
may also be a significant increase in intracranial pressure
if the autoregulatory mechanism is overwhelmed by
an increase in peripheral blood pressure. Therefore,
the presence of cerebral aneurysms and arteriovenous
malformations (AVMs) are relative contraindications
for ECT. Other relative contraindications to ECT include
conditions associated with increased intracerebral
pressure, space-occupying cerebral lesions (tumor),
recent intracerebral hemorrhage, pheochromocytoma,
and recent myocardial infarction8.
Preoperative Management
There is little time on the day of ECT to perform a
detailed evaluation and, therefore, patients are typically
seen in a preanesthetic assessment clinic ahead of time
and have received medical clearance. Any preoperative
evaluation starts with a directed history and physical.
Many of these patients can be quite old including
over 90 years of age, with poor dentition and body
hygiene, and be very apprehensive. Consent may be
difficult to obtain. Preoperative fasting status must be
determined as patients often do not comprehend the
need for withholding food and drink prior to even a
short general anesthetic. Special attention should be
paid to cardiovascular health, especially a history of
myocardial infarction, congestive heart failure (CHF),
hypertension (HTN), aneurysms, and arrhythmias,
which should result in additional cardiac evaluation.
Any focal signs of CNS pathology should result in
further neurological assessment11. Documentation of an
airway examination, allergies, and current medications
should be included as well as informed written consent.
Although bag masking is usually all that is required,
airway equipment as indicated should be readily
UPDATE ON ANESTHESIA CONSIDERATIONS FOR ELECTROCONVULSIVE THERAPY
available. Also, standard ASA monitors for blood
pressure, heart rate, temperature, oxygen saturation, and
capnography should be used. The seizure is monitored
via electroencephalogram (EEG), and a bite block
is used to protect the patient’s dentition and tongue.
Blood pressure and heart rate modulating agents need
to be prepared if needed, typically including labetalol,
esmolol, nitroglycerin and/or nicardipine.
The risk of arrhythmia, ischemia and hypertension
can be diminished with oxygenation and pretreatment
with appropriate medication, discussed below. In
general, a demand pacemaker should be converted to
a non-sensing asynchronous mode with a magnet to
disable rate responsiveness at the time of treatment;
however, different models and brands each have slightly
different considerations. Cardiology consultation
should be obtained, if warranted, prior to treatment12.
JCAHO requirement of side site documentation applies
in all cases.
Drug Interactions
Usually, the condition requiring ECT is also treated
pharmacologically, and potential drug interactions are
important. Most psychiatric patients may be taking
medications with anticonvulsant properties and these
medications should be reduced prior to the procedure
as tolerated since they increase the seizure threshold2.
Anticonvulsants should be continued only in epileptic
patients, and the medication withheld the morning of
treatment to prevent inhibition of an adequate seizure.
Lithium is a popular agent used in bipolar disorder and
as an augmentation agent in treatment of refractory
major depression. Lithium has been associated with
post-procedure delirium and can prolong the effects
of succinylcholine8. Even though benzodiazepines
may help reduce anxiety before the procedure, their
use increases the seizure threshold2. If they cannot
be stopped, an option is to exchange long acting
benzodiazepines for short-acting ones. Alternatively
flumazenil may be used prior to the procedure and
has shown no adverse effects on seizure quality1.
Theophylline can significantly lower seizure threshold
and prolong seizure duration, and this medication
should be minimized or discontinued if possible prior
to treatment8. Caffeine augments electroconvulsive
seizures13.
495
There are very limited studies regarding
interference of ECT from continuation of various
psychiatric medications but controversy continues in
this area.
Intraoperative Considerations
Successful ECT anesthesia should meet
several requirements according to the American
Psychiatric Association14. It should be administered
by an anesthesiologist who is responsible for both the
anesthesia and the cardiopulmonary management10.
In general, the anesthesiologist aims to help provide
a procedure with an adequate seizure duration, free
of associated side effects and injuries, and a quick
recovery. The goal of ECT is to induce a 30-60
seizure2. Therefore, only brief anesthesia is required.
However, there are many anesthetic options that may
be considered. The anesthetic’s properties, including
half-life, recovery time, effects on the CNS, autonomic
nervous system and cardiovascular systems and
interaction with other drugs must be considered to
tailor an appropriate therapeutic plan.
Induction Agents
Methohexital was for many decades the most
commonly used induction agent because it has minimal
effect on seizure threshold while providing quick
induction and recovery. It is designated as “first choice
hypnotic” by the American Psychiatry Association14.
Methohexital has a wide therapeutic dose range
of 0.5-1mg/kg and is easy to titrate. Thiopental is
another barbiturate, but compared to methohexital,
results in shorter seizure duration and is associated
with increased hemodynamic changes1. Propofol has
become a more popular choice, and multiple studies
have been conducted comparing it to methohexital.
Although propofol causes seizures of a shorter duration,
the seizures are still of adequate length to provide full
therapeutic benefit1. Propofol has repeatedly been
shown to be associated with a milder hemodynamic
response than methohexital1,15 Whether the drug
provides a faster cognitive recovery is debatable. The
most recent study available concluded that propofol is
associated with a slightly quicker postictal recovery15.
Because propofol can increase the seizure threshold, it
should not be used in doses greater than 1mg/kg11, or
M.E.J. ANESTH 20 (4), 2010
496
in patients for whom an adequate seizure duration with
maximal stimulus is not obtained.
Etomidate is another drug that may be considered.
It has been repeatedly studied and is known to cause
seizures of a longer duration than either propofol or
methohexital. Unfortunately, etomidate is associated
with increased confusion after ECT and longer
recovery time16. However, because etomidate does not
increase the seizure threshold, studies have shown its
use requires significantly lower electrical currents17.
Etomidate has also been associated with both reduced
hemodynamic responses but higher rates of nausea. A
recent small study comparing etomidate to propofol
showed no significant difference in hemodynamic
parameters18. Therapeutic doses in ECT range from
0.15-0.3mg/kg1.
Volatile anesthetics, in particular sevoflurane,
are also being studied for use in ECT. However, it
has been concluded that sevoflurane offers no benefit
over methohexital, yet is more time consuming to
the physician16. One trial compared sevoflurane to
thiopental and concluded sevoflurane lead to a quicker
recovery with comparable hemodynamic changes19.
Muscle Relaxants
In addition to IV anesthetics, muscle relaxants
are critical in ECT to prevent convulsions thus
protecting the patient from musculoskeletal injury.
Succinylcholine has been used in ECT since the
1950s and is still the muscle relaxant of choice3.
It is contraindicated in patients with closed angle
glaucoma, malignant hyperthermia potential, and
malignant hyperthermia For ECT, doses up to 1mg/
kg may be used11. The anesthesiologist must be aware
of patients with a history of pseudocholinesterase
deficiency. When succinylcholine is contraindicated,
mivacurium, rocuronium, or cis-atracurium are
traditional alternatives (unless the patient has
pseudocholinesterase deficiency). These agents are
nondepolarizing muscle relaxants with significantly
longer half-lives and thus, are not considered superior
to succinylcholine in most instances.
Attenuation of Hemodynamic Responses
To attenuate the immediate parasympathetic
discharge, which lasts 10-15 sec, pretreatment with IV
Cody Mayo et. al
atropine or glycopyrrolate is generally recommended.
There is some controversy in the literature about
the use of atropine on ever patient and some prefer
glycopyrrolate because is causes less cognitive
impairment since it does not cross the blood brain
barrier16. The subsequent sympathetic discharge,
which lasts 5-7 min can be attenuated by a wide
variety of drugs including beta blockers, calcium
channel blockers, nitrates, and the antiquated ganglion
blockers.
Typically, the psychiatrist and anesthesiologist
communicate as to which agents will be administered
during ECT, as there are slight regional variations. For
patients with cardiovascular complications, esmolol
or labetalol have been shown to be the most effective
in controlling heart rate and mean arterial pressure5.
Labetalol reduces BP spikes and cardiac dysrhythmias,
but may also be associated with a shorter seizure
duration. Esmolol is slightly preferred by some
because it reduces peak systolic BP a little more than
labetalol1. However, it may induce a dose-dependent
bradycardia20 Verapamil 0.1mg pre-ECT decreases
both heart rate and BP21, while nicardipine has only
been proven to lower the BP. Nicardipine has not been
proven to lower cerebral blood flow and may cause a
baroreceptor induced reflex tachycardia20.
Studies have also looked at the effects of adding
remifentanil to a sedative hypnotic. Remifentanil
appears to have no effect on the seizure duration but
is effective in lowering the HR and BP for up to 3
min after the procedure22. Some studies have shown
a decrease in seizure duration when remifentanil is
added to methohexital, however in these studies, the
dose of methohexital was also reduced by 40%.
The myocardium has been another area of study.
Many studies have failed to show either new ECG
changes or troponin isoenzyme elevations after ECT.
Twenty-four percent of the patients in these studies
had cardiovascular disease, including conduction
abnormalities, recent MIs and existing regional wall
motion abnormalities23. Another study that used
echocardiography to evaluate cardiac function during
ECT found no evidence of new regional wall motion
abnormalities and recommended beta blockers as the
drug of choice to minimize heart rate and function
changes24.
UPDATE ON ANESTHESIA CONSIDERATIONS FOR ELECTROCONVULSIVE THERAPY
In recent years research has attempted to correlate
Bispectral index (BIS®) of electroencephalography
(EEG) to the duration of and recovery from an ECT
induced seizure. Entropy technology, from which several
brands are now available with similar bioengineering,
assesses the hypnotic state of an anesthetized patient. It
may assist in indicating appropriate depth of anesthesia
prior to seizure. White et al have shown that BIS®
readings just after induction positively correlate to the
duration of the seizure25. This potentially allows the
clinicians to predict relative sufficiency of the induced
seizure; however, limited data is available and more
studies are warranted.
Postoperative Concerns
After the treatment, the awake and
hemodynamically stable patient should be monitored
for at least 30 minutes, usually by a psychiatric nurse or
assistant known to the patient. Mental status should be
noted and the patient observed for post-ictal delirium.
A short-acting benzodiazepine such as lorazepam may
be needed for agitation. Headache and muscle soreness
are the most common complaints and may indicate that
an increase in succinylcholine may be warranted at the
497
next treatment. Any decrease in pulse oxymetry should
be evaluated for possible aspiration. Chest auscultation,
X- ray and even blood gas analyses may be indicated. If
the patient remains asymptomatic, discharge may still
be possible.The patient is allowed to resume normal
activity as tolerated and any medications that were
held prior to the procedure should be restarted. Patients
should not work or drive on the day of treatment.
Conclusion
ECT is a proven therapy for select psychiatric
patients, and appropriate anesthesia is a critical part of
successful ECT. The anesthesiologist aims to provide
amnesia and musculoskeletal relaxation without
increasing the seizure threshold. First line drugs are
propofol and succinylcholine. The hemodynamic
changes following the electric current are usually
the only ones requiring management. In general,
beta-blockers control heart rate and BP. However
the anesthesiologist is also responsible for managing
cardiopulmonary complications that may be present
before the procedure as well as those that arise during
ECT. Careful review of the patient’s medical history
may reveal pertinent anesthetic considerations.
M.E.J. ANESTH 20 (4), 2010
498
Cody Mayo et. al
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MANAGEMENT OF OBSTETRIC HEMORRHAGE
Amitava Rudra*, Suman Chatterjee**, Saikat Sengupta***,
Ravi Wankhede***, Biswajit Nandi****,
Gaurab Maitra***, and Jayanta Mitra****
Abstract
Major obstetric hemorrhage is an extremely challenging obstetric emergency associated with
significant morbidity and mortality. Pharmacological treatment of uterine atony has not altered
much in recent years apart from the increasing use of misoprostol, although controversy surrounds
its advantages over other uterotonics. Placenta accreta is becoming more common, a sequel to the
rising caesarean section rate. Interventional radiology may reduce blood loss in these cases. Uterine
compression sutures, intrauterine tamponade balloons and cell salvage have been introduced in the
last decade.
Keywords: Antepartum hemorrhage, postpartum hemorrhage, uterotonics.
Obstetric hemorrhage is the world’s leading cause of maternal mortality1. Postpartum
hemorrhage (PPH) accounts for the majority of these deaths1. The global maternal ratio of 402
deaths per 100,000 live births2 obscures the fact that 99% of these deaths occur in the developing
world3. In addition, even in many developed countries, it is also the maternal complication for
which the highest rate of substandard care is observed4. Furthermore, Zeeman’s5 study of obstetric
critical care provision identifies hemorrhage as one of the most frequent reasons for admission to
intensive care unit. Major obstetric hemorrhage accounts for 30% of cases6. Obstetric hemorrhage is
often sudden, unexpected, and may be associated with coagulopathy. Blood loss can be notoriously
difficult to assess in obstetric bleeds. Bleeding may sometimes be concealed and the presence of
amniotic fluid makes accurate estimation challenging. Hence, early recognition and treatment are
essential to ensure the best outcome.
Therefore, it is important to have a thorough knowledge of the pathophysiology, etiology, and
management strategies of obstetric hemorrhage.
The initial assessment of a patient with an obstetric hemorrhage depends on its causes, but
in general
(1) Take a detailed medical and obstetric history and examine the patient to find the site and
cause of the bleeding;
(2) Empty the patient’s bladder;
(3) Ensure that there are no retained products of conception or genital tract lacerations (anesthesia
may be necessary);
(4) Estimate blood loss; and
(5) Assess the patient’s hemodynamic status and initiate appropriate resuscitation.
Professor of Anesthesiology, K.P.C. Medical College, Kolkata., India.
*
** Assistant Professor of Anesthesiology, Medical College & Hospital, Kolkata, India.
*** Consultant Anesthesiologist, Apollo Gleneagles Hospital, Kolkata., India.
****Associate Consultant Anesthesiologist, Apollo Gleneagles Hospital, Kolkata., India.
Corresponding author: Dr. A. Rudra, 1, Shibnarayan Das Lane, Kolkata.-700006, India. E-mail: [email protected]
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M.E.J. ANESTH 20 (4), 2010
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A. Rudra et. al
Massive obstetric hemorrhage is variably defined
as: blood loss more than 1500 ml, a decrease in
hemoglobin more than 4 g/dl; or acute transfusion of
more than 4 units; or patient receiving treatment for
coagulopathy7.
The gravid uterus receives up to 12% of the
cardiac output, thus obstetric hemorrhage can be
rapidly become life threatening.
Classification of Obstetric Hemorrhage
Antepartum Hemorrhage (APH)
This is bleeding after 24 weeks gestation and
before delivery. The causes include:
l Placenta previa
l Placental abruption
l Trauma
Mechanism of Hemostasis
8
l Uterine rupture
After disruption of vascular integrity, mechanisms
of hemostasis include (a) platelet aggregation and
plug formation, (b) local vasoconstriction, (c) clot
polymerization, and (d) fibrous tissue fortification
of the clot. Contraction of the uterus represents the
primary mechanism for controlling blood loss at
parturition. Endogenous oxytocics effect myometrial
contraction after delivery.
Underestimation of peripartum hemorrhage
is a frequent problem. Visual assessments typically
underestimate the true amount of blood loss. Moreover,
inadequate intravenous fluid administration is common.
Hence, the primary problems were delayed recognition
of hypovolemia and inadequate volume resuscitation.
Table 1
Staging scheme for assessment of obstetric hemorrhage
Primary Postpartum Hemorrhage
This is defined as blood loss within 24 hours
of delivery, which is > 500 ml following a vaginal
delivery and > 1000 ml following a caesarean delivery.
The causes include:
l Uterine atony
l Retained product of conception
l Genital tract trauma
l Clotting defects
l Inverted uterus
Secondary Postpartum Hemorrhage
This is blood loss more than 24 hours after
delivery. The causes include:
Finding
% Blood loss
l Pre-eclampsia/HELLP syndrome
None
<15% to 20%
l Intrauterine sepsis
Tachycardia
Mild hypotension
l Pre-existing coagulopathy
20% to 25%
Peripheral vasoconstriction
l Incompatible blood transfusion
l Retained dead fetus
Tachycardia (100 to 120 bpm)
Hypotension (SBP 80 to 100 mmHg)
25% to 35%
Restlessness
Oliguria
Tachycardia (>120 bpm)
Hypotension (SBP <60 mmHg)
>35%
Altered consciousness
Anuria
bpm = beats per minute; SBP = Systolic blood pressure
ANTEPARTUM HEMORRHAGE
Antepartum hemorrhage is a relatively frequent
problem, occurring in 5% to 6% of pregnant women8.
Recent evidence suggests that antepartum hemorrhage
of unknown origin does produce more premature labor
and delivery and subsequently, more fetal and neonatal
problems9. Cases with abnormal placentation, usually
placenta previa or placental abruption, can result
in serious complications for both mother and child.
Antepartum hemorrhage can also result in postpartum
hemorrhage.
MANAGEMENT OF OBSTETRIC HEMORRHAGE
501
The antepartum bleeding secondary to placenta
previa or abruption is responsible for perinatal mortality
rates as high as 22% and 37%, respectively10.
intravascular coagulation in 10% of cases. However, if
fetal demise occurs, the incidence is much higher (up
to 50%)12.
Placenta previa
Placenta accreta
Placenta previa is abnormally low implantation
of the placenta in the uterus. Three types of placenta
previa are defined, depending on the relationship
between the cervical os (rather than the fetal presenting
part itself).
Placenta accreta is defined as an abnormally
adherent placenta. Placenta accreta vera is defined
as adherence to the myometrium without invasion of
or passage through uterine muscle. Placenta increta
represents invasion of the myometrium. Placenta
percreta includes invasion of the uterine serosa or other
pelvic structures. Any of these placental implantations
can produce a markedly adherent placenta that cannot
be removed without tearing the myometrium.
1. Complete previa (37%) - the internal os is
completely covered.
2. Partial previa (27%) – the internal os is partially
covered.
3. Marginal previa – Part of the internal os is
encroached on by the placenta.
The incidence varies between 0.5% to 1% of
pregnancies, usually in association with prior uterine
scarring such as a previous caesarean section, uterine
surgery, or a previous placenta previa. Bleeding is
caused by tearing of the placenta and its attachment
from the decidua.
The classic sign of placenta previa include:
1. Painless vaginal bleeding during the second or third
trimester.
2. With the first episode of bleeding, contractions
typically are absent.
3. Onset of bleeding is not related to any particular
event.
When the diagnosis of placenta previa suspected,
the position of the placenta should be confirmed by
ultrasonography11.
Abruptio placentae
Abruptio placentae is separation of a normally
implanted placenta from deciduas basalis after 20 weeks
of gestation and prior to delivery (incidence 0.2% to
2%). It is classified as mild, moderate, or severe. Fetal
distress occurs because of loss of area for maternal
fetal gas exchange. When the separation involves only
the placental margin, the escaping blood can appear
as vaginal bleeding. Alternatively, large volumes of
blood loss (1-2 litres) can remain entirely concealed in
the uterus. Chronic bleeding and clotting between the
uterus and placenta can cause maternal disseminated
The combination of a placenta previa and a
previous uterine scar increases the risk significantly.
In the general obstetric population, placenta accreta
occurs in approximately 1 in 2500 and cannot be
reliably diagnosed by ultrasonography. In patients with
placenta previa and no previous caesarean sections,
the incidence is 5% to 7%. With one previous uterine
incision, the incidence of placenta accreta has been
reported to be 24% to 31% and with two or more
previous uterine incisions, the incidence rises to about
50% 13,14.
Ultrasonography and MRI may be useful when
abnormal placentation is suspected. However, they
both have a poor sensitivity and the diagnosis is often
made on opening the abdomen and uterus. Therefore,
the anesthesiologist must keep in mind the possibility
and be prepared to treat sudden massive blood loss.
Uterine rupture
Rupture of the gravid uterus can be disastrous
to both the mother and fetus. Fortunately, it does not
occur often. Uterine rupture can be associated with
separation of a previous caesarean section and healed
incision (scar) in the uterus, rapid spontaneous delivery,
or excessive oxytocin stimulation. Moreover, trauma
during attempted forceps delivery also may cause
uterine rupture in a patient with an unscarred uterus.
Overall, however, more than 80% of uterine ruptures
are spontaneous and without an obvious explanation.
The rupture of a classic uterine scar increases
morbidity and mortality because the anterior uterine
wall is highly vascular and also may include the area of
placental implantation. Lateral extension of the rupture
M.E.J. ANESTH 20 (4), 2010
502
A. Rudra et. al
can involve the major uterine vessels and typically is
associated with massive bleeding. Therefore, when
vaginal birth is planned after a previous caesarean
section, it is required that a surgical team, including
an obstetrician, anesthesiologist, and nursing staff be
available, so that emergency caesarean section can be
initiated without delay should uterine rupture occur.
POSTPARTUM HEMORRHAGE
Bleeding after childbirth (postpartum hemorrhage)
is an important cause of maternal mortality, accounting
for nearly one quarter of all maternal deaths worldwide.
Common causes for postpartum hemorrhage (PPH)
include failure of the uterus to contract adequately after
birth leading to atonic PPH, tears of the genital tract
leading to traumatic PPH and bleeding due to retention
of placental tissue. Atonic PPH is the most common
cause of PPH and the leading cause of maternal death.
Uterine atony
Uterine atony is the leading cause of PPH,
observed alone in 50% to 60% of cases, it presents as
painless continuous bleeding, often developing slowly
at the beginning. Blood can be concealed in the uterus
and not exteriorized until external compression of
the uterine fundus is performed. With up to 15% of
maternal cardiac output at term supplying the gravid
uterus, an atonic uterus can lose 2 liters of blood in
5 minutes. Atony is associated with “overdistension”
of the uterus (multiparity, polyhydramnios, multiple
gestation), as well as retained placenta, excessive
oxytocin use during labor, and operative intervention.
Initial management is medical – fluid resuscitation
to restore blood volume; oxygen supplementation
(high flows via face mask); bladder emptying, uterine
massage, and uterotonics. This may allow avoidance
of operative intervention.
Among the uterotonics (Table 2) oxytocin is the
initial therapy – up to 40 IU/ L infused as rapidly as
possible15-18. Oxytocin is a systemic vasodilator, and
may aggravate hypotension. Increasing this dose does
not offer any benefit. Methylergonovine (Methergine)
is a second line agent, though it is often bypassed
in favour of the prostaglandin analog, carboprost
(Hemabate). Neither methylergonovine nor carboprost
should be administered intravenously – both are given
intramuscularly. Methylergonovine is administered
at a dose of 0.2 mg17; if two subsequent doses do not
appropriately increase uterine tone, carboprost (0.25
mg) is administered either intramuscularly or into the
myometrium. The total dose of carboprost should not
exceed 1.5 mg. Both methylergonovine and carboprost
have significant side effects. Methylergonovine is a
peripheral vasoconstrictor; rapid intravenous injection
can cause acute hypertension and cerebrovascular
accident, and has been associated with pulmonary
oedema and coronary vasospasm. Carboprost is a
synthetic analog of prostaglandin F2α; it is a potent
systemic and pulmonary vasoconstrictor, and
bronchoconstrictor18. Intravenous administration can
be associated with severe bronchospasm, and systemic
and pulmonary hypertension, even intramuscular
administration should be used with caution in asthma.
Retained placenta
This is the second most important etiology of
postpartum hemorrhage (roughly 20% - 30% of cases),
Table 2
Commonly used uterotonics
Medication
Class
Administration
Dosing
Side effects
Comments
Oxytocin
Neurohypophyseal
Infusion
Up to 40 IU/l
Hypotension with
rapid infusion
Initial therapy
Methylergonovine
Ergot alkaloid
Intramuscular
0.4 mg IM;
repeat once
Hypertension
Sustained
increase in
uterine tone
Carboprost
Prostaglandin
Intramuscular
0.25 mg 1M
repeat up to 1.0
mg total
Systemic &
pulmonary
hypertension,
bronchospasm
Never
administer
intravenously
MANAGEMENT OF OBSTETRIC HEMORRHAGE
but it must be systematically investigated first, because
uterine atony is frequently associated and can be
misleading12. It is suggested by the finding of an absent
or incomplete delivery of placenta. Hence, uterus will
not contract, and arteries of the deciduas basalis will
continue to bleed. The degree of hemorrhage is often
not severe, but it may be insidious, and visual estimates
are inaccurate. The condition usually necessitates
manual exploration of the uterus.
Genital tract lacerations
The most common injuries incurred at child birth
are lacerations and hematomas of the perineum, vagina,
and cervix. Most injuries have minimal consequence,
but some puerperal lacerations and hematomas
are associated with significant hemorrhage, either
immediate or delayed. Genital tract lacerations should
be suspected in all patients who have vaginal bleeding
despite a firm, contracted uterus. The cervix and
vagina must be inspected carefully in these patients.
Retroperitoneal hematomas are dangerous because
they can become large and develop insidiously, and
treatment often requires exploratory laparotomy, blood
transfusion, and possibly hysterectomy.
Uterine inversion
An atonic uterus and an open cervix allow the
uterus to “turn inside out” through the birth canal.
Fundal pressure and inappropriate traction on the
umbilical cord to hasten placental delivery contribute
to uterine inversion. The diagnosis is usually obvious.
Clinical features include abdominal pain and often
severe hemodynamic instability. Along with that a
reflex bradycardia can be immediate by the effect
of traction on the ligaments supporting the uterus.
Uterine relaxation needed for reduction of the uterus
with short-time tocolysis (trinitrite) as first line,
using a potent vasopressor intravenously at the same
time to counteract hypotension (phenylphrine or
adrenaline)12.
503
cause of the bleeding; (b) empty the patient’s bladder;
(c) ensure that there are no retained products or genital
tract lacerations; (d) estimate blood loss; and (e)
assess the patient’s hemodynamic status and initiate
appropriate resuscitation.
Monitor
1.
Monitor ECG, blood pressure and oxygen
saturation continuously.
2.
Monitor urine output hourly.
3.
Consider invasive monitoring if the patient
is hemodynamically unstable or repeated
venepunture is anticipated.
Resuscitate
The aim of resuscitation is to restore circulating
blood volume and to maintain tissue perfusion: (a)
high-flow oxygen (8L/min), (b) head-down tilt and left
lateral tilt to avoid aorto-caval compression (if not yet
delivered); (c) intravenous access (two 14 or 16 gauge
cannula) and take blood for complete blood count,
clotting and cross-match; (d) fluids: crystalloids,
colloid (avoiding dextrans) and if necessary (not to
exceed 3.5 liters prior to blood transfusion), blood;
(e) O Rhesus negative blood should be immediately
available, type specific cross-match will be time
consuming; (f) try to avoid dilutional coagulopathy
with emperical administration of clotting products, (g)
accept hemoglobin of 8 gm/dl.
As hypothermia impairs coagulation and shifting
of oxygen dissociation curve to left (impair oxygen
release at tissue level), fluids should be warned and
the patient kept warm with active warming devices or
warmed blankets. Appropriate correction of acidosis
and hypocalcaemia is also required.
Because timing is the essence, all members of
the obstetric team should be familiar with the protocol
(Box 1).
Stop the Bleeding
MANAGEMENT
General
The initial assessment of the patient with an
obstetric hemorrhage depends on its cause, but in
general (a) take a detailed medical and obstetrical
history and examine the patient to find the site and
Pharmacological
1)
Oxytocin is the drug of choice for the prevention
and treatment of atonic PPH. Five to 10 units
are given slowly by intravenous bolus followed
by an infusion of 10 units per hour. Vasodilation
M.E.J. ANESTH 20 (4), 2010
504
A. Rudra et. al
Health Organization takes a different view,
concluding that oral misoprostol is more
expensive, has more side effects, and,
crucially, is less effective than oxytocin20.
produced by oxytocin may cause hypotension in
cardiac or hemodynamically unstable patients.
2)
3)
Ergometrine (0.5 mg intravenously or
intramuscularly) is as effective as oxytocin,
however, intravenous administration possess
undesirable effects. The agent is contraindicated
in hypertensives due to its blood pressure raising
effects.
Prostaglandins:
A) Hemabate (250 mcg intramuscularly
or intramyometrially) contracts the
walls of uterus. However, the agent has
potential liability to cause life threatening
bronchospasm19.
B) Misoprostol can be administered orally,
sublingually or rectally. Oral or sublingual
prostaglandin may be useful in cases
in which injectable uterotonics are not
available or practical. However, the World
Box 1 Bleeding parturient management
Invasive/surgical iliac artery or uterine
artery ligation (bleeding unresponsive to
oxytocics)
There is little in the literature to guide practice
when pharmacological treatment fails. However,
bimannual compression, uterine balloon tamponade,
arterial embolization, uterine compression sutures,
and uterine artery or internal iliac artery ligation
are commonly practiced procedures. The review by
Doumouchtsis et al21 of the conservative management
of PPH found no statistical difference between the
various methods, and the Cochrane collaboration22
failed to identify any relevant randomized control
trials.
(1) Bimannual compression
l Provide early diagnosis, treat the cause
l Follow general principles of resuscitation
(airway, breathing, and circulation)
l Call for help
(2) Uterine balloon tamponade
l Begin second large-bore intravenous line
l Order blood tests (hemoglobin, coagulation
screen, cross-match)
l Order blood (hematology consultation?)
l Provide crystalloid/colloid (Pentastarch) to
maintain isovolaemia
l Start high-pressure infusion system
It has become a well-recognized alternative
method of treatment in the conservative
management of PPH in association with local or
medical treatment, or in the event of their failure.
This therapeutic approach avoids morbidity
associated with peripartum hysterectomy and
preserve fertility.
The reported success rate of uterine artery
embolization in the literature is more than 90%
24-27
. In most patients, fertility is preserved and
normal menstruation returns almost 100%21.
Minor complications such as pain and fever due to
inflammation are rare (0% - 10%)27. More severe
l Provide air warming blanket
l Provide auto transfusion device?
l Begin prompt treatment of clotting disorders
l Monitor urine output
l Consider use of vasopressors
In the case of intractable PPH, Doumouchtsis
et al21 proposes balloon tamponade as the most
straight forward, rapid, and least invasive surgical
option. An overall success rate of 84% has been
reported 21,23. Various balloon devices have been
used, with the Sengstaken–Blakemore esophageal
catheter being the most frequently employed21.
(3) Uterine arterial embolization
l Begin arterial line (serial hemoglobin,
coagulation studies)
l Begin central venous pressure line (after
stabilization)
Compression of the uterus between one hand in
the vagina and, another on the anterior abdominal
wall, thereby reducing the bleeding.
MANAGEMENT OF OBSTETRIC HEMORRHAGE
505
other interventions have failed, hysterectomy
may be required to control bleeding and save
life. The decision, however difficult, should be
made sooner rather than later and prior to the
development of coagulopathy.
complications like pelvic infection, pulmonary
embolism, or necrosis of uterus and bladder have
been reported but are extremely rare28,29.
Transfer to the radiology suite is usually done
when vital signs are stable because facilities
equipped to handle major bleeding are often
much better in the operating room. Placement of
arterial catheters and occlusion balloons before
delivery is currently the treatment options of
choice whenever major haemorrhage is highly
suspected. These balloons can be used to reduce
blood loss significantly while the patient is
prepared to undergo embolization.
(4) Uterine compression suture (B-Lynch suture)
These are useful for patients with uterine
atony who respond to bimannual compression.
B-Lynch et al30 first described the compression
suture in 1997 and others have since developed
the technique using vertical31, transverse32, or
multiple square suture33,34 to oppose the anterior
and posterior walls of the uterus. Successful
subsequent pregnancies have been reported,
although evidence of fundal grooves from the
sutures has been noted31. Uterine necrosis,
intrauterine fibrous bands, abdominal adhesions,
and pyometria are other noted complications35.
(5) Arterial ligation
Although ligation of internal iliac, uterine
arteries can reduce pelvic blood flows and pulse
pressure (85%) distal to the ligation, it may be
ineffective if there are extensive collaterals. It
can be useful in cases of uterine atony with a
success rate of 84% has been described provided
they are implemented quickly21. Bilateral ligation
of these arteries does not appear to interfere with
subsequent reproduction.
(6) Peripartum hysterectomy
As a last resort, but decided on quickly when all
(7) Adjuncts
There are some new techniques that are
currently controversial and not universally
accepted. These include the use of interventional
radiology, methotrexate in placenta accreta, cell
salvage as a means of reducing donor blood
transfusion, tranexamic acid and factor VIIa to
aid coagulation.
Anesthesia
Anesthetic management – both in choice
and technique – should be based on a thorough
understanding of the physiology of pregnancy and also
on the pathophysiology of the problems.
The existence of some of the obstetric risk factors
may be known early in pregnancy from history and
examination (Table 3).
(A) Detection of anemia more than physiologic
anemia of pregnancy is important because
anemia at delivery increases the likelihood of
blood transfusion.
(B) Coagulation studies may be required in the
presence of congenital (Von Willebrand’s disease)
or acquired (DIC, dilutional coagulopathy,
heparin) coagulation defects.
(C) Imaging investigations are useful in the detection
of placental abnormalities, with placenta
previa and placenta accrete, the most important
identifiable risk factors for massive hemorrhage.
(D) Ultrasound studies identify placental location,
and their ability to detect placenta accreta.
In elective placenta previa cases, Royal College
Table 3
Antenatal investigations and associated conditions
Investigations
Associated conditions
Full blood count (including hemoglobin, platelets)
Anaemia, thrombocytopenia
Clotting screen (including fibrinogen, D-dimers)
Abdominal ultrasound
MRI
Anticoagulants, DIC, Dilutional coagulopathy
Placenta previa/accreta/increta/percreta
Placenta accreta/increta/percreta
M.E.J. ANESTH 20 (4), 2010
506
A. Rudra et. al
of Obstetricians and Gynaecologists states that
the choice of anesthetic is at the discretion of the
anesthesiologist but there is increasing evidence to
support the safety of regional anesthesia. If regional
anesthesia is used, consideration should be given to a
combined spinal epidural technique to allow time for
surgery. As general anesthesia may be necessary, the
patient should be fully prepared for conversion. For
placenta accreta cases, although some centers advocate
the use of regional anesthesia, general anesthesia may
allow for more control11.
During general anesthesia, prolonged induction –
delivery and uterine incision – delivery intervals were
associated with a higher incidence of low Apgar scores
and acidotic babies. On the other hand, with spinal
anesthesia in the absence of hypotension, a longer
induction – delivery interval did not alter either the
Apgar score or the acid-base values of the neonates.
However, a uterine incision – delivery interval of more
than 180 seconds was associated with a high incidence
of low Apgar scores and acidotic infants; thus, might
be related to reduced placental circulation.
Advantages and disadvantages of regional
vs. general anesthesia
A. Regional Anesthesia
1. Advantages
l Less blood loss.
l Awake patient with less chance of aspiration.
Moreover, parturient will be able to experience
delivery of baby.
2. Disadvantages
l Peripheral vasodilation
hypotension.
may
exacerbate
l General anesthesia may be necessary for
patient’s comfort if a hysterectomy is
necessary.
B. General anesthesia
1. Advantages
l Hemodynamic stability.
l Security of the airway from the onset of the
surgery.
l Comfortable patient.
2. Disadvantages
l Chance of difficult intubation, inability to
intubate, and possible gastric aspiration.
l Unconscious patient.
In emergencies, hemodynamic instability and
concerns over coagulopathy make general anesthesia
the technique of choice. Nevertheless, if a working
epidural is in place then cautious top-ups may be
appropriate.
A high-dependency setting is appropriate for at
least half of those with a major obstetric haemorrhage11.
The majority who do require intensive care do so only
for mechanical ventilation and usually for less than 48
hours.
An alternative to blood transfusion in the recovery
period is intravenous iron. Ferrous sucrose has an
excellent safety profile36.
Accurate diagnosis and appropriate management
of obstetric hemorrhage can reduce maternal morbidity
and mortality.
Conclusion
Obstetric hemorrhage, a leading cause of
maternal as well as fetal morbidity and mortality
worldwide, can be masked by early pregnancy related
physiologic adaptation and complicated by abnormal
placentation, ammiotic fluid emboli and infections
etiologies. Obstetric hemorrhage is often sudden,
unexpected and may be associated with coagulopathy.
Because approximately 600-700 ml blood flows
through the placental intervillous spaces each minute,
obstetric hemorrhage can rapidly result in severe signs
of shock.
Imaging technologies like ultrasound and
magnetic resonance imaging have allowed earlier
identification of the cause and institution of therapy for
women at risk of hemorrhage. However, limitations
in diagnostic sensitivity and specificity as well as
the underestimation of blood loss and inadequate
resuscitation remain common problems. Early
recognition and treatment are essential to ensure the
best outcome from these life threatening conditions.
MANAGEMENT OF OBSTETRIC HEMORRHAGE
507
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of uterine arteries a safe alternative to hysterectomy in patients with
postpartum hemorrhage? A J R; 2001, 177:145-149.
25.Mitty HA, Sterling K M, Alvarez M, et al: Obstetric haemorrhage
prophylactic and emergency arterial catheterization and
embolotherapy. Radiology; 1993, 188:183-187.
26.Hong TM, Tseng HS, Lee RC, et al: Uterine artery embolization:
an effective treatment for intractable obstetric haemorrhage. Clin
Radial; 2004, 59:96-101.
27.Soncini E, Pelicelli A, Larini P. et al: Uterine artery embolization
in the treatment and prevention of postpartum hemorrhage. Int J
Gynaecol Obstet; 2007, 96:181-5.
28.Cottier JP, Fignon A, Tranquart F, et al: Uterine necrosis after
arterial embolization for postpartum hemorrhage. Obstet Gynecol;
2002, 100:1074-1077.
29.Porcu G, Roger V, Jacquier A, et al: Uterus and bladder necrosis
after uterine artery embolization for postpartum haemorrhage. Br J
Obstet Gynecol; 2005, 112:122-123.
30.B-Lynch C, Coker A, Lawal A, et al: The B-Lynch surgical technique
for the control of massive postpartum haemorrhage: an alternative to
hysterectomy? Five cases reported. BJOG; 1997, 104:372-375.
31.Ghezzi F, Cromi A, Uccella S, et al: The hayman technique: a
simple method to treat postpartum haemorrhage. BJOG; 2007,
114:362-365.
32.Ouahba J, Piketty M, Huel C, et al: Uterine compression suture for
postpartum bleeding with uterine atony. BJOG; 2007, 114:619-622.
33.Cho J, Jun H, Lee C: Haemostatic suturing technique for uterine
bleeding during caesarean delivery. Obstetr Gynecol; 2000, 96:129131.
34.Baskett T: Uterine compression sutures for postpartum haemorrhage.
Efficacy, morbidity and subsequent pregnancy. Obstetr Gynecol;
2007, 101:68-71.
35.Ochoa M, Allaire A, Stitley M: Pyometria after haemostatic square
suture technique. Obstetr Gynecol; 2002, 99:506-509.
36.Bhandal N, Russell R: Intravenous versus oral iron therapy for
postpartum anaemia. BJOG; 2006, 113:1248-1252.
M.E.J. ANESTH 20 (4), 2010
508
A. Rudra et. al
scientific articles
COMPARING TWO METHODS OF LMA INSERTION;
CLASSIC VERSUS SIMPLIFIED (AIRWAY)
Mohammad Haghighi*, Ali Mohammadzadeh*, Bahran Naderi*,
Abbas Seddighinejad* and Homa Movahedi*
Abstract
Background: The aim of this study is to compare two methods of LMA insertion, "classic"
versus "simplified" (AIRWAY), due to factors such as: time to insertion, number of attempts, blood
stained LMA, air leak around LMA, and gastric inflation. The word "AIRWAY" refers to the
similarity of this method to oropharyngeal airway insertion.
Method: One hundred ASA class I and II patients elected for lower limb orthopedic surgery
but without any head and face injury or head and neck abnormality, having their tooth intact, were
selected and divided to two groups of fifty; classic and simplified.
In the classic group, the index finger used as a guide, pushes the back of LMA towards the hard
palate, inserting it into the pharynx till a resistance is felt and the LMA is then fixed it its place.
In the AIRWAY group, the deflated LMA is entered into the mouth in a 180 degree insideout position compared to the classic method without using fingers and is proceeded until it enters
the pharynx (sudden loss of resistance) and then returned 180 degree back to its normal position
to be fixed in the right place. The attempt numbers, time to insertion, complications such as
laryngospasm, blood stained LMA and gastric inflation is being investigated.
Result: Demographic data such as age, sex and ASA class, demonstrate no meaningful
statistic difference between the two groups.
Successful first attempt in AIRWAY group (86%) had no meaningful statistic difference with
the classic group (80%) (p>0.05). The overall success rate in LMA insertion (within two attempts)
was 100% and 82% in AIRWAY and classic groups respectively (p>0.05) and 11 patients with
failed insertion attempts, were excluded from the study. The time for successful insertion was
meaningfully less in the AIRWAY group compared to the classic one (p<0.0001).In the classic
group 32% of LMAs became blood stained compared to 16% in the AIRWAY group, which
the difference was not meaningful. No other complications such as laryngospasm or oxygen
desaturation occurred.
Conclusion: Comparison of the whole advantages and disadvantages of both groups, mention
that, by putting the LMA insertion time together with the low complication rates, the AIRWAY method
can be assumed as a preferred simplified method with few complications for inserting LMA.
Keyword: LMA, Facilated method insertion, Airway management
From Dept. of Anesth. & Intensive Care Medicine, GUILAN Univ. of Medical Sciences, RASHT, Iran.
*
Assistant Professor of Anesthesia and Intensive Care.
Corresponding author: Dr. Mohammad Haghighi, Department of Anesthesiology and Intensive Care Medicine, Guilan,
University of Medical Sciences, Rasht, Iran. Tel: 0098 9113315256, Fax: 0098 1317764118.
E-mail: [email protected]
509
M.E.J. ANESTH 20 (4), 2010
510
Introduction
LMA has changed to a common alternative way
in airway management. This instrument has been used
more successfully by inexperienced staff and has given
an appropriate way in managing the airway both in
controlled and spontaneous breathing methods.
Considering the problems of a successful airway
management which occurs frequently in unauthorized
people (e.g.: residents, health care centers staff) in
ERs and trauma centers, LMA works as a supraglottic
airway manager which is placed close to the larynx to
let spontaneous or controlled ventilations with airway
pressures less than 15 mmHg be applied5 even in prone
and lateral positions1,2,3,4,6.
There are several methods of inserting LMA none
of them considered to be the definite one2,3, but all tend
to decrease the complications7,8,9,10,11.
One of these methods is the classic one, with
LMA inflated a little and another method used in
paralyzed patients is the triple airway maneuver with
the patient's mouth opened, head extended and forward
mandibular pressure12.
In the standard method of inserting LMA usually
the cuff is empty and the first attempt success rate is
672,3,11%90-. A little inflation of the cuff is useful in
LMA passing posterior pharyngeal arch and eases
the insertion resulting a higher success rate. Here the
instrument is positioned midline and while having direct
contact with patient's mouth and tongue is preceded
forward into the pharyngeal space via some help from
operator's hand in contact with the esophagus touching
it with LMA's tip2,3,4,7,8.
In this study we inserted the LMA with a new
approach which is similar to the way an oral airway
is inserted and thus is named the AIRWAY method.
This method was first practiced as a pilot on 20 cases
and demonstrated itself as an easier method with less
complications besides not having those problems such
as hand entrance into patient's mouth and contact with
patient's tooth which can be harmful13,14.
Patients and Methods
In this study which was performed on the first 6
months of 1386 in Pursina educational hospital, one
hundred ASA class I and II parents candidate for limb
M. Haghighi et. al
orthopedic surgery but without any head and facial
injury or head and neck abnormality, having their tooth
intact, were selected and divided into two groups of
fifty; classic and simplified (airway).
Informed contest was achieved from the patients
and any patient having any contraindications for LMA
insertion was excluded. Insertions were performed
randomly by anesthesiologists with at least 100
successful LMA insertions.
Two groups of 50; named AIRWAY (facilitated)
and CLASSIC were studied. In the classic method, the
index finger is used as a guide which by pushing the
back of LMA towards the hard palate, slides it into the
pharynx up to the point of feeling a resistance. The
LMA cuff is then filled with an appropriate volume of
air and then fixed in place.
In the airway method the LMA without being
primarily filled with air, is turned in a 180 degree
inside-out position compared to the classic position and
is inserted into the patient's mouth without contacting
the anesthesiologist's hand till there is a sudden loss
of resistance due to pharyngeal entrance, and then is
returned 180 degree to the normal position and inserted
in the pharynx (Figure 1-6).
Induction of anesthesia was done with fentanyl
(12-μg/kg), TPN (46-mg/kg), Succynilcholine (0.5mg/
kg). Maintenance was with Halothane and O2/N2O
(50%/50%) while the patient breathing spontaneously.
All patients received ECG, SpO2 & ETCO2
monitoring while airway management efficacy
was supervised by bilateral auscultation, chest wall
movement and no resistance in inspiration and
expiration and finally confirmed by ETCO2.
Insertion ease was considered as the time needed
for LMA insertion from the beginning to ventilation
confirmation.
The number of insertion efforts and complications
such as laryngospasm, blood-stained LMA and
abdominal distention was also evaluated. Epigastric
area auscultation during manual ventilation was done
and if insertion failed it was repeated by giving repeated
doses of TPN and after the third failure, alternative
methods were used for airway management.
Airway efficiency and patency and LMA position
was checked by a resident who didn't know anything
COMPARING TWO METHODS OF LMA INSERTION; CLASSIC VERSUS SIMPLIFIED (AIRWAY)
Figire 1
The patient candidate for LMA insertion
Figire 4
LMA direction to pharynx
Figire 2
Without hand contact
Figire 5
The 180˚ rotation of LMA
Figire 3
LMA insertion as airway method
Figire 6
Total insertion of LMA
511
M.E.J. ANESTH 20 (4), 2010
512
M. Haghighi et. al
about the patient's group and air leak was detected by
giving 20 CmH2O pressure and divided into grade 1:
no leak; grade 2: palpable leak; grade 3: just palpable
leak with appropriate ventilation; grade 4: audible leak
with inappropriate ventilation and grade 5: complete
obstruction with no ventilation.
age, weight, and ASA class had also no difference
(Table 1).
Because the airway method compared to the
classic method increases the first attempt success
rate from 70% to 95% so with α = 0.05 and power
of 90%, the number of patients in each group was
calculated as 50.
Successful first attempt insertion rate in airway
group was 86% compared to classic group as 80% with
no meaningful difference (p>0.05).
The data collected was analyzed be SPSSver
10 and compared in two groups with unpaired T-Test
or MANWITHNYU by case. Again Chi-square test
was used to analyze numerical data and p<0.05 was
considered as meaningful.
Results
One hundred patients entering in two groups of
50, the classic group contained 36 male and 14 female
and the airway group 41 and 9 respectively with no
meaningful difference. Demographic data such as
In the classic group 90% of patients had LMA
number 4 and 10% number 3 and in the airway
group 86% and 14% respectively, which showed no
meaningful difference.
Eleven patients were excluded from the study
because of unsuccessful insertion. The successful
insertion time was meaningfully shorter in airway
group than classic (p<0.0001).
Blood stained LMA rate was 32% in classic and
16% in airway group with no meaningful difference.
No laryngospasm or SpO2 decrease occurred. Gastric
distention from positive pressure ventilation was
meaningfully more in classic than airway group. Air
leak was 76% in grades 1 and 2 and 24% in grade 3 of
the classic group compared to 88% and 12% in airway
group respectively with no meaningful difference
(p>0.05).
Table 1
Demographic, monitoring and Parameters complication data
parameter
Classic group
Airway group
P value
Age (years) (mean ± SD)
N = 50
30 ± 9.4
N = 50
32 ± 7.9
ns
Weight (kg) (mean ± SD)
68 ± 9.6
10.7 ± 70
ns
3614/
419/
ns
-----
-----
372 ± 51
363 ± 33
4
90%)45(
86%)43(
3
10%)5(
14%)&(
sex m/f
Use of facilitative method
Thiopental Na(mg)
size LMA
ns
ns
No .Of attempt( n)
ns
1
80%)40(
86%)43(
2
12%)6(
14%)7(
3
8%)4(
-----
Time of successful insertion(min)
21.7 ± 4.8
10.6 ± 3.7 6
<0.0001
Blood on LMA (n)
(16)32%
(8)16%
0.06
Gastric insuffilation (n)
(11)22%
(5)10%
ns
Leak around the cuff (n)
Grade 1
Grade 2
Grade 3
(20)40%
(18)36%
(12)42%
(22)44%
(22)44%
(6)12%
ns
ns
ns
COMPARING TWO METHODS OF LMA INSERTION; CLASSIC VERSUS SIMPLIFIED (AIRWAY)
Discussion
Using airway method is shown to be more
successful in LMA insertion in terms of time
needed compared to classic method. Analyzed data
demonstrated less time needed in airway method. The
disadvantage of standard method of inserting LMA
is that in this form, LMA slides over the tongue and
may displace the tongue and epiglottis posteriorly but
the alternative methods such as semi-filled or lateral
usually make less mechanical insult and easier LMA
passage.
The results show 80% success rate in the first
attempt. In airway method there was a 86% success
rate in first attempt and 14% in the second one.
Condra et al had 97% and 100% success rates
respectively probably due to lower LMA cuff volume
which couldn't prevent posterior displacement of the
tongue as well.
A variety of LMA insertion methods have been
discussed. In Dingley et al study in Wales, 30% of
invertors used the original method while 34% used
the alternative ones like semi-filled for laryngoscopic
procedures.
Wakeling et al mentioned LMA complete filling
for facilitating its insertion and lessening mucosal
damage.
Dingley's studied about sore throat in 3 groups13
which showed that using insertion aid lowers the
complications.
Nagai S. et al used the modified method for
pediatric LMA insertion15, rotating it 90 degree and
after inserting two thirds of it through the larynx them
re-rotating it and leading it deeply.
513
Nakayama studied 145 pediatric cases using
rotating versus routine method9. The success rate in
first and second attempt was 99% versus 751,2,3,4% using
semi-filled method simultaneously which changed the
rates to 96% and 100% respectively.
One of our limitations was blinding the LMA
insertion time and the number of attempts. We used
another person for recording the results to lessen the
bias of time and number of attempts.
Airway method insertion facilitates LMA passage
towards the larynx and sliding over the tongue.
Successful attempts correlates well with complications
such as hypoxia, laryngospasm, and trauma, due to the
number of attempts (secondary to light anesthesia and
mucosal damage).
Complications in two groups were not in a
meaningful range but further studies with larger groups
may give more acceptable results. Gastric distention
due to displacement of LMA is appropriate in airway
group which can be considered as a success factor.
Many methods including low inflation, jaw trust,
LMA insertion education, airway axis usage, fiberoptic
bronchoscopic insertion and NGT guidance all have
advantages and disadvantages3,6,7,8,4,5.
Our study doesn't need low inflation, special
maneuvers such as jaw trust and aiding instruments.
This method is known as a facilitating method for
LMA insertion7,8,9,11,10.
Overall comparison of success and failure rates
in this method including the insertion time, shows that
the airway method can be considered as a facilitating
method with low complication rates.
Further studies with larger groups are needed to
clarify the differences between different methods.
M.E.J. ANESTH 20 (4), 2010
514
M. Haghighi et. al
References
1. Brain AIJ: The laryngeal mask-a new concept in airway management.
Br J Anaesth; 1983, 55:801-805.
2. Wakeling HG, Butler PJ, Baxter PJ: The laryngeal mask airway: a
comparison between two insertion techniques. Anesth Analg; 1997
Sep, 85(3):687-90.
3. Lopez-Gill M, Brimacombe J, Alvarez M: Safety and efficacy of the
laryngeal mask airway. Anesthesia; 1996, 51:969-972.
4. Dingley J, Asai T: Insertion methods of the laryngeal mask airway:
a survey of current practice in Wales. Anaesthesia; 1996, 51:596599.
5. Gursoy F, Algren JT, Skjonsby BS: Positive pressure ventilation
with laryngeal mask airway. Anesth Analg; 1996, 82:33-38.
6. Dingley J, Baynham P, Swart M, Vaughan RS: Ease of insertion of
the laryngeal mask airway by inexperienced personnel when using
an introducer. Anesthesia; 1997 Aug, 52(8):756-60.
7. García-Aguado R, Viñoles J, Brimacombe J, Vivo M, LópezEstudillo R, Ayala G: Suction catheter guided insertion of the
ProSeal laryngeal mask airway is superior to the digital technique.
Can J Anaesth; 2006 Apr, 53(4):398-403.
8. Brimacombe J, Keller C, Judd DV: Gum elastic bougie-guided
insertion of the ProSeal laryngeal mask airway is superior to the
digital and introducer tool techniques. Anesthesiology; 2004 Jan,
100(1):25-9.
9. Nakayama S, Osaka Y, Yamashita M. The rotational technique with
a partially inflated laryngeal mask airway improves the ease of
insertion in children. Paediatr Anaesth; 2002 Jun, 12(5):416-9.
10.Hsu YW, Pan MH, Huang CJ, Cheng CR, Wu KH, Wei TT, Chen
CT: Comparison of the cuffed oropharyngeal airway and laryngeal
mask airway in spontaneous breathing anesthesia. Acta Anaesthesiol
Sin; 1998 Dec, 36(4):187-92.
11. Matta BF, Marsh DS, Nevin M: Laryngeal mask airway: a more
successful method of insertion; 1995 Mar, 7(2):132-5.
12.Aoyama K, Takenaka I, Sata T and Shigematsu A: The triple airway
maneuver for insertion of the laryngeal mask airway in paralyzed
patients. Can J Anesth; 1995, 42:1010-1016.
13.Brimacombe J, Holyoake L, Keller C, Brimacombe N, Scully M,
Barry J, Talbutt P, Sartain J, McMahon P: Pharyngolaryngeal,
neck, and jaw discomfort after anesthesia with the face mask and
laryngeal mask airway at high and low cuff volumes in males and
females. Anesthesiology; 2000 Jul, 93(1):26-31.
14.Dingley J, Whitehead MJ, Wareham K: A comparative study of the
incidence of sore throat with the laryngeal mask airway. Anaesthesia;
1994 Mar, 49(3):251-4.
15.Nagai S, Inagaki Y, Harada T, Watanabe T, Hirosawa J, Ishibe Y:
A modified technique for insertion of the laryngeal mask airway in
children. Masui; 2000 Dec, 49(12):1367.
PRETREATMENT WITH REMIFENTANIL IS ASSOCIATED
WITH LESS SUCCINYLCHOLINE-INDUCED
FASCICULATION
Karim Nasseri**, Mehdi Tayebi Arastheh*
and S hoaleh S hami **
Abstract
Background: Succinylcholine is a popular muscle relaxant and one of its most common
side effects is muscle fasciculation. The purpose of this study was to evaluate the efficacy of
remifentanil in preventing succinylcholine-induced fasciculation in patients undergoing general
anesthesia.
Methods: In a prospective, double blind study, 60 ASA I & II patients were randomly assigned
into two groups (30 each) to receive either remifentanil1 µg/kg (Group R), or saline 3 ml (Group
S) as a pretreatment agent, one minute before induction of general anesthesia by propofol, fentanyl,
and 1.5 mg/kg succinylcholine. The duration and the intensity of fasciculation were assessed using
a four-point rating scale. Data were analyzed by Mann-Whitney U-test, Fisher exact test and
Student-t-test using SPSS software.
Results: In the remifentanil group the duration (p<0.001) and the intensity (p<0.001) of
fasciculation were lower compared to the saline group. However the incidence of bradycardia was
higher in the remifentanil group in comparison to the group which received normal saline.
Conclusions: Our findings indicate that remifentanil can reduce the duration and the intensity
of succinylcholine induced fasciculation. However, it induces greater bradycardia.
Key words: remifentanil, succinylcholine, propofol, fasciculation.
From Departments of Anesthesia and Intensive Care and Faculty of Nursing and Midwifery.
*
Kurdistan University of Medical Sciences, Sanandaj, Iran.
** Faculty of Nursing and Midwifery.
Corresponding author Dr. Karim Nasseri: Be’sat Hospital, Keshavarz St, Sanandaj, Iran. Tel: +989183715405,
Fax: +988716664663. E-mail: [email protected].
515
M.E.J. ANESTH 20 (4), 2010
516
Introduction
Succinylcholine survives into its sixth decade
(1952 to the present) by distinctive advantages, namely,
low cost, fast onset of action, fast recovery, excellent
muscular relaxation, and nontoxicity of its metabolites1.
However, it has some undesirable side effects, such as
fasciculation and postoperative myalgia.
Numerous methods have been used to alleviate or
attenuate fasciculation2,3. Although these methods were
helpful to a certain extent, each one had drawbacks of
its own.
Remifentanil is a synthetic and esterasemetabolized opioid with a rapid onset, an ultra-short
duration of action and a stable, short context-sensitive
half time compared with other opioids4,5. Recent
studies have suggested that propofol in combination
with remifentanil may have muscle relaxant
properties and could provide adequate conditions for
laryngoscopy and tracheal intubation without using
muscle relaxants6,7.
We designed a prospective double blind,
randomized study to evaluate the effectiveness of
remifentanil in preventing fasciculation following
succinylcholine injection in patients anesthetized with
propofol, fentanyl, and succinylcholine.
Methods
After approval by our institutional Ethics
Committee and procurement of patients’ written
informed consent, we studied 60 adult patients, ASA
physical status I or II, scheduled for ambulatory
urological or gynecological surgery under general
anesthesia. This study was carried out in the Be’sat
Hospital, Keshavarz St. Sanandaj, Iran. Exclusion
criteria included known allergy to the pretreatment
agent arrhythmia, hypo-or hypertension, dehydration,
hyperkalemia, increased intraocular pressure,
increased intracranial pressure, history of malignant
hyperthermia, presenting a difficult airway,
pregnancy, treatment with any drug known to interact
with neuromuscular function, and significant renal,
neuromuscular, or hepatic disease.
The observer and the patients were unaware of the
pretreatment used and patients were randomized using
computer-generated random numbers into two groups
K. Nasseri et. al
(30 each) in accordance to the pretreatment designed:
NaCl 0.9% (control), and remifentanil 1µg/kg (study)
that were always adjusted to a 3-mL volume. Standard
monitoring included ECG, non-invasive oscillometric
blood pressure, pulse oximetry, and end-tidal carbon
dioxide levels.
No agent was given for premedication. The
induction regimen was standardized for all patients
and consisted of the following:
At time 0, injection of fentanyl 1 µg/kg together
with the pretreatment designed for each group;
2 min later, anesthesia was induced with propofol
2 mg/kg IV and succinylcholine 1.5 mg/kg. Following
succinylcholine, the patient was observed by an
observer who was unaware of patient’s group and
fasciculation was graded according to a 4-point rating
scale8:
no fasciculation = 0.
mild, fine fasciculation of the eyes, neck, face or
fingers without limb movement = 1.
moderate fasciculation occurring at more than
two sites or obvious limb movement = 2.
vigorous or severe, sustained, and widespread
fasciculation = 3.
Changes in the cardiac rhythm or blood pressure
following induction of anesthesia were also recorded.
Patients were ventilated via face mask and none
of them intubated. Anesthesia was maintained with
a mixture of N2O/O2 60%/40% with isoflurane11.3%.
Sample-size calculation was performed based on
the pilot study, in that, the incidence of fasciculation
was 96%, and we aimed at detecting a decrease to less
than 50% with remifentanil pretreatment. With a power
of 80% and type 1 error of 5%, we calculated that 30
subjects were required per group.
Statistical analysis was performed using SPSS
14.0 for Windows. Demographic data were analyzed by
using the Mann-Whitney U-test. The incidence and the
intensity of fasciculation were analyzed using Fisher’s
exact test and Student-t-test. Student’s t-test was used
to analyze bradycardia and arrhythmia between the two
groups. A value of P <0.05 was considered statistically
significant.
PRETREATMENT WITH REMIFENTANIL IS ASSOCIATED WITH LESS SUCCINYLCHOLINE-INDUCED
FASCICULATION
Results
Demographic data showed there was no ststistical
difference balance Groups R & S (Table 1).
Table 1
Demographic data and duration of surgery in Groups R-S
Age (years)
Group R
(n = 30)
31.3 ± 11.7
Group S
(n = 30)
37.8 ± 13.7
0.6
Weight (kg)
67.4 ± 10.9
69.4 ± 12
0.5
16:14
7 (2.4)
19:11
8 (3.1)
0.6
0.9
Gender ratio (m/f)
Duration of surgery (min)
P
Group R: Remifentanil. Group S: Saline 0.9%
Values are mean ± sd or numbers (gender ratio).
The duration and the intensity of muscle
fasciculation
were
significantly reduced
by
pretreatment with remifentanil as compared to that of
saline: (P<0.05) (Table 2).
Table 2
The duration and the intensity of muscle fasciculation in
Group R & S
Pretreatment
Group R
Group S Differeces (95%
(n = 30)
(n = 30)
CI)
Intensity
0(n)
4*
1
1(n)
20*
12
2(n)
5*
10
3(n)
1*
7
Duration(second) 21.4(17.8) 41.9(20.6)* 20.5(10.2-30.9)
Group R: Remifentanil. Group S: Saline 0.9%
* P<0.05 compared with Group NS.
Baseline MAP and HR values were not
significantly different between the two groups.
However, after induction of anesthesia, MAP decreased
significantly in group remifentanil compared to
baseline values (P<0.05). The percentage decrease in
MAP values from baseline was significantly higher in
Group remifentanil than in Group saline (16.6% ± 11.8
vs. 6.3% ± 10.7); (P<0.05). Ephedrine was not used in
any patient.
Following induction of anesthesia, HR decreased
in Group remifentanil compared to baseline (P<0.05);
whereas, HR in Group saline did not show significant
changes compared to baseline. Also, the percentage
change from baseline HR values was significantly
higher in Group remifentanil than in Group saline
(19.2% ± 9.7 vs. 2.9% ± 12.4). In Group remifentanil,
eight patients developed a decrease of HR by more than
517
20% from baseline necessitating the use of atropine,
while in Group saline none of the patients required
atropine (P<0.05).
Discussion
Succinylcholine is the relaxant of first choice
for endotracheal intubation and for short operative
procedures requiring good muscular relaxation.
However, its use is associated with considerable
fasciculation.
Fasciculation have been attributed to a
prejunctional depolarizing action of succinylcholine,
resulting in repetitive firing of the motor nerve
terminals and antidromic discharges that manifest
as uncoordinated muscle contractions9. To solve this
problem, several preventive methods had been tried
including: pre-treatment with a small dose of nondepolarizing muscle relaxant10, Pre-treatment with
lignocaine11, diazepam12, magnesium sulphate13, highdose Propofol14, and self-timing of succinylcholineinduced fasciculation15.
Few studies have been designed to evaluate the
effect of pretreatment with opioids on succinylcholine
induced fasciculation, none of them used remifentanil.
Lindgren and colleagues designed16 a prospective
study to compare the effects of tubocurarine,
alcuronium, pancuronium, and fentanyl on muscle
fasciculation associated with succinylcholine in 171
children undergoing otolaryngological surgery. They
concluded that the most effective pre-treatment was
fentanyl (2.0 µg/kg) followed, in order, by alcuronium,
fentanyl (1 µg/kg), tubocurarine and pancuronium. In
another study with a different design, the same authors
evaluated the change in intragastric pressure after
the administration of succinylcholine in 32 children
pretreated with physiological saline or alfentanil
50 µg/kg. anesthesia was induced with thiopentone
5 mg/kg. They concluded that alfentanil 50 µg/kg
effectively inhibits the incidence and the intensity
of succinylcholine induced muscle fasciculation,
moreover, intragastric pressure remains in control
values17.
Yli-Hankala and colleagues18 studied the effects
of alfentanil on succinylcholine induced muscle
fasciculation, in a double blind study in 34 children and
M.E.J. ANESTH 20 (4), 2010
518
30 adults. They concluded that alfentanil significantly
decreased the intensity of visible fasciculation caused
by succinylcholine. In children the duration of muscle
fasciculation was shorter in the alfentanil group than in
the control group. In adults, the intensity rather than the
duration of fasciculation was attenuated by alfentanil.
The inhibition of fasciculation caused by alfentanil was
demonstrated in children in electromyogram recorded
on the biceps muscle.
Our results demonstrated the efficacy of 1 µgkg remifentanil in reducing both the incidence and
the intensity of fasciculation. All patients of our study
received fentanyl as premedication, and propofol as
anesthesia inducing agent, so fentanyl and/or propofol
could not here influenced the results.
The mechanism of the inhibitory action of
remifentanil on succinylcholine induced muscle
fasciculation is unclear. Remifentanil is a new
synthetic μ opioid agonist that is characterized by a
rapid onset of action due to a short blood-effect site
equilibration half-time and a rapid offset of action due
to its high clearance by nonspecific blood and tissue
esterases19. On the other hand, Propofol has been
shown to decrease muscle tone in a dose-dependent
manner in clinical use, and this effect is attributed not
only to the central nervous system depression but also
to a block in the skeletal muscle sodium channels14.
Additionally, the administration of propofol 3.5 mg/
kg may attenuate both the incidence and the intensity
K. Nasseri et. al
of muscle fasciculation14. All patients in our study
received an induction dose of propofol (2 mg kg-1),
that did not attenuate fasciculation20,21.
Propofol and remifentanil are both shortacting anesthetic agents that complement each other
pharmacodynamic profiles (i.e., hypnosis, analgesia
and return of consciousness)19. In a report, the
pharmacodynamics of remifentanil and its interaction
with propofol were investigated. The authors reported
that propofol reduces remifentanil requirements to
suppress responses to laryngoscopy, intubation, and
intra-abdominal surgical stimulation in a synergistic
manner19. Remifentanil combined with propofol is
therefore a promising combination for preventing
succinylcholine induced muscle fasciculation.
There are some limitations with this study. First,
the study design was observational, and we measure
a subjective variable (fasciculation) rather than
objective variables (increase in potassium, myoglobin,
and CPK).The objective variables are not as easy to
measure as fasciculation22. Second: We evaluated only
remifentanil; therefore, comparisons to other drugs
especially non depolarizing muscle relaxants, cannot
be made.
In conclusion, we believe that remifentanil 1
µg/kg administered for induction of anesthesia is
capable of reducing the incidence and the intensity of
succinylcholine-induced fasciculation, however, it can
concomitantly induce bradycardia.
PRETREATMENT WITH REMIFENTANIL IS ASSOCIATED WITH LESS SUCCINYLCHOLINE-INDUCED
FASCICULATION
519
References
1. Chingmuh Lee, Ronald L. Katz: Clinical implications of new
neuromuscular concepts and agents: So long., neostigmine! So long,
sux!. Journal of Critical Care; 2009,24(1):43-49.
2. Yanez P, Martyn JA: Prolonged d-tubocurarine infusion and/or
immobilization cause upregulation of acetylcholine receptors and
hyperkalemia to succinylcholine in rats. Anesthesiology;1996,
84(2):384-91.
3. Kopman AF, Klewicka MM, Ghori K, Flores F, Neuman GG:
Dose-response and onset/offset characteristics of rapacuronium.
Anesthesiology; 2000, 93(4):1017-21.
4. Egan TD: Remifentanil pharmacokinetics and pharmacodynamics.A
preliminary appraisal. Clin Pharmacokinet; 1995, 29:80-94.
5. Egan TD, Minto CF, Hermann DJ, Barr J, Muir KT, Shafer SL:
Remifentanil versus alfentanil: comparative pharmacokinetics and
pharmacodynamics in healty adult male volunteers. Anesthesiology;
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6. Begec Z, Demirbilek S, Ozturk E, Erdil F, Ersoy MO: Remifentanil
and propofol for tracheal intubation without muscle relaxant
in children:the effects of ketamine. Eur J Anaestesiol; 2009,
26(3):213-7.
7. Massó E, Sabaté S, Hinojosa M, Vila P, Canet J, Mass E, Langeron
O: Lightwand tracheal intubation with and without muscle relaxation.
Anesthesiology; 2006, 104(2):249-54.
8. Joshi GP, Hailey A, Cross S, et al: Effects of pretreatment with
cisatracurium, rocuronium, and d-tubocurarine on succinylcholineinduced fasciculations and myalgia: a comparison with placebo. J
Clin Anesth; 1999, 11:641–5.
9. SF, Wong, F Chung: Succinylcholine-associated postoperative
myalgia. Anaesthesia; 2002, 55(2):144-152.
10.Betteli G:Which muscle relaxants should be used in day surgery
and when. Curr Opin Anaesthesiol; 2006, 19(6):600-5.
11.Amornyotin S, Santawat U, Rachatamukayanant P, Nilsuwankosit
P, Pipatnaraphong H: Can lidocaine reduce succinylcholine-induced
myalgia? J Med Assoc Thai; 2002, 85:969-74.
12.Hassani M, Sahraian MA: Lidocaine or diazepam can decrease
fasciculation induced by succinylcholine during induction of
anesthesia. Middle East J Anesthesiol; 2006, 18(5):929-31.
13.Sakuraba S, Serita R, Kosugi S, Eriksson LI, Lindahl SG, Takeda
J: Pretreatment with magnesium sulphate is associated with less
succinylcholine-induced fasciculation and subsequent tracheal
intubation-induced hemodynamic changes than precurarization with
vecuronium during rapid sequence induction. Acta Anaesthiol Belg;
2002, 57(3):253-7.
14.Karamaz A, Kaya S, Turhanoglu S, Ozyilmaz MA: Effects of
high-dose propofol on succinylcholine-induced fasciculations and
myalgia. Acta Anaesthiol Scnd; 2003, 47(2):180-4.
15.Baraka, A: Self-taming of succinylcholine-induced fasciculations.
Anaesthesiology; 1977, 46:292-293.
16.Lindgren L, Saarnivaara L: Effect of competitive myoneural
blockade and fentanyl on muscle fasciculation caused by
suxamethonium in children. Br J Anaesth;1983, 55(8):747-51.
17.Lindgren L, Saarnivaara L: Increase in intragastric pressure
during suxamethonium-induced muscle fasciculations in children:
inhibition by alfentanil. Br J Anaesth;1988, 60(2):176-9.
18.Yli-Hankala A, Randell T, Varpula T, Lindgren L: Alfentanil
inhibits muscle fasciculations caused by suxamethonium in children
and in young adults. Acta Anaesthiol Scnd;1992, 36(6):588-91.
19.Mertens MJ, Olofsen E, Engbers FH, Burm AG, Bovill JG, Vuyk
J: Propofol reduces perioperative remifentanil requirements in a
synergestic manner. Anesthesiology; 2003, 99:347–59.
20.Manataki AD, Anaoutoglu HM, Tefa LK, Glatzounis GK,
Papadopoulos GS: Continuous propofol administration for
suxamethonium-induced postoperative myalgia. Anaesthesia; 1999,
54:419-22.
21.Smith I, Ding Y, White PF: Muscle pain after outpatient laparoscopyinfluence of propofol versus thiopental and enflurane. Anesth Analg;
1993, 76:1181-4.
22.Theroux MC, Rose JB, Ivengar S, Katz MS: Succinylcholine
pretreatment using gallamine or mivacurium during rapid sequence
induction in children: a randomized, controlled study. J Cin Anesth;
2001, 13(4):287-92.
M.E.J. ANESTH 20 (4), 2010
520
K. Nasseri et. al
EPIDURAL ANALGESIA DURING LABOR-0.5%
LIDOCAINE WITH FENTANYL VS 0.08%
ROPIVACAINE WITH FENTANYLWesam F. Mousa*, R.R. Al-Metwalli**
and M anal M ostafa ***
Abstract
Background: Although lidocaine is a cheap and globally available local anesthetic, yet it
is not a popular drug for labor analgesia. This is claimed to its higher intensity of motor block,
possibility of transient neurological symptoms (TNS) and its placental transfer with probable
drawbacks on fetal well-being. However, these effects could be concentration dependent and, the
evidence linking them to lidocaine is still lacking. This study was designed to evaluate the efficacy
and safety of 0.5% epidural lidocaine plus fentanyl during labor.
Methods
One hundred and twenty healthy full term nulliparous women in early labor with a single fetus
presented by the vertex were enrolled in this randomized, double-blind clinical trial. Parturient
were assigned to receive epidural analgesia either with lidocaine 0.5% plus fentanyl 2 µg-1mL (LF),
or ropivacaine 0.08% plus fentanyl 2 µg-1ml (RF) when their cervix was dilated to 4 centimeters.
Analgesia was provided with 20 ml bolus of the study solution and maintained at 10 ml-1h. Upper
level of sensory loss to cold, Visual Analogue Pain Score (VAPS), motor block (modified Bromage
score), the duration of the first and second stages of labor, numbers of instrumental vaginal and
cesarean deliveries, the neonatal apgar score, patient satisfaction and side effects, were recorded.
Results
There were no significant differences in sensory level, pain scores, duration of the first and second
stages of labor, numbers of instrumental and cesarean deliveries, the neonatal apgar scores, patient
satisfaction or side effect between groups. Although motor block was significantly high in lidocaine
group compared to ropivacaine group (p<0.05), all parturient were moving satisfactorily in bed.
Conclusions
Dilute epidural lidocaine (0.5%) with fentanyl effectively and safely initiates epidural
analgesia clinically indistinguishable from 0.08% epidural ropivacaine with fentanyl. Although
it induces significant motor block compared to ropivacaine, it still preserves maternal ability to
move satisfactorily in bed. Whether further reduction in lidocaine concentration could trim down
the motor block, remains to be investigated.
Keywords: Anesthesia: Obstetric Technique: Epidural Drug: Lidocaine.
*
Assistant Professor of Anesthesia and Intensive Care, Tanta University, Egypt. Consultant Anesthesia
and Intensive Care, Qatif Central Hospital, Saudi Arabia.
** Assistant Professor of Anesthesia and Intensive Care, King Faisal University.
P.O. Box: 40081, Post Code: 31952, Al-Khobar, Saudi Arabia.
*** Assistant Professor of Obstetric and Gynecology, Tanta University, Egypt.
Correspondence to: Dr. Wesam Farid Mousa, Qatif Central Hospital.
P.O. Box: 18476, Post Code 31911, Al- Qatif, Saudi Arabia. E-mail: [email protected]
521
M.E.J. ANESTH 20 (4), 2010
522
Introduction
Lidocaine can be used to provide complete
analgesia during labor, yet it has been frequently
accused with higher intensity of motor blockade that is
frequently linked to bad obstetric and fetal outcome as
well as decreased maternal satisfaction. As with other
local anesthetics1-3, lowering lidocaine concentration
and addition of fentanyl, could minimize the intensity
of the motor block while maintaining effective
analgesia.
Although TNS usually occur after spinal
anesthesia, likely with hyperbaric lidocaine4, they are
uncommon after epidural anesthesia with different
types of local anesthetics5,6. Despite clear evidence
of placental transfer of lidocaine at rate of 0.5/0.77,
reported effects on the newborn have been subtle and
probably not clinically significant.
Our purpose of this study is to evaluate the efficacy
and safety of 0.5% lidocaine plus fentanyl 2 µg-1ml
for epidural analgesia during labor, in comparison to,
ropivacaine 0.08% plus fentanyl 2µg-1ml.
Methods
This prospective, double-blind, randomized
study protocol was developed in collaboration with
obstetricians. After approval of the local Ethics
Committee and patients’ written informed consent, one
hundred and twenty parturients were en rolled in this
study. Inclusion criteria included: request for analgesia,
nulliparity, age18-35 years, body weight <90 kg, ASA
physical status I or II, gestational age 37 <weeks,
single fetus in cephalic presentation, normal fetal
heart rate and cervical dilatation of 3-5 cm. Exclusion
criteria included: patients receiving analgesia prior
to enrollment, presence of complicated hypertension,
diabetes mellitus, neurological disease, recent
hemorrhage, preeclampsia, eclampsia, suspicion of
fetal malformation or intrauterine growth retardation,
fever of more than°38 C or history of allergy to local
anesthetics.
Parturients were randomized by using a computergenerated randomization table to receive epidural
analgesia of either 0.5% lidocaine with fentanyl 2µg1
ml (LF), or 0.08% ropivacaine with fentanyl 2µg-1ml
(RF). The LF solution was attained by adding 62.5 ml
W. F. Mousa et. al
lidocaine 1% (625 mg) and 5 ml of fentanyl (250 µg) to
a 57.5 ml of preservative-free 0.9% saline. The while
RF solution was attained by adding 20 ml of 0.5%
ropivacaine (100 mg) and 5 ml of fentanyl (250 µg) to
a 100 ml of preservative-free 0.9% saline. Twenty ml
was then removed from the resultant 125 ml of either
LF or RF solutions to be given to an anesthesiologist
not directly involved in the patient’s care or data
collection to initiate epidural analgesia. The remaining
105 ml of each study solution was used for continuous
epidural analgesia (10 ml-1 hr).
Maternal oxygen saturation (SpO2), heart rate and
automated noninvasive blood pressure were monitored
throughout labour.
Upon request of epidural analgesia, each parturient
was preloaded with 500 ml of lactated Ringer>s
solution before the initiation of epidural analgesia. A
20-gauge epidural catheter (SIMS Portex LTD, UK)
was inserted under aseptic precautions in the lateral
position at L3-L4 or L4-L5 interspaces with the loss
of resistance to saline technique. The epidural catheter
was then secured and the parturient placed in the supine
position with left uterine displacement with the head of
the bed elevated 20-30 degrees. Labor analgesia was
initiated by the blinded anesthesiologist with a total
volume of 20 ml of one of the study solutions given as
four fractionated boluses (5 ml-each) within 4 minutes
to achieve a bilateral block at ≥T 10-sensory level.
Once the epidural analgesia is established, continuous
infusion of 10 ml per hour of the analgesic solution
was delivered to the laboring women to maintain labor
analgesia. Further boluses of 5-10 ml of lidocaine 0.5%
or ropivacaine 0.08% were given from the allocated
randomized syringes for breaking through pain. Each
fractionated dose was managed as a test dose (aspirating
the catheter to detect accidental intravascular injection
while unintended intrathecal administration of the
epidural analgesic was recognized by the observation
of a rapid onset of profound analgesia similar to that
observed with intrathecally administered analgesics).
Hypotension (systolic blood pressure below 100
mmHg or a 20% reduction from baseline) was treated
with additional left uterine displacement, maternal
oxygen administration, IV fluid bolus, or ephedrine as
indicated.
The visual analogue pain scale (VAPS) [0-100
EPIDURAL ANALGESIA DURING LABOR-0.5% LIDOCAINE WITH FENTANYL VS 0.08%
ROPIVACAINE WITH FENTANYL-
mm scale: 0 = no pain, 100 = worst pain ever] was
measured at the peak of contractions before and 5,
10, 20, 30 min after the administration of the epidural
analgesia and then at hourly intervals.
Sensory level to cold, a Modified Bromage
Score (1 = complete block; unable to move feet or
knee, 2 = almost complete block; able to move feet
only, 3 = partial block; just able to move knee, 4 =
detectable weakness of hip flexion, 5 = no detectable
weakness of hip flexion while supine with full flexion
of knees) were obtained 30 min after epidural injection
and again at hourly intervals. Side effects including
nausea/vomiting, pruritis, backache, shivering, urinary
retention, and respiratory depression, were reported.
The duration of the first and second stages
of labor, mode of delivery (spontaneous vaginal,
instrumental vaginal vacuum-assisted and cesarean
deliveries), and 1, 5-min neonatal apgar scores were
recorded in each patient. Parturient satisfaction was
assessed immediately after delivery as excellent (score
4), good (score 3), fair (score 2), or poor (score 1).
Routine intrapartum monitoring was documented
by the obstetrician which included; electronic
continuous fetal heart rate monitoring (CFHM),
hourly progress of labor, cervical dilation, station, and
position of the fetal head, and the degree of caput and
molding.
The progress of labor is considered abnormal
523
if it is two or more hours beyond the normal rate of
progress (defined as 1 cm or more dilation per hour
during the active phase of labor). Abnormal progress of
labor was managed by artificial rupture of membranes,
oxytocin infusion or cesarean delivery according to
the obstetrician clinical judgment. Patients are allowed
to push when cervical dilation is confirmed and
when they have the desire to bear down. If maternal
effort was judged to be inadequate by the attending
obstetrician, epidural infusion rate was halved or
stopped. Prolonged second stage (failure to deliver the
fetus after the start of pushing for 1 h) was managed
with either ventouse extraction, obstetric forceps or by
cesarean delivery. The possibility of Transient Neural
Symptoms (TNS) [symmetric pain and/or dysesthesia
in the buttocks, lower lumbar region and/or legs] were
investigated in all parturients during the first three days
after delivery.
Statistical analysis was performed using unpaired
t test to compare parametric data whereas the Fisher>s
exact test was used to compare data expressed as
percentages. P<0.05 was considered significant.
Results
One hundred twenty four women were initially
included in the study. Four patients (two in each group)
were excluded due to accidental dural puncture. The
demographic, labor and delivery characteristics of the
parturients were similar in each group (Table1).
Table 1
Maternal Demographic Data and Labor Characteristics
LF
(n = 60)
RF
(n = 60)
p
26 ± 4.92
25 ± 4.39
0.311
Height (cm)
165.6 ± 3.59
166.367 ± 2.16
0.156
Weight (kg)
75.07 ± 2.25
77.13 ± 2.14
1.01
Gestational age (wk)
38.20 ± 1.18
38.28 ± 0.94
0.67
Duration of 1st stage (min)
539.67± 25.61
545.33 ± 26.13
0.23
Duration of 2nd stage (min)
61.33 ± 6.76
63 ± 6.59
0.17
36 (60%)
34 (56.66%)
0.85
56(93.33%)
1(1.66%)
2(3.33%)
1(1.66%)
55(91.66%)
1(1.66%)
3(5%)
1(1.66%)
1.00
1.00
1.00
1.00
Age (yr)
Oxytocin use (n) %
Mode of delivery (n):
Spontaneous vaginal
Instrumental vaginal
C/S (dystocia)
C/S (fetal distress)
M.E.J. ANESTH 20 (4), 2010
524
Fig. 1
VAPS at each observation time for the first 30 min. VAPS was maintained at zero
level throughout the study as was measured at hourly intervals
Visual Analog pain Scale
The number of neonates that
presented with Apgar scores below
7 at one and five minutes were not
significantly different between both
groups. None of the neonates needed
naloxone or NICU admission. Maternal
satisfaction was similar in both groups
(Table 2).
No significant differences were
detected in the incidence of side
effects or complications between the
two groups (Table 3). Twelve hours
postoperatively, three patients (2 in RF
group and 1 in LF group) developed
TNS that persisted for two days.
Lidocaine group
Visual Analog pain Scale
Ropivacaine group
VAPS (mm)
VAPSVAPS
(mm) (mm)
The upper level of sensory loss to
cold was similar in both groups after 30
min (Fig. 2). The epidural infusion was
maintained at a rate of 10ml l-h in both
groups without affecting the maternal
effort. No patient in either groups
requested supplementary analgesia.
Visual Analog pain Scale
Lidocaine group
Ropivacaine group
Lidocaine group
Ropivacaine group
40
60
pre5 min
10 min
20 min
30 min
30
50
injection
20
40
Time after injection (min)
10
30
200
pre5 min
10 min
20 min
30 min
10
0 injection
pre5 min
10 min
20 min
30 min
Time after injection (min)
injection
Level of sensory block
Distribution
50.00%
Time after injection
(min)
Fig.
2
Lidocaine group
of the upper level of sensory loss to cold atRopivacaine
30 min group
45.00%
40.00%
Level of sensory block
35.00%
Lidocaine group
30.00%
Level of sensory block
Ropivacaine group
Lidocaine group
50.00%
25.00%
Percent
of patients
Percent
of patients
The differences in motor block
between groups became noticeable
within 60 min of the initiation of
epidural analgesia and persisted
throughout labor. Patients in LF group
developed significantly more motor
block (85% of patients had modified
Bromage score of 4 and 15% had score
of 3) than patients in RF group (85% of
patients had modified Bromage score of
5 and 15% had score of 4). No patient in
either group developed profound motor
block (modified Bromage score of 1 or
2) (Fig. 3). Resolution of the sensory
and motor block was complete within
2 hours after delivery and discontinuing
the epidural infusion.
100
90
80
70
100 60
90 50
100
80 40
90
70 30
20
80
60
10
70
50 0
Percent of patients
Both solutions produced effective
analgesia during labor without
significant differences in VAPS at any
observation time for the first 30 min
(Fig. 1). VAPS was then maintained at
zero level throughout the study as was
measured at hourly intervals.
W. F. Mousa et. al
45.00%
20.00%
50.00%
15.00%
40.00%
45.00%
10.00%
35.00%
Ropivacaine group
40.00%
5.00%
30.00%
35.00%
0.00%
25.00%
30.00%
20.00%
T10
T9
T8
15.00%
5.00%
10.00%
0.00%
5.00%
T7
T6
T5
T4
T6
T5
T4
Dermatome
T8
T7
T6
T5
T4
Dermatome
25.00%
15.00%
20.00%
10.00%
T10
T9
0.00%
T10
T9
T8
T7
Motor Block
Dermatome
Lidocaine group
Ropivacaine group
90%
80%
70%
60%
The Percent
most intense
Of 50%
Patients 40%
Fig. 3
motor block experienced by each patient at any assessment
interval throughout
Motorlabour
Block is presented
Lidocaine group
30%
Motor Block
90%20%
80%10%
Ropivacaine group
Lidocaine group
0%
Ropivacaine group
70%
90%
60%
80%
50%
Percent Of 70%
Patients 60%
40%
30%
Percent Of 50%
Patients
1
2
3
4
5
Modified Bromage Score (1-5)
20%
40%
10%
30%
0%
20%
10%
1
0%
1
2
3
4
Modified Bromage Score (1-5)
2
3
4
Modified Bromage Score (1-5)
5
5
EPIDURAL ANALGESIA DURING LABOR-0.5% LIDOCAINE WITH FENTANYL VS 0.08%
ROPIVACAINE WITH FENTANYL-
Table 2
Apgar scores and Maternal Satisfaction
LF
(n = 60)
RF
(n = 60)
p
Apgar scores
First minute <7 (%)
2(3.33%)
2(3.33%)
1.00
Apgar scores
Fifth minute <7 (%)
2(3.33%)
1(1.66%)
1.00
Maternal Satisfaction
(%)
Excellent (4)
Good (3)
Fair (2)
Poor (1)
42(70%)
18(30%)
0
0
39(65%)
21(35%)
0
0
0.70
0.70
Table 3
Side Effects and Complications
LF
(n = 60)
RF
(n = 60)
p
Hypotension
2(3.33%)
1(1.66%)
1
Nausea/Vomiting
2(0.03%)
1(1.66%)
1
Pruritis
25(42%)
27(45%)
0.85
Backache
5(8%)
4(7%)
1
Shivering
3(5%)
3(5%)
1
Urinary retention
1(1.66%)
0
1
Respiratory
depression
0
0
Pain, dysesthesia
1(1.66%)
2(3.33%)
1
Discussion
This study showed that continuous epidural 0.5%
lidocaine with fentanyl effectively provides labor
analgesia comparable to epidural 0.08% ropivacaine
with fentanyl without significant adverse maternal
or fetal outcomes. Albeit, this low concentration of
lidocaine continues to be associated with significant
more motor block compared to ropivacaine, parturients
were able to ambulate adequately in bed with improved
maternal satisfaction. We chose that dilution of
ropivacaine/fentanyl for comparison because it became
the mainstay of routine painless labour in clinical
practice in many centers and it appears to provide a
true walking epidural8.
In recent years there has been a steady decline
in the concentrations of local anesthetics used for
epidural analgesia in labor1-3,8. Previous reports9,10 using
525
higher concentrations of continuous epidural lidocaine
for labor analgesia concluded that; associated high
intensity of motor block was not accompanied with
any detrimental effects in terms of obstetric outcomes,
duration of the second stage of labor, or the mode of
delivery. Our study using low lidocaine concentration
(0.5%) confirmed the previously mentioned studies
with the advantage of less motor block.
In the present study, the use of low concentrations
of epidural lidocaine (0.5%) continued to be associated
with sufficient motor block that precluded true
«walking epidural» (observed in ropivacaine group).
Despite the belief that links motor blocking properties
of epidurally administered analgesics to prolonged
second stage and increased instrumental delivery rate,
there are some studies, in which least concentrated
doses of local anesthetic were used for epidural
labor analgesia, and patients were able to walk, yet,
instrumentation delivery rate was increased11-13. Also,
Evron et al14 in their prospective, randomized double
blinded study showed that the lower intensity of the
motor block is not associated with any benefit in
terms of obstetric outcomes, duration of the second
stage of labor, and obstetric intervention. Moreover,
the clinical benefits of an ambulating parturient on
the progress of labour and labour outcome, other than
improved patient satisfaction, remain controversial15,16.
In addition Nafisi10 suggested that a pain free mother
can cooperate more fully and can push more effectively
and this may neutralize the left over motor blocking
effect of lidocaine observed in our study.
In our study, neonatal Apgar score values were
similar in both lidocaine and ropivacaine groups.
Lidocaine is frequently chosen for epidural anesthesia
for Cesarean delivery due to its rapid onset when
compared to bupivacaine. Epidural injection of large
dose of lidocaine during Cesarean section may result
in a greater accumulation of the drug in newborn17,18,
however, reported effects on newborns are probably not
clinically significant because the term fetus is able to
biotransform lidocaine by hepatic enzymatic activity7.
Our results showed that transient neurologic
toxicity (TNS) could occur after continuous epidural
analgesia with either lidocaine or ropivacaine with
no statistical differences between both groups. Other
studies described the occurrence of TNS after epidural
M.E.J. ANESTH 20 (4), 2010
526
analgesia during labor with bupivacaine, ropivacaine
and lidocaine5,6,19. Recently, Shifman et al5 investigated
the incidence of TNS in puerperas after epidural
analgesia during labor using either 1% lidocaine or
0.2% ropivacaine infusion compared to control. They
concluded that epidural analgesia during labor is not
a cause of TNS and the type of a local anesthetic
(lidocaine, ropivacaine) does not affect its incidence.
The incidence of TNS in our study is lower compared
to the previously mentioned study (2% versus 25% for
lidocaine and 3% versus 27% for ropivacaine). This
lower incidence could be credited to the use of lower
local anesthetic concentrations in our study.
Local anesthetics were first implicated as
potentially neurotoxic drugs after reporting cauda
equina syndrome following continuous spinal
anesthesia20. The Food and Drug Administration issued
a safety alert in May of 199221 warning practitioners
about the association of cauda equina syndrome with
continuous spinal anesthesia. Later in 1993, Schneider
et al22 reported a new syndrome of possible transient
neurologic toxicity (currently referred to as TNS) after
hyperbaric subarachnoid anesthesia with 5% lidocaine.
It was postulated by the authors that the stretching of
the cauda equina by the lithotomy position stretched
some of the nerve fibers within the cauda equina,
rendering them vulnerable to toxic potential of a 5%
solution of lidocaine. Wong et al. in 199623 reported
the first case of TNS after epidural anesthesia. In that
case, the patient received a total of 600 mg of 2%
lidocaine (preceded by 45 mg of 1% lidocaine as a test
dose) over a period of 20 minutes, to provide a level
of T7. In view of the large-dose of local anesthetic
injected (645 mg) and the large concentration used, the
transdural transfer of lidocaine would have resulted in
a fairly large concentration of the anesthetic, probably
sufficient to cause TNS by a mechanism similar to
that produced by 0.5% lidocaine injected intrathecally,
W. F. Mousa et. al
especially when administered for surgery performed
on patients in the lithotomy position24.
It was postulated that continuous infusions of
a local anesthetic will result in elevated intrathecal
concentrations in the spinal fluid. This factor combined
with the fact that most deliveries are performed with
the parturient in the lithotomy position, could result in
TNS after epidural injections of local anesthetics for
delivery25.
In our study, we did not give a test dose of
high lidocaine concentration with epinephrine as in
addition, it might affect our clinical end results, there
is increasing evidence that this practice is neither
sensitive nor specific to detect either vascular or
intrathecally catheter misplacement26,27. Instead, we
used the “fractionated bolus” technique that considers
every dose administered via the catheter as a test dose
to safeguard against the possibility of intrathecal or
intravascular catheter migration28.
In conclusion, epidural lidocaine (0.5%) with
fentanyl effectively and safely initiates epidural
analgesia clinically indistinguishable from 0.08%
epidural ropivacaine with fentanyl. Although it induces
significant motor block compared to ropivacaine, it
still preserves maternal ability to move satisfactorily in
bed. For our knowledge, this is the first study to use low
lidocaine concentration (0.5%) for epidural analgesia.
Whether further reduction in lidocaine concentration
could trim down the motor block, remains to be
investigated.
Acknowledgements
I wish to thank all members of the Department of
Anesthesia in Tanta University Hospital, Qatif Central
Hospital and King Fahad University Hospital for their
encouragement and help in the clinical work.
EPIDURAL ANALGESIA DURING LABOR-0.5% LIDOCAINE WITH FENTANYL VS 0.08%
ROPIVACAINE WITH FENTANYL-
527
References
1. Owen MD, D’Angelo R, Gerancher J C, et al: 0.125%ropivacaine
is similar to 0.125% bupivacaine for labor analgesia using patientcontrolled epidural infusion. Anesth Analg; 1998, 86:527-531.
2. Campbell DC, Zwack RM, Crone LL, Yip RW: Ambulatory labor
epidural analgesia: bupivacaine versus ropivacaine. Anesth Analg;
2000, 90:1384-9.
3. Owen MD, Thomas JA, Smith T, et al: Ropivacaine 0.075% and
bupivacaine 0.075% with fentanyl 2µg/mL are equivalent for labor
epidural analgesia. Anesth Analg; 2002, 94:179-83.
4. Keld DB, Hein L, Dalgaard M, et al: The incidence of transient
neurologic symptoms (TNS) after spinal anaesthesia in patients
undergoing surgery in the supine position. Hyperbaric lidocaine
5% versus hyperbaric bupivacaine 0.5%. Acta Anaesthesiologica
Scandinavica; 2000, 44:285-290.
5. Shifman EM, Butrv AV, Floka SE, Got IB: Transient neurological
symptoms in puerperas after epidural analgesia during labor.
Anesteziol Reanimatol; 2007, 6:17-20.
6. James RM, Osama BN, David JB, et al: Transient Neurologic
Symptoms After Epidural Analgesia. Anesth Analg; 2000, 90:437.
7. Tucker GT: Pharmacokinetics of local anaesthetics. Br J Anaesth;
1986, 58:717-731.
8. Campbell DC: Labour analgesia: what’s new and PCEA too? Can J
Anesth; 2003, 50(90001):R8-8.
9. Chestnut DH, Bates JN, Choi WW: Continuous infusion epidural
analgesia with lidocaine: efficacy and influence during the second
stage of labor. Obstet Gynecol; 1987, 69:323-7.
10.Nafisi S: Effects of epidural lidocaine analgesia on labor and delivery:
A randomized, prospective, controlled trial. BMC. Anesthesiology;
2006, 6:15.
11.Liu E, Sia A: Rates of caesarean section and instrumental vaginal
delivery in nulliparous women after low concentran epidural
infusions or opioid analgesia :systematic review. BMJ; 2004,
328(7453):1410.
12.Zhang J, Yancey MK, Klebanoff MA, Schwarz J, Schweitzer D:
Does epidural analgesia prolong labor and increase risk of cesarean
delivery? A natural experiment. Am J Obstet Gynecol; 2001,
185:128-134.
13.Sharma SK, McIntire DD, Wiley J, Leveno KJ: Labor Analgesia
and Cesarean Delivery :An Individual Patient Meta-Analysis of
Nulliparous Women. Anesthesiology; 2004, 100(1):142-148.
14.Evron S, Glezerman M, Sadan O, Boaz M, Ezri T: Patientcontrolled epidural analgesia for labor pain :effect on labor, Delivery
and neonatal outcome of0.125% bupivacaine vs0.2% ropivacaine.
International Journal of Obstetric Anesthesia; 2004, 13: 5-10.
15.Bloom SL, McIntire DD, Kelly MA: Lack of effect of walking on
labour and delivery. N Engl Med; 1998, 339:76-9.
16.Albers LL, Anderson D, Craigin L: The relationship of ambulation
in labor to operative delivery. J Nurse-Midwifery; 1997, 42:4-8.
17.Gaiser RR, Cheek TG, Adams HK, Gutsche BB: Epidural lidocaine
for Cesarean delivery of the distressed fetus. Int J Obstet Anesth;
1998, 7:27-31.
18.Price ML, Reynolds F, Morgan BM: Extending epidural blockade
for emergency Caesarean section. Int J Obstet Anesth; 1991, 1:1318.
19.Wong CA, Benzon H, Kim C: Bilateral radicular pain after epidural
lidocaine. Reg Anesth; 1996, 21:600-1.
20.Rigler ML, Drasner K, Krejcie TC, et al: Cauda equina syndrome
after continuous spinal anesthesia. Anesth Analg; 1991, 72:275-81.
21.FDA Safety Alert. Cauda equina syndrome associated with the use
of small-bore catheters in continuous spinal anesthesia. Washington
DC: Food and Drug Administration, 1992.
22.Schneider M, Ettlin T, Kaufmann M, et al: Transient neurologic
toxicity after hyperbaric subarachnoid anesthesia with 5% lidocaine.
Anesth Analg; 1993, 76:1154-7.
23.Wong CA, Benzon H, Kim C: Bilateral radicular pain after epidural
lidocaine. Reg Anesth; 1996, 21:600-1.
24.Pollock JE, Liu SS, Neal JM, Stephenson CA: Dilution of spinal
lidocaine does not alter the incidence of transient neurologic
symptoms. Anesthesiology; 1999, 90:445-50.
25.Freedman JM, De-Kun L, Drasner K, et al: Transient neurologic
symptoms after spinal anesthesia. Anesthesiology; 1998, 89:63341.
26.Norris MC, Ferrenbach D, Dalman H: Does epinephrine improve
the diagnostic accuracy of aspirationduring labor epidural analgesia?
Anesth Analg; 1999, 88:1073-6.
27.Norris MC, Fogel ST, Dalman H: Labour epidural analgesia without
an intravascular “test dose”. Anesthesiology; 1998, 88:1495-1501.
28.Campbell DC: Labour analgesia: what’s new and PCEA too? Can J
Anesth; 2003, 50(90001):R8-8.
M.E.J. ANESTH 20 (4), 2010
528
W. F. Mousa et. al
THE OCCUPATIONAL FATIGUE
IN ANESTHESIOLOGISTS:
ILLUSION OR REAL?
Afaf Mansour*, Waleed Riad**
and A shraf M oussa ***
Abstract
Background: Fatigue is usually reported after lack of sleep or excessive physical or mental
effort. Endocrine disorders are also associated with the symptoms of fatigue. Symptoms of fatigue
were reported 20% of working population. Anesthesiologists are more exposed to stress at work
because of long working hours and high demand of the job. The aim of this study was to evaluate
fatigue at work from anesthesiologist’ own perspectives and to identify the possible risk factors
associated with fatigue.
Methods: Two hundred and ten persons, were participated in this survey, they were 50
anesthesiologists, 60 diabetic patients and 100 employees. Participants were asked to answer
two self report Questionnaires: The Multidimensional Fatigue Inventory (MFI-20) and General
Health Questionnaire (GHQ-12) which used to assess the degree of fatigue and mental health
respectively.
Results: Total fatigue score was significant in anesthesiologists compared to both patients
(P value = 0.047) and employees (P value < 0.001). All sub-items of fatigue score were higher
in anesthesiologists compared to those of employees (P value < 0.001), however only general
and mental fatigue were higher in comparison to patients (P value = 0.02). The GHQ score of
the anesthesiologists was significantly higher when compared to those of the employees (P value
< 0.001) but no difference with patients (P value = 0.090). Physical, mental and total score of
fatigue were higher in female anesthesiologist.
Conclusion: fatigue and psychological distress are common among anesthesiologists in
comparison to patients and ordinary hospital employees. Female anesthesiologists were affected
more by fatigue.
Keywords: fatigue, anesthesia, psychological distress.
*
Psychiatry department, College of Medicine, Alexandria University, Egypt.
** Departments of Anesthesia, King Khaled Eye Specialist Hospital, Riyadh Saudi.
*** Anesthesia Department, King Faisal, Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
Address for correspondence: Dr Waleed Riad, Department of Anesthesia, King Khaled Eye Specialist Hospital,
P.O. Box: 7191, Riyadh 11462, Kingdom of Saudi Arabia. Tel: 966-1-4821234-3215,
Fax: 966-1-4821908, E-mail: [email protected]
The authors did not receive any form of funding from any institution to carry out this study.
529
M.E.J. ANESTH 20 (4), 2010
530
Introduction
Fatigue is an everyday experience that
individuals report after inadequate rest or sleep, after
exertion physical power, after mental effort or when
1
they lack motivation to initiate activities . Many
endocrine disorders, such as diabetes, are associated
2
with the symptoms of fatigue . Previous survey on the
working population reported 22% incidence of fatigue
3
symptoms . Persistent fatigue is strongly associated
with functional status and can lead to absenteeism and
4
work disability .
Anesthesiology is a stressful occupation5 due
to the long working hours, demanding interpersonal
relations, need for sustained vigilance, fear of
litigation, competence, unpredictability of work and
6
production pressure . Long-work-hours including
night duties with limited and/or interrupted sleep has
7
been reported to be common in anesthesiologist .
Chronic stress and fatigue favor the development of
exhaustion with professional dissatisfaction and poor
8
work-performance . Willful efforts to remain awake
and alert when one are sleep-deprived and fatigued is
highly stressful and frequently unsuccessful in the face
1
of such a potent basic pathophysiological onslaught .
Some indirect evidence link fatigue with impaired
9
medical decision making and reduced patient safety .
Because of its high prevalence and increasingly
acknowledged negative effect on the patient’s well
being, fatigue has become an important research
variable. Besides being investigated as a symptom or
side effect, it has also been studied as a precursor of
disease10.
The main objective of this study was to explore
and understand the phenomenon of fatigue rather than
testing a hypothesis. It was important to evaluate fatigue
at work from anesthesiologist’ own perspectives and
its association with psychological distress, comparing
them with fatigue samples of employees and diabetic
patients. Identification of possible risk factors
underlying fatigue, were also observed.
Materials and Methods
With the approval of the local Research
Committee, a total of 210 persons, aged 20-50
years participated in this survey. They received two
A. Mansour et. al
questionnaires, MF1-20 and GHQ-12, with a covering
letter explaining the purpose and the general outline of
the study, describing how the data would be used, and
guaranteeing anonymity of responses. The voluntary
nature of participation was emphasized. Written
consent was obtained from all participants.
The target group was fifty ansethiologists (33
males, 17 females, 10% married) working in the
same hospital and subjecting to high workload, stress,
and irregular sleep. The second group comprised 60
diabetic patients (adisease known to induce fatigue)
followed up in the outpatient clinic. The last group
comprised one hundred employees with wide range of
work profile with no nightshift.
Persons with substance abuse, smoking,
neurological or psychiatric disorders and very obese
persons, were excluded from the study because of
the known association between these factors and
6
fatigue . Illiterate persons were also excluded because
questionnaires used in this study are self report
instruments. It took each participant approximately 20
minutes to fill out all the required informations.
The Questionnaires
The Multidimensional Fatigue Inventory (MFI11
20) is a multidimensional self report instrument
designed to measure five aspects of fatigue: general,
physical, reduced motivation, reduced activity and
mental fatigue. The sum score of the responses (0, 1,
2, 3 or 4) is designated as total fatigue (TF) ranging
from 0 to 80. Each subscale contains 4 items for
each dimension. It is a 5 point scale ranging from
agreement (yes) to disagreement (no). Higher scores
mean a higher degree of fatigue, more concentration
problems, reduced motivation, or low level of activity.
It is short, does not contain any somatic items, and
is designed to provide a complete description of the
fatigue experience. It was extensively tested in clinical
setting and validated in different population. Subjects
are instructed to indicate how they felt in the last
month.
General Health Questionnaire: (GHQ-12) by
Goldberg, was used in the present work to assess
12
different aspects of mental health of the participants .
The most important reasons for using the GHQ are
13
brevity, intelligibility, and psychometric properties .
THE OCCUPATIONAL FATIGUE IN ANESTHESIOLOGISTS: ILLUSION OR REAL?
appropriate. If ANOVA Test was significant, Tukey
HSD Multiple Comparisons Test was used to compare
different groups. Correlation between groups was done
using Pearson Correlation Coefficient. For all tests of
significance, a P value of 0.05 was used as the level of
significance. Numerical data were expressed as a mean
value and standard deviation (SD) while categorical
data were expressed as numbers and percentages.
Results
The sociodemographic characteristics are shown
in Table 1.
Total score of fatigue was statistically significant in anesthesiologists when compared to scores
of both diabetic patients (P = 0.047) and employees
(P < 0.001) (Fig. 1).
Fig. 1
Total Fatigue Score Questionnaire Data expressed as a mean
value while error bars represent (SD),
60
50
40
Score
Reliability coefficients for GHQ ranged from 0.7813
0.95 . The GHQ used in this study includes 12 items.
Each item has the following 4 answer choices: not at
all, no more than usual, more than usual, and much
more than usual. This questionnaire has been used as
a self-report screening instrument for detecting minor
psychiatric disorders in the general population. The
traditional scoring method (0, 0, 1, 1) is designed to
identify individuals reporting psychological distress
to be classified as probable cases of minor psychiatric
disorders. Given a possible range of scores ranging
from 0 to 12, the threshold for cases classification used
in the present study was four or higher. This means
that all those participants scoring four or more on the
GHQ were considered to have mental problems and
3
therefore may need health care . The present work
14
used the improved scoring system , in which, for
the “negative” items only, three responses categories
(rather than two) are scored as indicating illness. It
appears to represent a useful improvement over the
conventional scoring, since it provides a wide range
among items in the proportion of “ill” responses.
Statistical Analysis
The results were analyzed using SPPS version
14 (SPSS Inc., Chicago, IL, USA). Statistical analysis
was done using independent sample, two tailed t-test
or one-way analysis of variance (ANOVA) whatever
531
30
20
10
0
Table 1
Demographic data
Anesthesiologists
(n = 50)
Anesthesiologists
Patients
Group
Employees
Patients
(n = 60)
Employee
(n = 100)
10 (20%)
21(42%)
19 (38%)
7 (11.7%)
14 (23.3%)
39 (65%)
46 (46%)
34 (34%)
20 (20%)
Male
33 (66%)
31 (51.7%)
58 (58%)
Female
17(34%)
29 (48.3%)
42 (42%)
35 (70%)
15 (30%)
38 (63.3%)
22 (36.7%)
60 (60%)
40 (40%)
Education
25 (41.7%)
0 (0%)
‹ 12 years
11 (18.3%)
12-14 years
0 (0%)
17(28.3%)
6 (12%)
University
7 (11.7%)
Postgraduate
44 (88%)
Data expressed as number and percentage. Unmarried = single, divorce or widow.
26 (26%)
7 (7%)
50 (50%)
17 (17%)
Age: (years)
20-30
31-40
41-50
Sex
Marital status
Married
Unmarried
M.E.J. ANESTH 20 (4), 2010
532
A. Mansour et. al
Table 2
Score of Sub-items of fatigue Questionnaire
Fatigue Questionnaire
General fatigue
Physical fatigue
Reduced activity
Reduced Motivation
Mental fatigue
Anesthesiologists
(n = 50)
Patients
(n = 60)
Employee
(n = 100)
10.0 (5.0)
9.2 (5.2)
7.3 (4.7)
5.9 (4.3)
9.6 (5.2)
8.0 (4.7)*
8.1 (4.6)
6.1 (4.0)
4.8 (3.4)
7.5 (4.6)*
5.4 (2.5)*
4.8 (3.0)*
2.8 (2.4)*
2.9 (2.5)*
4.8 (2.4)*
Data expressed as a mean value (SD), * P < 0.05 versus anesthesiologists.
High degree of fatigue was reported in 78%
of anesthesiologists, 73.3% of diabetic patients and
53% of the employees. Subitems scores are presented
in Table 2, which show that anesthetic group scored
significantly higher on all subscales.
Fig. 2
General Health Score Questionnaire Data expressed as a
mean value while error bars represent (SD)
10
Score
8
6
4
2
0
Anesthesiologists
Patients
Group
Employees
Only general and mental fatigue scores were
higher in the anesthetic group in comparison to
patients’ scores. (P = 0.02).
The GHQ-12 score of the anesthesiologist group
was higher (statistically significant) when compared to
that of employees (P < 0.001) and with no statistical
difference with scores of diabetic patients (P = 0.090)
(Fig. 2). Psychiatric distress (as judged by total
score on GHQ ≥ 4) was experienced by 84% of the
anesthesiologist, in comparison to 78.3% of diabetic
patients and 54% of the employees.
The impact of fatigue on gender (Table 3)
revealed that physical, mental and total score of
fatigue were higher in female anesthesiologist
(P = 0.002, 0.003 & 0.006 respectively). Male
employees showed significant physical, reduced
motivation and overall fatigue than scores of women
Table 3
Fatigue comparisons between male and female within the three groups
Anesthesiologists
Diabetic Patients
(n = 50)
(n = 60)
General fatigue
Male
8.8 (5.3)
Female
12.3 (3.5)
Physical fatigue
Male
7.7 (5.4)
Female
12.0 (3.5)†
Reduced activity
Male
6.2 (4.8)
Female
9.2 (4.0)
Reduced Motivation
Male
5.0 (4.2)
Female
7.5 (4.0)
Mental fatigue
Male
8.1 (5.2)
Female
12.4 (4.2)†
Total score
Male
36.4 (23.3)
Female
53.6 (17.6)†
Data expressed as a mean value (SD), * P value < 0.05, † P value < 0.01.
Employee
(n = 100)
7.9 (4.8)
8.1 (4.6)
5.7 (2.7)
5.1 (2.3)
7.4 (4.6)
8.7 (4.5)
5.9 (2.6)†
3.2 (2.8)
6.1 (4.1)
6.2 (4.0)
3.3 (2.4)
2.2 (2.4)
3.8 (3.0)
5.9 (3.5)
3.5 (2.7)†
2.8 (2.1)
7.3 (4.8)
7.8 4.5)
4.4 (2.4)
5.2 (2.3)
32.7 (19.7)
36.9 (19.5)
23.7 (8.6)*
18.0 (8.4)
THE OCCUPATIONAL FATIGUE IN ANESTHESIOLOGISTS: ILLUSION OR REAL?
(P = 0.033, 0.008 & 0.005 respectively). No statistical
significant differences were observed between women
and men suffering from diabetes in all dimensions of
fatigue.
Correlation between total fatigue score MF1-20
and GHQ-12 was strongly positive in anesthesiologist
only (r = 0.93 & P = 0.01). In the employees, moderate
positive correlation between marital status and total
fatigue score was found (r = 0.37 & P = 0.01). There
was no evident correlation between age and fatigue.
Discussion
The present study showed that fatigue in
anesthesiologists was significantly high when compared
to that of diabetic patients and employees: The GHQ12
score was significantly high when compared to that
of the employees but not to that of diabetic patients.
Physical, mental and total score of fatigue were higher
in female anesthesiologists. Correlation between total
fatigue score and GHQ was strong positive only in
anesthesiologists, the employees showed moderate
positive correlation between marital status and total
fatigue score.
Studies on fatigue showed that the prevalence rates
varied widely depending on the surveyed population.
3
It was reported to be 22% in working and general
15
Norwegian population , and 38% in a UK community
16
survey . Our study proved that chronically-ill patients
perceived more fatigue than healthy employees.
King and colleagues attributed the fatigue in
diabetic subjects to the occurrence of hypoglycemia at
night which could not be explained by the biochemical
17
parameters . Consistent with our results, Huibers et al,
found the point prevalence of severe fatigue (59% to
63%) among employees and its course characterized
18
by remission and relapse in time . It had been reported
that disturbed sleep and fatigue are much prevalent in
shift workers thus giving the former good reasons for
19
quitting the shift work .
Parker proved that the reduction in physician
performance and vigilance resulted from fatigue and
20
sleep loss . Muller et al observed that occupational
fatigue significantly increased at the end of night
21
shift . On the other hand, Kinzl et al found that 12.4% of
22
the studied anesthesiologists reported feeling fatigue .
533
This difference could be attributed to a difference in
methodology in use, sample size and culture.
The participants who had scored above the cutoff point (≥ 4) on GHQ were more likely to suffer from
a mental disorder. Psychiatric distress was experienced
by 84% of the anesthetics, 78.3% of the patients and
54% of the employees. Previous studies showed a
range between 22 and 46% of the respondents of the
UK hospital specialists’ exhibit clinically important
23
level of psychiatric morbidity . This difference could
be attributed to different cut-off point used.
A strong positive correlation between fatigue and
psychological distress was observed only in the studied
anesthesiologists. Previous studies have shown that
fatigue is associated with psychological distress in a
3,16
way that varies across different populations . Thomas
found that in residents, the higher the depression scores
24
the more progressive anger and fatigue . Bültmann et
al found 57% of the studied employees reporting both
fatigue and psychological distress at the same time
while 6% reporting fatigue only without psychological
3
distress .
Gender influence showed that female
anesthesiologists suffered from fatigue more than male
anesthesiologists while the opposite was reported in
the employees. This could be explained by traditional
responsibilities of women towards home duties and
children. This is consistent with Hardy et al who
attributed this difference to reduced physical fitness,
reproductive or combined occupational and domestic
25
responsibilities . On the contrary, previous studies
4,15,16
.
found fatigue more among female employees
However, Bültmann and colleagues found fatigue score
to be highly similar in men and women employees.
These differences in the results could be attributed to
different conceptualization and operationalization of
3
fatigue and psychological distress .
Only the employees showed moderate positive
correlation between marital status and fatigue in the
current study. Previous work observed that in both
genders, employees who reported living alone had
25
significant higher fatigue scores . Parker et al proved
that high level of marital disharmony was found among
physicians particularly anesthetists and attributed on
20
fatigue . Others showed no or minor effects of marital
15,25
status on fatigue .
M.E.J. ANESTH 20 (4), 2010
534
A. Mansour et. al
Conclusion
Acknowledgement
The present study showed that fatigue was more
represented in the anesthesiologists group compared
to other studied groups. It showed strong positive
association with psychological distress. Gender, more
than age or marital status, seems to affect fatigue in the
anesthesiologists.
The authors wish to thank the participating
anesthesiologists, who willingly took the time during
busy working days to share their experiences with us.
Also, the authors express their appreciation for the
cooperation of the personnel of the employee unit and
participating diabetic patients.
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analgesia. Can J Anesth; 2003, 50:854-5.
10.Apple SA, Mulder P: Excess fatigue as a precursor of myocardial
infarction. Eu Heart J; 1988, 9:758-64.
11.Smets EM, Garsen B, Bonke B, De Haes JC: The multidimensional
fatigue inventory (MFI) psychometric qualities of an instrument to
assess fatigue. J Psychosom Res; 1995, 39:315-25.
12.Goldberg DP: Manual of the General Health Questionnaire. NFER
Publishing, Windsor: England, 1978.
13.Jackson G: The General Health Questionnaire. Occup Med; 2007,
57:79.
14.Duncan-Jones P, Grayson DA, Moran PA: The utility of latent trait
models in psychiatric epidemiology. Psychol Med; 1986, 16:391405.
15.Loge JH, Ekeberg O, Kaasa S: Fatigue in the general Norwegian
population: normative data and association. J Psychosom Res; 1998,
45:53-65.
16.Pawlikowska T, Chalder T, Hirsch SR, Wallace P, Wright DJ,
Wessely SC. Population based study of fatigue and psychological
distress. BMJ; 1994, 308:763-6.
17.King P, Kong MF, Parkin H, Macdonald IA, Tattersall RB:
Well-being, cerebral function, and physical fatigue after nocturnal
hypoglycemia in IDDM. Diabetes care; 1998, 21:341-45.
18.Huibers MJ, Bültmann U, Kasl SV, Kant I, van Amelsvoort LG,
van Schayck CP, Swaen GM. Predicting the two-year course of
unexplained fatigue and the onset of long-term sickness absence
in fatigued employees: results from the Maastricht Cohort Study. J
Occup Environ Med; 2004, 46:1041-7.
19.Jansen NW, van Amelsvoort LG, Kristensen TS, van den Brandt
PA, Kant IJ: Work schedules and fatigue: a prospective cohort
study. Occupa Environ Med; 2003, 60 Suppl, 1:i47-53.
20.Parker JB: The effects of fatigue on physician performance- an
underestimated cause of physician impairment and increased patient
risk. Can J Anesth; 1987, 34:489-95.
21.Muller R, Carter A, Williamson A: Epidemiological diagnosis
of occupational fatigue in a fly-in-fly-out operation of the mineral
industry. Ann Occup Hyg; 2008, 52:63-72.
22.Kinzl JF, Traweger C, Trefalt E, Riccabona U, Lederer W: Work
stress and gender-dependent coping strategies in anesthesiologists at
a university hospital. J Clin Anesth; 2007, 19:334-8.
23.Coomber S, Todd C, Park G, Baxter P, Firth-Cozens J, Shore S:
Stress in UK intensive care unit doctors. Br J Anesth; 2002, 89:87381.
24.Thomas NK: Resident burnout. JAMA; 2004, 292:2880-9.
25.Hardy GE, Shapiro DA, Dorrill CS: Fatigue in the workforce in
the National Health Service trusts: levels of symptomatology and
links with minor psychiatric disorder, demographic, occupational
and work role factors. J Psychosom Res; 1997, 43:83-92.
THE EFFECT OF ADDITION OF LOW
DOSE ATRACURIUM TO LOCAL
ANESTHETIC IN RETROBULBAR
BLOCK FOR CATARACT SURGERY
Mohammad Hossein Eghbal*, Hesam Tabei*,
Shoja Alhagh Taregh*, Mohammad Reza Razeghinejad**
Abstract
Background: Addition of some neuromuscular blockers to local anesthetics proved to be
effective in improving the quality of anesthesia in different regional techniques. This study was
carried out to determine whether the addition of low-dose atracurium to a local anesthetic has any
effect on the onset and duration of akinesia in retrobulbar block.
Patients and Methods: This study was conducted on sixty-four unpremedicated, ASA I or
II patients scheduled for cataract surgery under local anesthesia. The patients were assigned to one
of the two treatment groups in a randomized, double-blind manner. The case group received 2 ml
of 2% lidocaine (40 mg) and 0.5 mL atracurium (5 mg). The control group received 2 ml of 2%
lidocaine (40 mg) and 0.5 ml 0.9% NaCl. The onset of akinesia (the inability to move the eye in all
four directions) was scored as 0 to 2: 0, no akinesia; 1, partial akinesia; and 2, complete akinesia.
The onset and duration of akinesia and also adverse effects and complications of each method were
recorded throughout the study.
Results: In 4 out of 64 patients, complete akinesia was not achieved and statistical analysis
was done on 60 others with complete akinesia. With regard to age, sex, weight, and duration of
the surgery, there were no significant differences between the case and control groups. The onset
of complete akinesia was quicker and duration longer in the case group than in the control group.
The onset of complete block was 4.7 ± 1.1minutes in the case group and 6.9 ± 0.96 minutes in the
control group (P<0.001). The duration of akinesia was 104.07± 17.6 minutes in the case group and
87.1 ± 16.2 minutes in the control group (P<0.001).
Conclusion: This study demonstrated that atracurium had a local action on the extraocular
muscles. It shortened the onset period of retrobulbar block, prolonged its duration, and provided
excellent surgical conditions without any specific complications.
Keywords: Akinesia, Atracurium, Nondepolarizing neuromuscular blockers, Retrobulbar
anesthesia.
From Shiraz University of Medical Sciences, Shiraz, Iran.
*
Department of Anesthesiology.
** Department of Ophthalmology.
Corresponding author: Mohammad Reza Razeghinejad, MD, Poostchi Ophthalmology Research Center, Shiraz University
of Medical Sciences, Shiraz, Iran, Tel/Fax: +98 711 2302830. E-mail:[email protected]
The authors have no commercial or proprietary interest on the materials discussed in this manuscript
535
M.E.J. ANESTH 20 (4), 2010
536
Introduction
There are different approaches to the delivery of
local injection anesthesia for cataract surgery. The two
main approaches are retrobulbar and peribulbar.
The retrobulbar approach appears to be more
commonly practiced. This block can provide adequate
anesthesia, akinesia and control of intraocular pressure
as well as postoperative analgesia1,2. The most fearful
complications with this technic are globe perforation,
brain stem anesthesia and retrobulbar hemorrhage,
which is the most frequent complication and occurs in
1% of the cases1,3,4.
Many believe that the peribulbar block is a safer
technique, but to produce akinesia a larger volume of
anesthetic solution is required. In addition, development
of akinesia takes longer and is more frequently
inadequate after peribulbar injections compared with
retrobulbar injection1.
Some clinical trials have shown that addition
of a neuromuscular blocker (e.g., vecuronium or
pancronium) to the local anesthetic solution improves
the quality of anesthesia in different regional
techniques5-7. The beneficial effect of atracurium added
to local anesthetics on akinesia in peribulbar block in
the cataract surgery has been reported5.
The aim of this study was to determine whether
the addition of low-dose atracurium to a local anesthetic
mixture had any effects on the onset time and duration
of akinesia in retrobulbar block in patients who
undergoing cataract surgery.
Patients and Methods
This study was conducted on sixty-four
unpremedicated ASA I or II patients undergoing
cataract surgery (phacoemulsification and intraocular
lens implantation) with local anesthesia8. All patients
gave informed consent and the study was approved by
the Local Ethics Committee. The patients with a history
of abnormal bleeding, allergy to local anesthetics,
cardiac, hepatic or renal failure, Parkinsonism, unstable
angina, clustropobia, high myopia, and monocularity
were excluded.
Patients were assigned to one of the two treatment
groups in a randomized, double-blind manner. The case
M. H. Eghbal et. al
group comprised 31 and the control group included 33
patients. The case group received 2 mL of 2% lidocaine
(40 mg) and 0.5 mL atracurium (5 mg). The control
group received 2 mL of 2% lidocaine (40 mg) and 0.5
mL 0.9% NaCl.
Local anesthetic solutions were prepared by a
nurse anesthetist. All the blocks were performed by the
same experienced ophthalmologist who was unaware
of the mixture administered. The onset of akinesia
(the inability to move the eye in all four directions)
was determined by the ophthalmologist for the first
10 minutes and was scored as 0 to 2:0, no akinesia; 1,
partial akinesia; and 2, complete akinesia (Table 1).
Table 1
Akinesia scoring system after retrobulbar injection of lidocaine
or a mixture of lidocaine and atracurium.
0: more than 2-mm movement in any main direction.
1: 1-mm movement in more than 2 main directions or 2-mm
movement in any main direction.
2: 0- to 1-mm movement in 1 or 2 main directions.
The onset time of complete akinesia was recorded
for each patient. All the patients were monitored by
automatic noninvasive blood pressure, heart rate, and
pulse oximetry throughout the surgical procedure and
during the first postoperative hour. After completion
of surgery, an anesthesiologist unaware of group
assignment recorded the offset time of akinesia in the
recovery unit. The adverse effects and complications
were also recorded during the study.
Statistical analysis was performed using Student’s
t test. The results are expressed as mean and standard
deviation (SD). Significance was determined at the
P<0.5 level.
Results
In 4 out of 64 patients, complete akinesia (score
2) was not achieved. These patients were excluded and
statistical analysis was performed on 60 other patients
who achieved complete akinesia. Regarding age, sex,
weight, and duration of the surgery, there were no
significant differences between the case and control
groups (Table 2). However, there was a significant
difference between the case and control groups
A THE EFFECT OF ADDITION OF LOW DOSE ATRACURIUM TO LOCAL ANESTHETIC IN RETROBULBAR
BLOCK FOR CATARACT SURGERY
regarding the time onset and duration of akinesia. The
onset time of complete block was 4.7 ± 1.1 minutes in
the case group and 6.9 ± 0.96 minutes in the control
group. This difference was statistically significant
(P<0.001). Duration of akinesia was 104.07 ± 17.6
minutes in the case group and 87.1 ± 16.2 minutes in
the control group which was significant (P<0.001).
There was no specific complication in both case
and control groups. No patient needed supplemental
anesthetic agent injection.
Table 2
Comparison of the two treatment groups regarding age, sex,
weight duration of surgery, time to onset of akinesia and
duration of akinesia.
Case
Control
Significance
Age (yr)
63.37
62.97
0.8
Sex (F/M)
2218/
2416/
0.37
Weight (kg)
68.7 ±
9.9
72.2 ±
11.1
0.1
Duration of
surgery (min)
20.4 ±
5.09
21.1 ±
6.1
0.5
4.7 ± 1.1
6.9 ±
0.96
<0.001
104 ±
17.6
87.1 ±
16.2
<0.001
Time to onset of
akinesia (min)
Duration of
akinesia (min)
Discussion
There is debate over whether the peribulbar
approach provides more effective and safer anesthesia
for cataract surgery than retrobulbar block. In the
retrobulbar approach, a needle is inserted into the
intraconal space, a space behind the eye formed by the
extraocular muscles that contains the major nerves of
the eye and its adnexa. Therefore, it may be associated
with potentially serious ocular damages such as scleral
perforation, stimulation of the oculocardiac reflex
and injection of anesthetic agent into the perioptic
meningeal space. However, this route may have the
advantage of rapid onset of analgesia and akinesia with
the use of relatively smaller volumes of anaesthetic
agent1,9.
The most popular peribulbar anesthetic technique
involves dual injections above and below the globe. In
the inferior site the needle is inserted for a distance of
25 mm at a point between the lateral third and medial
two thirds of the lower orbital margin and four ml of
537
anesthetic solution is injected outside the muscle cone
at the level of globe equator. In the case of upper side,
the needle is introduced through the upper lid at about
2 mm medial and inferior to the supraorbital notch and
3 ml of anesthetic solution are deposited10. In addition
to conjunctival edema often seen, a higher initial IOP
is accompanied because of higher volume of anesthetic
agent11.
The need for additional injection is higher with
peribulbar block in comparison with retrobulbar block1.
In order to augment the effect of local anesthetics,
Küçü kyavuz et al.5 and and Reah et al.6 studied the
effect of neuromuscular blockers on the peribulbar
block. Küçü kyavuz et al.5 reported the effect of 8 mL
of a lidocaine-bupivacaine mixture, plus0.5 mL (5
mg) atracurium was better than the 8 mL of the same
local anesthetic mixture plus 0.5 mL 0.9% NaCl. Time
to the onset of akinesia in minutes was 10 ± 3 in the
atracurium and 7 ± 2 in the control one. The duration
of akinesia in minutes was the same in both groups
(192 ± 99 versus 194± 53) which was not statistically
significant (p>0.05). Moreover, no side effects related
to peribulbar block or drugs were observed in any
patient.
Reah et al.6 compared the effect of 5 ml of 2%
Lignocaine with 1:200000 adrenaline, 5 ml 0.75
bupivacaine and 150 IU hyaluronidase with either 0.9%
saline 0.25, or vecuronium bromide 0.25 ml. They
concluded that the addition of vecuronium at a dose
of 0.5 mg to the local anesthetic mixture improves the
quality of akinesia. Although Reah et al.6 and Küçü
kyavuz et al.5 studied the effect of neuromuscular
blocking agents in peribular block, reporting that the
addition of neuromuscular blocking agents to the local
anesthetic mixture improves the quality of akinesia,
our study is the first to use low-dose atracurium in
retrobulbar block.
In this study, the onset of complete block was
more rapid in the atracurium group compared with the
control group. This finding is in concordance with that
of the two mentioned studies. But, the total amounts
of local anesthetic agent in both of these studies were
more than those of our study. However, the need for
additional injection is higher with peribulbar block in
comparison with retrobulbar block1.
Nowadays, topical anesthesia is the more popular
M.E.J. ANESTH 20 (4), 2010
538
M. H. Eghbal et. al
techique for ophthalmic anesthesia. This contributes to
a controversy about the optimal technique for cataract
surgery. Though topical anesthesia reduces the risk of
complications related to needle and systemic toxicity,
yet it has the potential disadvantages of incomplete
akinesia12. Induction of complete akinesia is an ideal
situation for the beginner surgeons, because complete
akinesia is not achievable by topical anesthesia.
anesthesia technique has been proved. Though the
mechanism is still unclear, the hypothesis is that
the neuromuscular blockers probably interfere with
muscle spindle activity. The motor unit, the number
of muscle fibers innervated by a single motor neuron,
is the characteristic features of intraorbital muscles
which makes the extra ocular muscles most sensitive
to the effect of neuromuscular blocking agents6.
A major concern in retroblbar block is the potential
for central spreading and inadvertent intrathecal
injection. The possibility of central spread is a rare
occurrence; Nicoll et al.13 reported the incidence of
0.27%. In our study there was no case of central spread
of medication which seems to be related to taking into
account the predetermined precautions in retrobulbar
injection.
Our study demonstrated that atracurium had a
local action on the extraocular muscles. It shortened the
onset time of retrobulbar block, prolonged the duration
of retrobulbar block, and provided excellent surgical
conditions without known complications. Shortening
the onset time of akinesia leads to saving of the time
and cost of operating room. Moreover, increasing the
duration of akinesia could enable the surgeon to do
other ophthalmic operations which last longer than a
routine phacoemulsification surgery. Further studies
are required to confirm the local effect of atracurium
on akinesia of the globe.
The additional effect of low-dose nondepolarizing
neuromuscular blocking agents to the local anesthetic
solution in improving the quality of anesthesia and
provision of motor block during intravenous regional
References
1. A lhassan MB, K yari F, E jere HO: Peribulbar versus retrobulbar
anaesthesia for cataract surgery. Cochrane Database Syst Rev; 2008,
CD004083.
2. D avison JA: Features of a modern retrobulbar anesthetic injection
for cataract surgery. J Cataract Refract Surg; 1993, 19:284-9.
3. G unja N, Varshney K: Brainstem anaesthesia after retrobulbar
block: a rare cause of coma presenting to the emergency department.
Emerg Med Australas; 2006, 18:83-5.
4. A shaye AO, U bah JN, S otumbi PT: Respiratory arrest after
retrobulbar anaesthesia. West Afr J Med; 2002, 21:343-4.
5. Kucukyavuz Z, A rici MK: Effects of atracurium added to local
anesthetics on akinesia in peribulbar block. Reg Anesth Pain Med;
2002, 27:487-90.
6. R eah G, B odenham AR, B raithwaite P, E smond J, M enage
MJ: Peribulbar anaesthesia using a mixture of local anaesthetic and
vecuronium. Anaesthesia; 1998, 53:551-4.
7. A bdulla WY, Fadhil NM: A new approach to intravenous regional
anesthesia. Anesth Analg; 1992, 75:597-601.
8. M uravchick S: Preoperative assessment of the elderly patient.
Anesthesiol Clin North America; 2000, 18:71-89, vi.
9. K umar CM: Orbital regional anesthesia: complications and their
prevention. Indian J Ophthalmol; 2006, 54:77-84.
10.W ong DH: Regional anaesthesia for intraocular surgery. Can J
Anaesth; 1993, 40:635-57.
11.S anford DK, M inoso Y de C al OE, B elyea DA: Response
of intraocular pressure to retrobulbar and peribulbar anesthesia.
Ophthalmic Surg Lasers; 1998, 29:815-7.
12.B oezaart A, B erry R, N ell M: Topical anesthesia versus
retrobulbar block for cataract surgery: the patients’ perspective. J
Clin Anesth; 2000, 12:58-60.
13.N icoll JM, A charya PA, A hlen K, B aguneid S, E dge KR:
Central nervous system complications after 6000 retrobulbar blocks.
Anesth Analg; 1987, 66:1298-302.
LABOR ANALGESIA IN PREECLAMPSIA:
REMIFENTANIL PATIENT CONTROLLED INTRAVENOUS
ANALGESIA VERSUS EPIDURAL ANALGESIA
Hala El-Kerdawy*, Adel Farouk**
Abstract
Background: Epidural analgesia is considered to be the preferred method of labor analgesia in
preeclamptic patients. Systemic opioids are another good effective, easy to administer alternative
but may cause maternal and fetal respiratory depression. Remifentanil’s rapid onset and offset of
effects, should make it an ideal drug for the intermittent painful contraction during labor. Method:
30 preeclamptic patients were randomly assigned to one of two equal groups; Epidural Group:
received epidural analgesia according to a standardized protocol using bupivacaine plus fentanyl.
Remifentanil Group: PCA was set up to deliver remlfentanil 0.5 μg/kg as a loading bolus infused
over 20 seconds, lockout time of 5 minutes, PCA bolus of 0.25 μg/kg, continuous background
infusion of 0.05 μg/kg/min, and maximum dose is 3 mg in 4 hours. Women were advised to start
the PCA bolus when they feel the signs of a coming uterine contraction. Results: All women
demonstrated a significant decrease in VAS score in the first hour after administration of analgesia
(P<0.05). Analgesic quality as regard Visual Analog Pain Scores, sedation score, and post-delivery
patient satisfaction in both groups, are comparable (P>0.05). PCA remifentanil infusion until time
of delivery produce no observable maternal, fetal or neonatal side effects (P<0.05).
Conclusion: PCA intravenous remifentanil is an effective option for pain relief with minimal
maternal and neonatal side effects in labor for preeclamptic patients with contraindications to
epidural analgesia or requesting opioid analgesia.
Keywords: Preeclampsia, PCA remifentanil, epidural, labor analgesia.
*
Department of Anesthesia, and ** Department of Gynecology and Obstetric, Cairo University, Cairo, Egypt.
Corresponding author: Dr. Hala El-Kerdawy, Consultant Anesthetist, Anesthesia Department, Saad Specialist Hospital.
P.O. Box: 30353, Al-Khobar 31952, Saudi Arabia. Mobile: 00966502573767. E-mail: [email protected]
539
M.E.J. ANESTH 20 (4), 2010
540
H. Kerdawy et. al
Introduction
The goal of labor pain relief for pre-eclamptic
parturients is to provide the most effective analgesia in
order to reduce stimulation of the sympathetic nervous
system1,2.
Epidural analgesia was proven safe for use
in such patients3 and particularly beneficial to the
mother and baby as it prevents the exacerbation of
hypertension and improve uteroplacental circulation.4
The anesthesiologist concerns with epidurals stem
from the episodes of hypotension, predisposition of
preeclamptic patients to develop pulmonary edema4,
and coagulopathies. The latter interfering with the
ability to provide neuraxial anesthesia5; hematoma
formation6,7 spinal cord compression and permanent
paralysis. Disturbances of platelet counts, platelet
function or disseminated intravascular coagulation
can also increase the risk for excessive bleeding.
Coagulopathy, anesthetists are concerned about
epidural.
On the other hand systemic opioids are the most
common form of labor analgesia worldwide and when
administered by the proper delivery system, can also
be the second most efficacious form of pain relief2.
Intramuscularly administered narcotics is a poor
method of drug delivery for labor pain as the relatively
slow absorption leads to fluctuating peaks and troughs
in serum levels8. This method of administration also
is painful and is contraindicated when the patient is
thrombocytopenic (<50000-75000 platelets)2.
The intravenous administration of narcotics
is the best method of administration for labor pain.
Ideally, the patient controlled analgesia (PCA) system
is available to these women. The particular narcotics
used in this system include morphine, fentanyl,
meperidine, nalbuphine, and alfentanil9. The ideal
agent of choice is a short-acting narcotic that does
not accumulate over time and has a large therapeutic/
toxic plasma ratio. Regardless of the narcotic chosen,
particular monitoring requirements must be in place to
avoid potential maternal and neonatal complications2.
Therefore, the minimum requirements of monitoring
for the mother during administration consist of an
hourly respiratory rate and sedation score used for
normal labour.
Meperidine the most commonly used for labor
pain is associated with a high incidence of maternal
nausea and sedation, as well as many adverse fetal and
neonatal effects10.
The use of intravenous patient controlled analgesia
(PCA) with fentanyl has been associated with up to
a 44% incidence of moderately depressed neonates
with low Apgar scores11. Moreover, fentanyl does not
always provide adequate pain relief for the intense
pain of the late first stage of labor, most likely due to
its slow onset of action12. A search for a new opioid to
overcome these problems has led to the introduction of
remifentanil for labor analgesia13,14,15.
Remifentanil has a unique pharmacokinetic
profile, with a potent ultra-short μ opioid receptor
agonist action. The metabolism of remifentanil is
independent of renal and hepatic function. It has rapid
onset (time to peak effect 60 to 80 sec) and offset times,
irrespective of the duration of administration16. The
drug’s context sensitive half-time is three minutes17.
Remifentanil rapidly crosses the placenta but is
quickly redistributed and metabolized in the fetus18,19.
There have been no reports of associated increases
in neonatal respiratory depression or lower Apgar
scores with the use of remifentanil prior to delivery.
With these properties, remifentanil appears to be the
opioid of choice for labor, since it can be appropriately
titrated for administration when analgesia is required
for either very brief or prolonged periods, without the
concern of prolonged recovery. It therefore resembles
the description of an ideal systemic analgesic for use
during labor.
To the best of our knowledge, no trial as yet been
carried out, to study the efficacy of using remifentanil
patient controlled analgesia for the pain management
in preeclamptic patients. This study was planned to
compare the use of remifentanil PCA intravenous
analgesia to epidural bupivacaine plus fentanyl for
labor analgesia in preeclamptic patients.
Material and Methods
After having patient informed consent, thirty
nulliparous preeclamptic parturient were studied.
Patients were recruited during early first stage of labor
before requesting pain relief were studied. Inclusion
criteria consisted of; ≥32 weeks gestation, normal
cephalic presentation, <5 cm cervical dilatation,
LABOR ANALGESIA IN PREECLAMPSIA: REMIFENTANIL PATIENT CONTROLLED INTRAVENOUS ANALGESIA
VERSUS EPIDURAL ANALGESIA
clinical diagnosis of preeclampsia. Which required at
least one of the following three criteria:
1) Systolic blood pressure greater than or equal
to 140 mmHg or diastolic blood pressure greater
than or equal to 90 mmHg, with proteinuria of 1 + on
dipstick.
541
sited for remifentanil delivery and the Remifentanil
hydrochloride concentration used was 50 μg/ml (3 mg
diluted to 60 ml of normal saline).
2) Systolic blood pressure greater than or equal
to 140 mmHg or diastolic blood pressure greater than
or equal to 90 mmHg with proteinuria of 2 + or more
on dipstick.
The PCA was set to deliver 0.5 μg/kg as a
loading bolus infused over 20 seconds, lockout time
of 5 minutes, PCA bolus of 0.25 μg/kg, continuous
background infusion of 0.05 μg/kg/min, and maximum
dose is 3 mg in 4 hours. Women were advised to start
the PCA bolus when they feel the signs of a coming
uterine contraction.
3) Systolic blood pressure greater than or equal
to 160 mmHg or diastolic blood pressure greater than
or equal to 110 mmHg with proteinuria of either 2 +
on dipstick.
Oxygen saturation (SpO2), Heart rate (HR),
Blood pressure (Bp), and Respiratory rate (RR)
were monitored continuously and recorded every 5
minutes.
Exclusion criteria were consisted of; remifentanil
allergy, progression to eclampsia, evidence of increased
intracranial pressure or focal neurologic deficit,
Women with a platelet count of less than 80 × 109/L,
or evidence of pulmonary edema, nonreassuring fetal
heart rate tracing requiring imminent delivery.
Hypotension, (defined as reduction of >25%
of baseline level), was treated by either additional
intravenous crystalloid or intravenous bolus doses
(e.g., 2.5-5.0 mg) of ephedrine. Reductions in
blood pressure of less than 25% in the presence of a
reassuring fetal heart rate tracing (as determined by the
managing obstetrician) were not treated. If the assigned
analgesia was inadequate for the patient at any time,
an alternative was offered and further study recording
were discontinued.
After arriving to delivery suit, an 18 G intravenous
cannula was established and lactated Ringer’s
solution at a rate of 100 ml/hour was given to all
parturients. Intravenous magnesium sulfate for seizure
prophylaxis from the diagnosis of preeclampsia until
24 hours postpartum was given when instructed by the
obstetrician. The standard magnesium sulfate regimen is
a 4g intravenous bolus given over 20 minutes, followed
by a continuous infusion of 2 g per hour. After proper
explanation of both techniques patients were randomly
assigned to one of two groups. (15 each)
Epidural Group: Following lumbar epidural
according to a standardized protocol, on epidural
catheter was placed under complete aseptic technique
at the L3-L4 or L4-L5 interspaces. A test dose of 3 mL
of 0.25% bupivacaine was administered, and epidural
analgesia was established with initial bolus of 1015 mL of 0.25% bupivacaine plus 1 μg/kg fentanyl.
Analgesia was maintained by continuous infusion of
0.125 bupivacaine plus 2 μg/ml fentanyl at a rate of
10-12 ml per hour aiming to obtain a T-10 sensory
level.
Remifentanil Group: Patients were first
introduced to the proper use of the PCA pump
(Grasby 3300). A dedicated intravenous cannula was
For hourly pain assessment and a visual
analogue pain score (0 marked no pain and 10
marked worst pain) was obtained and recorded at
three data points before analgesia, one hour after, and
after delivery. Satisfactory analgesia is considered if
VAS is ≤ 3. Hourly Sedation score was assessed and
recorded at the same data points using a four point
scale (1= alert, 2= slightly drowsy, 3= drowsy not
responding to gentle stimulation, 4= very drowsy).
Overall patient satisfaction were determined within
24 hours of delivery (1: poor, 2: fair, 3: good,
4: excellent). Requirement for pharmacologic
interventions to treat hypotension and the incidence
of complications were recorded.
Continuous cardiotocogram monitoring of fetal
heart rate uterine contraction were used and analyzed
by the obstetrician. Neonatal data included birth
weight, Apgar scores at 1 and 5 minutes, umbilical
cord arterial blood gas results, naloxone treatment,
neonatal intensive care admission. Any morbidities
and mortalities were recorded.
M.E.J. ANESTH 20 (4), 2010
542
H. Kerdawy et. al
Statistical Analysis
Maternal vital signs:
Demographic data were analyzed with unpaired
Student’s t test. Paired Student’s t test was used to
compare values in the same group. One way and two
ways ANOVA were used for within and between groups
comparisons of Maternal hemodynamics. Maternal
visual analog score, and sedation score, between groups
were compared using Kruskal-Wallis ANOVA test and
Friedman two-way ANOVA for within group analysis.
Maternal visual satisfaction score was compared using
Mann-Whitney test. Maternal side effects and fetal
side effects were analyzed using Chi-squared test. All
statistical analysis was performed using Excel and
SBSS statistical packages.
The two groups were comparable with respect
to maternal hemodynamic in the means of; SBP, HR,
SpO2, and Respiratory Rate. Data were analyzed at
three points before starting analgesia (baseline), 1 hour
after starting analgesia, and after delivery (Table 2).
Table 2
Changes in the mean Systolic Blood pressure before starting
analgesia (baseline), 1 hour after starting analgesia, and after
delivery. Values are mean ± SD
Baseline
After
analgesia
delivery
95 ± 8.7
97.7 ± 7.6
Mean BP (mmHg)
- Epidural group
- Remifentanil
Results
1 hr after
99.4 ± 13
100.5 ± 6.9 96.2 ± 6.6
99 ± 9
group
Mean HR (beat/min)
Demographic Data
Both groups were matches for Age, Weight,
Height, Gestational age, Baseline cervical dilatation,
and baseline lab results (P>0.05). Incidence of
instrumental delivery and cesarean section was higher
in Epidural group compared to the Remifentanil one
(P<0.05). (Table 1)
Table 1
Demographic Data and Type of delivery
(mean ± SD or numbers)
Variable
80.6 ± 10.8
- Remifentanil
81.2 ± 11.2 79.2 ± 10.3 80.1 ± 8.4
81 ± 7
79.8 ± 10.4
group
Mean SpO2 (%)
- Epidural group
98.2 ± 1.4
97.8 ± 1.9 97.3 ± 1.9
- Remifentanil
98.4 ± 1.3
97.5 ± 1.5 97.8 ± 1.5
- Epidural group
18.3 ± 3.4
17.5 ± 3.4 17.2 ± 3.1
- Remifentanil group
18.5 ± 3.4
17.8 ± 2.4 17.5 ± 2.6
group
Mean Respiratory rate
Epidural Remifentanil
Group
Group
(n = 15)
(n = 15)
Age (year)
26 ± 8
28 ± 9
Weight (Kg)
79 ± 22
84 ± 37
Height (cm)
163 ± 6
162 ± 7
Gestation (week)
36 ± 4
35 ± 3
Cervical Dilatation (cm)
3.2 ± 1.4
3.4 ± 1.5
Baseline lab. Results
= Platelet count (× 109/L)
= Serum Creatinine (mg/dL)
175 ± 63
0.8 ± 0.3
178 ± 55
0.8 ± 0.25
8*
3*
4*
10
0
3
Type of delivery
= Normal delivery
= Instrumental Delivery
= Cesarean Section
- Epidural group
* Significant difference compared to remifentanil group
Quality of analgesia
Maternal pain score, sedation score, and post
delivery satisfaction:
Maternal Visual Analog Pain Score (VAPS) and
Sedation scores were assessed before starting analgesia
(baseline), 1 hour after starting analgesia, and after
delivery. There were no inter-group differences in the
VAS or sedation scores at the three times measured
(P>0.05). Within group analysis revealed significant
decreased in VAS after starting the analgesia in both
groups (Table 3). In the PCA intravenous Remifentanil
group, the patient satisfaction was better than in
the epidural group although it is was statistically
insignificant. (P>0.05)
LABOR ANALGESIA IN PREECLAMPSIA: REMIFENTANIL PATIENT CONTROLLED INTRAVENOUS ANALGESIA
VERSUS EPIDURAL ANALGESIA
Table 3
Changes in the mean Maternal Visual Analog Pain Scale,
mean Sedation score (VAS) at baseline, 1 hour after analgesia,
and after delivery and patient satisfaction
Values are mean ± SD
Epidural Group
(n = 15)
Remifentanil
Group (n = 15)
Pain VAS Score
= Baseline
= 1 hr after
= After delivery
8 ± 1.7
2.6 ± 1.5
3 ± 1.4
7.9 ± 1.7
3±1
2.8 ± 1.1
Sedation Score (1-4)
= Baseline
= 1 hr after
= After delivery
1 ± 0.25
1.1 ± 0.35
1.06 ± 0.25
1
1.3 ± 0.48
1.1 ± 0.35
2.8 ± 1
3.1 ± 0.9
Patient Satisfaction
Score (1-4)
Table 4
The number of maternal side effects in the two groups.
Values are number (%)
Side Effects
543
Maternal Side effects
Nausea, and or vomiting in the epidural group was
higher than in remifentanil group but still statistically
insignificant (P>0.05). Itching and hypotension that
necessitated pharmacological interventions, were
statistically significantly higher in epidural group than
remifentanil group (P<0.05)
Fetal and neonatal outcome
Fetal heart rate abnormalities (fetal heart rate
deceleration to < 90 beats/min or late deceleration)
were recorded one hour after start of analgesia, in
both groups (Table 5). Two patients in epidural group
developed fetal heart rate abnormalities compared to no
patients in remifentanil group. Incidence of mechanical
ventilation, naloxone used was statistically significant
in epidural group compared with the remifentanil
one (P<0.05). There were no differences between the
neonates in the two groups as regard the APGAR score
measured at the two different times. Also no statistically
significant difference between groups as regard seizure
or umbilical cord blood gases analysis (P>0.05).
Epidural Group
(n = 15)
Remifentanil
Group
(n = 15)
Nausea
7 (46.6%)
5 (33%)
Vomiting
2 (13.3%)
1 (6.6%)
Discussion
Itching
3 (20%)*
1 (6.6%)
4 (26.6%)*
0 (0%)
The chief role of the anesthesiologists is to
provide safe labor analgesia20, the choice, however,
of the optimum technique in preeclamptic patients
is controversial21,22. The results of this study indicate
that PCA remifentanil for preeclamptic patients during
labor and delivery is associated with a decrease in
VAS pain score, acceptable sedation score, and good
patient satisfaction that is comparable to the epidural
technique. The maternal, fetal, and neonatal side
effects in remifentanil group were minimal and rapidly
resolved due to short duration of action and lack of
accumulation of remifentanil.
Hypotension
Table 5
Incidence of fetal and neonatal side effects.
Value are numbers (%)
Epidural
Group
(n = 15)
Remifentanil
Group
(n = 15)
2 (13.3%) *
0 (0%)
1 (6.6%)
0 (0%)
1 (6.6%)
0 (0%)
Naloxone
2 (13.3%)*
0 (0%)
Umblical cord gas
= Umblical artery pH
= Umblical vein pH
7.24 ± 0.09
7.3 ± 0.03
7.23 ± 0.07
7.32 ± 0.03
0 (0%)
0 (0%)
2 (13.3%)*
0 (0%)
FHR abnormalities at one
hour after analgesia
Apgar Score ≤7
= 1-minute
= 5-minutes
Seizure
Mechanical ventilation
* Significant difference compared to remifentanil group
There were no significant differences in the
maternal vital signs (SBP, HR, SpO2), or respiratory
rate (RR) between the two groups in the doses used,
indicating minimal or no serious side effects on the
mother by the use of either epidural bupivacainefentanyl, or intravenous remifentanil.
Maternal side effects (Nausea, vomiting, itching,
and hypotension), were lower in remifentanil group
compared to epidural group but was statistically
M.E.J. ANESTH 20 (4), 2010
544
significant in case of itching, hypotension, and the rate
of instrumental and cesarean section delivery (P<0.05).
Some studies found significantly greater requirements
for ephedrine in women with severe preeclampsia who
received epidural analgesia4,23. Although, maternal
side effects were not observed in our study, but its
potential it like any opioid analgesia, a well-trained
staff therefore is recommended for close observations.
The continuous remifentanil infusion until the
time of delivery produced no observable fetal or
neonatal side effects compared to the epidural group,
(P>0.05). This was indicated by the normal Apgar score,
reassuring fetal heart rate tracing, normal umbilical cord
gases, the absence of need for naloxone, or mechanical
ventilation for the neonates. This is attributable to
the assumption that remifentanil crossed the placenta
was either rapidly metabolized or redistributed in the
neonates causing no adverse effects.
Our findings of an absence of any fetal or neonatal
adverse effects are consistent with other studies13,14,15,24.
Other findings are in contradictory25,26,27 with respect
to maternal and neonatal side effects, which can be
explained by the various doses used and mode of
administrations.
The short duration of action and the lack
of accumulation of remifentanil resulted in rapid
spontaneous resolution of any side effects. Whereas
the significant FHR abnormalities in the epidural group
is similar to the findings of other study28, comparing
normotensive women with epidural analgesia, women
with hypertension and epidural analgesia had a
three-fold increased risk of ominous fetal heart rate
tracings.
All women demonstrated a significant decrease
in VAS score in the first hour after administration of
analgesia (P<0.05), denoting effective analgesia in
both groups. Comparison of the analgesic quality of the
Visual Analog Pain Scores, sedation score, and postdelivery patient satisfaction between the two groups,
H. Kerdawy et. al
show comparable analgesic efficacy of both techniques
(P>0.05). This suggests that remifentanil may have a
true analgesic effect on labor pain, an effect consistent
with many previous studies8,24.
A variety of doses and delivery systems have
been previously8,9,15,29 for the purpose of identifying
an efficient and safe approach of remifentanil
administration. The concomitant use of a background
infusion is controversial30. Some studies recommended
the use of a background infusion31, and others argued
that remifentanil administration without a background
provides safe but incomplete analgesia13. Because of
the fact that it is difficult, to coincide the peak effect
of remifentanil with each uterine contraction but with
the subsequent contraction32, a background infusion
was chosen in this study to provide constant baseline
analgesia and that only the contraction peaks required
treatment with rescue boluses. Our regimen results was
compared with similar one31 used resulted in effective
analgesia with a rate of conversion to regional analgesia
of 5%, which is the lowest reported to date.
With the PCA intravenous remifentanil used in
this study, the patient benefits from a greater sense of
control over her pain management, plus the anxiolytic
effect of using narcotic (remifentanil), which is an
important psychological effect that contributes to
the success of this technique. Remifentanil reduces
pain during labor and does not cause immediate or
prolonged hazards to mother or fetus.
Conclusion
PCA intravenous remifentanil is an effective
option for pain relief with minimal maternal and
neonatal side effects in labor for preeclamptic patients
with contraindications to epidural analgesia or
requesting opioid analgesia. Further studies in larger
population of preeclamptic patients are recommended
to ensure the safety of this regimen.
LABOR ANALGESIA IN PREECLAMPSIA: REMIFENTANIL PATIENT CONTROLLED INTRAVENOUS ANALGESIA
VERSUS EPIDURAL ANALGESIA
545
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M.E.J. ANESTH 20 (4), 2010
546
H. Kerdawy et. al
SPINAL ANESTHESIA FOR TRANSURETHRAL
RESECTION OPERATIONS: LEVOBUPIVACAINE
WITH OR WITHOUT FENTANYL
Ozgun Cuvas*, Hulya Basar*, Aydan Yeygel*,
Esra Turkyılmaz*, Mehmet Melih Sunay**
Abstract
Background: The objective of the present study was double fold; to compare the characteristics
of spinal blocks produced by 0.5% levobupivacaine with and without fentanyl in transurethral
resection and to test the hypothesis that, fentanyl added to levobupivacaine, may be used as an
alternative to pure levobupivacaine solution, in spinal anesthesia.
Methods: Forty males, aged >60 years, ASA I-III patients scheduled for elective transurethral
resection were included in a prospective, randomized, double-blinded study. Following a spinal
tap, intrathecal injection in Group L (n = 20), 2.5 mL of 0.5% levobupivacaine and in Group LF
(n = 20), 2.2 mL of 0.5% levobupivacaine with fentanyl 15 µg (0.3 mL) was performed. The
characteristics of sensory and motor block, hemodynamic data, side effects, patient and surgeon
satisfaction were recorded. Patients were observed until the level of sensory block was S1 and the
Bromage score was 0.
Results: There were no significant differences between the two groups for patient demographic,
intraoperative, hemodynamic parameters, side effects and satisfaction. The highest level of sensory
block was T9 in the Group L, and T6 in the Group LF (p = 0.001). Duration of motor block was
shorter in Group LF than in Group L (291.00 ± 81.08 min in Group L; 213.75 ± 59.49 min in Group
LF) (p = 0.001).
Conclusion: Both regimes are effective, and the addition of fentanyl to levobupivacaine may
offers the advantage of shorter duration of motor block and may be used as an alternative to pure
levobupivacaine solution in spinal anesthesia, for transurethral resections.
Key Words: Anesthetic technique, anesthesia, spinal; Anesthetics, local, levobupivacaine;
Analgesics, opioid, fentanyl.
*
**
Department of Anesthesiology and Intensive Care Medicine
Department of Urology, Ankara Training and Research Hospital, Ulucanlar, Ankara, Turkey.
Corresponding Author: Ozgun Cuvas, MD, Specialist, Department of Anesthesiology and Intensive Care Medicine,
Ankara Training and Research Hospital, Ulucanlar, Ankara-06340 (Postal code), Turkey.
Tel: 0312 595 31 84, GSM: 0542 292 82 98. E-mail: [email protected]
547
M.E.J. ANESTH 20 (4), 2010
548
Introduction
Spinal anesthesia is widely used for transurethral
resections because it allows early recognition of
symptoms caused by overhydration, transurethral
resection of prostate (TURP) syndrome, and bladder
perforation.
Many patients undergoing TURP or TURBT
(transurethral resection of bladder tumour) have
coexisting pulmonary or cardiac disease1. By reducing
the dose of local anesthetic used, side effects can be
decreased. However, a low dose of local anesthetic
cannot provide an adequate level of sensory block.
Levobupivacaine is the S(-)- enantiomer of
racemic bupivacaine. Levobupivacaine has similar
efficacy but an enhanced safety profile when compared
to bupivacaine, a major advantage in regional
anesthesia2,3. Intrathecal opioids added to local
anesthetics enhance analgesia without intensifying
motor and sympathetic block, and make it possible to
achieve successful anesthesia in spite of the use of a
low dose local anesthetic4-6.
Levobupivacaine may be a proper alternative
local anesthetic for spinal anesthesia in elderly patients
with coexisting systemic disease for TUR operations.
By adding fentanyl to levobupivacaine, side effects
can be reduced. In this study we aimed to investigate
the characteristics and side effects of spinal blocks
achieved by levobupivacaine with or without fentanyl,
for TURP-BT operations.
Methods and Materials
After obtaining the approval of the Ethics
Committee of our Institution and patients’ informed
consent, 40 males, aged >60 years, ASA I-III patients
scheduled for elective TURP or TURBT operations
were included in a prospective, randomized, doubleblind study. Patients with uncontrolled hypertension,
infection at the injection site, disorders of coagulation,
history of headache, reluctance to the procedure,
neurologic disease or hypersensitivity to amide local
anesthetics or fentanyl, were excluded.
No premedication was given. Patients were
randomly assigned into two equal groups for spinal
anesthesia according to numbers inserted in sealed
envelopes. After routine monitoring and infusion of
O. Cuvas et. al
8 mL.kg-1 of sodium chloride 0.9% solution, baseline
hemodynamic values were recorded and then spinal
anesthesia was performed with the patient in the left
lateral position, using a 25 G Quincke needle at the
L3-4 interspace and a midline approach. In Group
L (n = 20), 2.5 mL of 0.5% levobupivacaine (Abbott
Laboratories, Elverum, Norway) and in Group
LF (n = 20), 2.2 mL of 0.5% levobupivacaine with
fentanyl citrate 15 µg (0.3 mL) (Abbott Laboratories,
North Chicago, USA) were administered via intrathecal
injection.
Solutions
were
prepared
by
another
anesthesiologist so that the anesthesiologist performing
the block was unaware of which drug was injected.
Densities of the solutions were measured at
37°C by refractometry (T2-NE, Atago Co. Ltd,
Japan). The densities of the pure levobupivacaine and
levobupivacaine plus fentanyl solutions were 1.008
and 1.007, respectively.
The direction of the needle aperture was cranial
during the injection. After free flow of cerebrospinal
fluid was verified, anesthetic solution was given in 15
s without barbotage or aspiration. Immediately after
the injection, the patients were placed in the supine
position.
Heart rate (HR), non-invasive systolic, diastolic
and mean arterial blood pressures (SAP, DAP, MAP)
and oxygen saturation (SpO2) were recorded every 2.5
min for 15 min after intrathecal injection and every
5 min thereafter. A 30% decrease from baseline SAP
or SAP <90 mmHg was treated with incremental iv
boluses of ephedrine 5 mg and bradycardia (HR <45)
was treated with iv atropine 0.5 mg. Supplementary
oxygen 2 L min-1 was given via a nasal cannulae if
SpO2 was less than 93% with the patient breathing
ambient air.
Sensory and motor block were assessed every 2.5
min for 15 min after intrathecal injection and every 5
min thereafter until the sensory block regressed to S1.
Anesthesia was considered adequate for surgery if pain
sensation as assessed by the pinprick test, was lost at
the T10 level. Patients were then placed in the lithotomy
position and operation started.
The time to achieve sensory block of T10, highest
level of sensory block, the time to two-segment
SPINAL ANESTHESIA FOR TRANSURETHRAL RESECTION OPERATIONS: LEVOBUPIVACAINE ITH OR
WITHOUT FENTANYL
regression of sensory block and the time to regression
of sensory block to S1, were recorded.
Motor block was assessed using the Modified
Bromage Scale (0 = no motor block, 1 = inability to
raise extended legs, 2 = inability to flex knees, and
3 = inability to flex ankle joints). Onset time of motor
block, maximum motor block (Bromage score), duration
of motor block (the time from intrathecal injection to
the regression of motor block to Bromage score = 0)
and duration of complete motor block ( the time from
intrathecal injection to the regression of the block to a
Bromage score of <3) were recorded also. Complete
motor block was defined as a Bromage score of 3.
Pain was assessed every 5 min from the beginning
of surgery using the 10 score Visual Analog Pain
Scale (VAS). In the event a patient complaned of a
pain score over three, 1.5 µ. kg-1 iv fentanyl would be
administered, and in case of failed spinal block, general
anesthesia would be performed. Midazolam would be
given intravenously in 0.5 mg increments as indicated
for anxiolysis.
Volume of glycine used, duration of surgery and
patient and surgeon satisfaction were recorded at the end
of the operation. Patients were interviewed regarding
their opinion of the anesthetic procedure. Likewise, the
surgeon was asked to estimate the operating conditions
on a scale of excellent, good, fair and poor. Patients
were observed until the level of sensory block was S1
and the Bromage score was 0.
Adverse effects such as hypotension, bradycardia,
nausea, vomiting, shivering, sedation, respiratory
depression and pruritus, were recorded. Nausea and
vomiting were treated with metoclopramide 10 mg iv.
Paracetamol 1 gr iv (Bristol Myers Squibb, Renaudin
Laboratories, Itxassou, France) was given during
infusion lasting 15 min when the patient complained
of pain in the postoperative period. The patients were
discharged from the recovery room after the motor
block was completely resolved, had stable vital signs,
minimal nausea or vomiting and no severe pain or
bleeding.
Our primary endpoint was the difference in the
duration of motor block between the two groups. Other
endpoints included were the difference, between the
two groups, in the characteristics of sensory block,
operating conditions, hemodynamic and side effects.
549
A sample size of 19 patients per group was
required to detect a 30 minute difference according to
the duration of motor block between two groups with
a power of 80% and α = 0.05, based on a pilot study.
Twenty patients were included in each group. All of the
data were analysed with SPSS 12 (SPSS Inc., Chicago,
IL., USA) software. Descriptives were quoted as
mean ± SD, median (range), number (incidence) as
appropriate. Statistical analyses were performed using
Student’s t test (for parametric data) and Mann-Whitney
U test (for non-parametric data). The incidences of side
effects and satisfactions were analysed using Fisher’s
exact test and Chi-Square test. The paired t-test was
used to investigate hemodynamic changes over time
in each group. Statistical significance was set at the
p<0.05 level.
Results
There were no significant differences between the
two groups in demographic data, ASA classification,
type and duration of operation or volume of glycine
used (p>0.05) (Table 1).
Hemodynamic parameters were similar in
both groups before and during operation (p>0.05)
(Figure 1).
Fig. 1
Baseline and lowest blood pressures after spinal anesthesia
L = Levobupivacaine; LF = Levobupivacaine plus fentanyl.
SAP = Systolic arterial pressure, MAP = Mean arterial pressure,
DAP = Diastolic arterial pressure. There were no significant
differences between two groups (p>0.05)
The highest level of sensory block was T9 (T4-T10)
in Group L‫ و‬and T6 (T3-T10) in Group LF, respectively
(p =0.001 ). The time to achieve sensory block of T10,
time to two-segment regression of sensory block, time
M.E.J. ANESTH 20 (4), 2010
550
O. Cuvas et. al
Table 1
Demographic and Perioperative Data
Group L (n = 20)
Group LF (n = 20)
p
Age (yr)
70.20 ± 7.33
68.80 ± 5.80
0.674
Weight (kg)
71.15 ± 10.31
71.85 ± 7.23
0.902
Height (cm)
170.20 ± 6.04
171.55 ± 4.23
0.369
2/13/5
3/13/4
0.856
ASA Grade (I/II/III)
Type of operation
TUR-Prostate/Bladder tumour
12/8
13/7
0.744
Duration of operation (min)
68.00 ± 26.82
74.75 ± 32.50
0.478
Volume of glycine (L)
15.65 ± 10.60
17.00 ± 13.36
0.755
Data are means ± standard deviation or number of patients.
L = Levobupivacaine; LF = Levobupivacaine plus fentanyl.
to regression of sensory block to S1, onset time of motor
block, maximum motor block and duration of complete
motor block, were similar in both groups (p>0.05). On
the other hand, duration of motor block was shorter in
Group LF than Group L (p = 0.001) (Table 2).
for surgeon satisfaction and p = 0.165 for patient
satisfaction).
Table 3
Side Effects in Groups L and LF
Group L (n
= 20)
No patient required supplemental oxygen,
analgesia or anxiolysis intraoperatively. There were
no significant differences between the two groups with
respect to side effects (Table 3) or patient or surgeon
satisfaction (p>0.05).
Group LF (n
= 20)
p
1.0
Hypotension
3 (15)
3 (15)
4 (20)
1.0
Bradycardia
3 (15)
1 (5)
1.0
Nausea
2 (10)
0
0
Vomiting
0
0
Shivering
Sedation
0
4 (20)
0.106
0
0
Respiratory
0
0
depression
Pruritus
Data are number of occurrences and incidences (%).
L = Levobupivacaine; LF = Levobupivacaine plus fentanyl.
The surgeon satisfaction was 35% excellent, 65%
good in Group L, 50% excellent, 50% good in Group
LF and the patient satisfaction was 35% excellent,
55% good, 10% fair in Group L, 65% excellent, 30%
good, 5% fair in Group LF, respectively (p = 0.337
Table 2
Characteristics of Spinal Anesthesia in Two Groups
Group L (n = 20)
Group LF (n = 20)
p
Sensory block
Time to T 10 (min)
6.50 ± 2.62
6.32 ± 3.50
0.525
Highest level (dermatome)
T9 (T4-T10)
T6 (T3-T10)
0.001*
Time to two segment regression (min)
107.00 ± 52.35
106.00 ± 48.62
0.950
Time to regression to S1 (min)
376.75 ± 80.03
337.25 ± 61.29
0.088
4.00 ± 1.49
3.60 ± 1.07
0.931
19/1
18/2
0.553
291.00 ± 81.08
213.75 ± 59.49
0.001*
145.75 ± 51.79
0.231
Motor block
Onset time of Bromage 1 (min)
Maximum motor block (n)
(Bromage Score 3/2)
Duration of motor block (min)
Duration of complete motor block (min)
167.00 ± 58.47
Data are means ± standard deviation, median (range) or number of patients.
L = Levobupivacaine; LF = Levobupivacaine plus fentanyl.
* p<0.05: A significant differences between the two groups.
SPINAL ANESTHESIA FOR TRANSURETHRAL RESECTION OPERATIONS: LEVOBUPIVACAINE ITH OR
WITHOUT FENTANYL
Discussion
This study demonstrates that 15 µg fentanyl
added to 2.2 mL of 0.5% levobupivacaine provides
adequate anesthesia which is similar to that obtained
from 2.5 mL of 0.5% levobupivacaine for TURP-BT
operations, and the lower-dose of local anesthetic
used with fentanyl may offer the advantage of shorter
duration of motor block.
It has been well documented that a combination of
opioids and local anesthetics administered intratechally
has a synergistic analgesic effect7-8. The use of racemic
bupivacaine with fentanyl in spinal anesthesia for
urologic surgery is effective. Kuusniemi et al found that
the addition of fentanyl 25 µg to 5 mg of bupivacaine
for spinal anesthesia resulted in effective anesthesia
with motor block of short duration5. Kararmaz et al
compared the intrathecal injection of bupivacaine 4 mg
with fentanyl 25 µg and bupivacaine 7.5 mg and found
that the sensory block was adequate for surgery in both
groups, but the density and duration of motor block
were more in the bupivacaine group9.
Ben-David et al found that a small dose of
fentanyl (10 µg) added to dilute bupivacaine( 3 mL
of 0.17% solution) in ambulatory patients undergoing
knee arthroscopies intensified and increased the
sensory block without increasing the intensity of motor
block or prolonging recovery4. Goel et al showed that
intrathecal fentanyl 12.5 µg added to bupivacaine
0.17% 5 mg in a total volume of 3 mL produced optimal
surgical conditions for minor urological procedures10.
Reuben et al suggested that a combination of low
dose fentanyl (<20 µg) and bupivacaine produced
satisfactory analgesia in elderly patients undergoing
lower extremity revascularization procedures, in their
study11.
Beers et al reported that although a subarachnoid
block ≥L1 provided adequate analgesia during TURP
operations, the level of sensory block at T10 was
necessary to provide adequate analgesia because
bladder distension elicited pain under the block
levels <T1012.
At the time of designing our study there was only
one published trial that compared plain solutions of
0.5% levobupivacaine with or without fentanyl, in spinal
anesthesia13. Lee et al13 compared the 2.6 mL of 0.5%
551
levobupivacaine and 2.3 mL of 0.5% levobupivacaine
with fentanyl 15 µg in spinal anesthesia, but there were
no data regarding time to two segment regression,
time to S1 regression of sensory block and onset time,
duration of motor block or complete motor block.
In addition, there was no data about the densities of
solutions and rate of injection. Our study was therefore
designed to give more details.
Although Lee et al found that highest level of
sensory block was similar between the two groups, in
our study, however the combination of levobupivacaine
with fentanyl reached a higher level of sensory block.
The resolution of motor block was faster in this
combination group than in the levobupivacaine group.
Low dose local anesthetic used in levobupivacaine
with fentanyl group, offered the advantage of shorter
duration of motor block. This result was consistent with
the resulting from the other studies which investigated
the effects of bupivacaine with or without fentanyl
in spinal anesthesia5,9. The clinical significance of a
reduced duration of motor block resuting from lowerdose levobupivacaine plus fentanyl would be early
ambulation. The duration of sensory block to S1 level,
however, was not different between the groups, so the
overall block resolution was not different. Our results
may be used as a building stone for further doseresponse studies.
The duration of injection and baricity of injected
solutions may be reasonable factors explaining the
differences in the highest level of sensory block
between two our study that of Lee’s. We injected the
local anesthetic solution in 15 s where as Lee did not
suggested this time.
In considering our measurements, levobupivacaine
plus fentanyl solution is more hypobaric than the pure
levobupivacaine solution. No data is given about the
densities of solutions in the study of Lee13. Opioids
such as fentanyl are hypobaric and when added to a
local anesthetic will render the subsequent mixture
even more hypobaric14. Parlow et al stated that the
addition of opioids to isobaric local anesthetics alters
the density of the resulting solutions, as well as the
direction and extent of spread in a spinal model15.
In Lee et al study, three patients (12%) in
levobupivacaine
group
developed
shivering.
Hypotension occured in four patients (16%) (one
M.E.J. ANESTH 20 (4), 2010
552
in group levobupivacaine and three in group
levobupivacaine with fentanyl). No patient had nausea,
vomiting or pruritis. In our study, side effects related
to the spinal fentanyl (pruritus and vomiting) did not
occur similar to the results of Lee et al.
Patient satisfaction was good in all cases in the
study of Lee et al13. In our study, there were no significant
differences between the two groups with respect to side
O. Cuvas et. al
effects or patient and surgeon satisfaction.
In conclusion, both regimes are effective, and
fentanyl added to levobupivacaine, in the dosage
used in the present study, may offer an advantage of
decreased duration of motor block and could be an
alternative to the use of pure levobupivacaine solution
in spinal anesthesia for transurethral resections.
References
1. Mebust WK, Holtgrewe HL, Cockett ATK, Peters PC: Transurethral
prostatectomy: immediate and postoperative complications.
Cooperative study of 13 participating institutions evaluating 3,885
patients. J Urol; 2002, 167(1):5-9.
2. Mcleod GA, Burke D: Levobupivacaine. Anaesthesia; 2001,
56(4):331-41.
3. Casati A, Baciarello M: Enantiomeric local anesthetics: can
ropivacaine and levobupivacaine improve our practice? Curr Drug
Therapy; 2006, 1:85-9.
4. Ben-David B, Solomon E, Levin H, Admoni H, Goldik Z: Intrathecal
fentanyl with small-dose dilute bupivacaine: better anesthesia
without prolonging recovery. Anesth Analg; 1997, 85:560-5.
5. Kuusniemi KS, Pihlajamakin KK, Pitkanen MT, Helenius HY,
Kirvela OA: The use of bupivacaine and fentanyl for spinal
anesthesia for urologic surgery. Anesth Analg; 2000, 91:1452-6.
6. Ben-David B, Frankel R, Arzumonov T, Marchevsky Y, Volpin G:
Minidose bupivacaine-fentanyl spinal anesthesia for surgical repair
of hip fracture in the aged. Anesthesiology; 2000, 92(1):6-10.
7. Maves TJ, Gebhart GF: Antinociceptive synergy between intrathecal
morphine and lidocaine during visceral and somatic nociception in
the rat. Anesthesiology; 1992, 76:91-9.
8. Wang C, Chakrabarti MK, Whitwam JG: Specific enhancement
by fentanyl of the effects of intrathecal bupivacaine on nociceptive
afferent but not on sympathetic efferent pathways in dogs.
Anesthesiology; 1993, 79:766-73.
9. Kararmaz A, Kaya S, Turhanoglu S, Ozyilmaz MA: Lowdose bupivacaine–fentanyl spinal anaesthesia for transurethral
prostatectomy. Anaesthesia; 2003, 58:526-30,.
10.Goel S, Bhardwaj N, Grover VK: Intrathecal fentanyl added to
intrathecal bupivacaine for day case surgery: a randomized study.
Eur J Anaesthesiol; 2003, 20:294-7.
11.Reuben SS, Dunn SM, Duprat KM, O’sullivan P: An intrathecal
fentanyl dose-response study in lower extremity revascularization
procedures. Anesthesiology; 1994, 81:1371-5.
12.Beers RA, Kane PB, Nsouli I, Krauss D: Does a mid-lumbar block
level provide adequate anaesthesia for transurethral prostatectomy?
Can J Anaesth; 1994, 41(9):807-12.
13.Lee YY, Muchhal K, Chan CK, Cheung ASP: Levobupivacaine
and fentanyl for spinal anaesthesia: a randomized trial. Eur J
Anaesthesiol; 2005, 22:899-903.
14.Mcleod GA: Density of spinal anaesthetic solutions of bupivacaine,
levobupivacaine, and ropivacaine with and without dextrose. Br J
Anaesth; 2004, 92:547-51.
15.Parlow JL, Money P, Chan PSL, Raymond J, Milne B: Addition of
opioids alters the density and spread of intrathecal local anesthetics?
An in vitro study. Can J Anaesth; 1999, 46(1):66-70.
ASSOCIATION BETWEEN FACTORS PREDICTING
AND ASSESSING THE AIRWAY AND USE OF
INTUBATING LARYNGEAL MASK AIRWAY
Chryssoula Staikou*, Athanassia Tsaroucha*,
Anteia Paraskeva*, Argyro Fassoulaki*
Summary
Background and objective: The Intubating Laryngeal Mask Airway FastrachTM (ILMA) has
been used with success in difficult intubation cases. The purpose of this study is to evaluate the
effect of mouth opening, Mallampati classification, thyromental distance and Cormack-Lehane
Grade, on the ease of ILMA use.
Methods: Eighty one patients ASA I-II, were assessed preoperatively for mouth opening,
Mallampati classification and thyromental distance. After induction with propofol and rocuronium,
the first investigator recorded Cormack-Lehane Grade by direct laryngoscopy. Subsequently an
appropriate size ILMA was inserted by the second investigator and correct placement was confirmed
by adequate ventilation and normal capnogram. A maximum of three ILMA insertion attempts
were allowed and the number was recorded. Then blind intubation was attempted and classified as
follows, according to Intubation Difficulty Grade (IDG):
IDG-1: intubation succeeded: at first attempt requiring no or minor ILMA manipulations.
IDG-2: intubation succeeded at second attempt requiring major ILMA manipulations or size
change.
IDG-3: intubation failed after the second attempt or oesophageal intubation occurred at either
attempt. In failure of the technique direct laryngoscopy was the alternative approach.
Results: Success rates in insertion of ILMA and in blind intubation were 100% and 92.6%
respectively. No difference was found between Cormack-Lehane Grade I-II and II-IV or Mallampati
classification and number of ILMA insertion attempts or IDG. There was also no correlation
between mouth opening, or thyromental distance and number of ILMA insertion attempts or IDG.
It is concluded that easiness of ILMA use is irrelevant to mouth opening, thyromental distance,
Mallampati classification or Cormack-Lehane Grade.
Key words: Airway devices; Intubation Laryngeal Mask Airway Fastrach, Airway assessment;
Mallampati Classification, mouth opening, thyromental distance, Cormack-Lehane Grade.
*
Anesthesiology Dept., Aretaieio Hospital Univ. of Athens. Athens, Greece.
Corresponding author: Anteia Paraskeva, E-mail: [email protected], [email protected], Tel: +30-2107286323.
553
M.E.J. ANESTH 20 (4), 2010
554
Introduction
In contradiction to the classic Laryngeal
Mask Airway (cLMA), the Intubating Laryngeal
Mask Airway FastrachTM (ILMA), can be used for
ventilation, allowing blind or fiberoptic intubation
through the device. The specific design characteristics
of the ILMA permits its insertion with the patient’s
head in neutral position, without guidance by the
fingers into patient’s mouth and with the practitioner
not necessarily positioned behind the patient’s head.
Those features render the ILMA a valuable airway
device in the operating room as well as in emergency
medical units1,2.
Although insertion and placement of the classic
LMA has not been associated with prediction or
assessment of a difficult airway3,4, there is evidence
that easiness of ILMA use is inversely related to
difficult airway5. Indeed intubation with the ILMA has
achieved high success rates in patients with difficult
intubation6, or were traditional techniques to intubate
have failed7.
Nevertheless no study has evaluated a possible
association between airway assessment and easiness
of ILMA use in general population. In this study we
investigated the possible impact of mouth opening,
Mallampati classification, thyromental distance and
Cormack-Lehane grade, on ILMA insertion and blind
intubation.
Materials and Methods
Following approval of the Hospital Ethics
Committee and obtaining patient’s informed consent,
81 adults (13 males, 68 females), ASA I-II, scheduled
for surgical procedures under general anesthesia
with tracheal intubation were recruited for the study.
Exclusion criteria were mouth opening less than 2.5 cm,
oropharyngeal pathology and risk of regurgitation.
Preoperatively, an anesthesiologist ignorant of
the study to be undertaken, assessed mouth opening,
Mallampati classification (Class I-IV) and thyromental
distance.
Mallampati classification was assessed, while the
patient was sitting with the mouth wide open and the
tongue protruding without phonating8,9.
C. Staikou et. al
Mouth opening was considered as the width of
the interincisor gap at midline (expressed as number of
anesthesiologist’s fingers fitting in the gap)10.
Thyromental distance was defined as the distance
in cm, measured from the thyroid cartilage to inside of
the mentum, while the patient was sitting with the head
extended and the mouth closed11.
In the operating room, standard monitoring,
consisted of ECG, pulse oximetry, non-invasive blood
pressure measurement, gas analyser and side spirometry
(Datex-Ohmeda S/5TM Anesthesia Monitor, Helsinki,
Finland). After inserting an 18G venous catheter,
Ringer Lactate infusion was started and ranitidine 50
mg and metoclopramide 10 mg IV were given.
All patients were preoxygenated for 5 minutes
with 100% O2. Anesthesia was induced with propofol
2.5 mg/kg and fentanyl 2 μg/kg and rocuronium 0.6
mg/kg, provided face mask ventilation was feasible.
Two staff anesthesiologists participated in the
study .The first anesthesiologist by direct laryngoscopy
using a Macintosh blade 4 without external maneuver2
evaluated in all patients Cormack-Lehane Grade as:
Grade I (full view of the glottis).
Grade II (glottis partially exposed).
Grade III (only epiglottis seen).
Grade IV (epiglottis not seen).
At completion of laryngoscopy, face mask
ventilation was applied again providing 3-5 inflations
of 100% oxygen.
Then with the patient’s head in neutral position, a
second anesthesiologist, having an experience of more
50 successful ILMA uses and standing behind patient’s
head, attempted to insert in all patients, the appropriate
size of ILMA (ILMATM, Laryngeal Mask Airway
Company, UK): (size 3 if body weight less than 50 kg,
size 4 if body weight between 50 and 70 kg and size 5
if body weight more than 70 kg).
Correct insertion of ILMA, was confirmed by
easy bag ventilation without audible leak (at peak
airway pressures up to 20 cm H2O) and by a normal
capnogram. A maximum of 3 ILMA insertion attempts
was allowed and the number of attempts was recorded.
Manual ventilation by face mask with 100% O2 and
additional boluses of propofol (20-40 mg) were given
A ASSOCIATION BETWEEN FACTORS PREDICTING AND ASSESSING THE AIRWAY AND USE OF INTUBATING
LARYNGEAL MASK AIRWAY
to maintain an adequate level of anesthesia between
ILMA insertion attempts.
After successful insertion, blind intubation of the
trachea was attempted by the same anesthesiologist,
with a wire-reinforced, silicone, cuffed tracheal tube
specially designed for the ILMA. A 7, 7 or 7.5 and 7.5
or 8 mm ID tube was used for 3, 4 and 5 size ILMA
respectively. Attempts for blind intubation were
classified by the Intubation Difficutly Grade (IDG) as
follows:
IDG-1: successful blind intubation at first attempt
without any or after minor manipulation of the ILMA,
to optimize the position of the ILMA.
IDG-2: successful blind intubation at second
attempt after further manipulation of the ILMA (the
ILMA was withdrawn a few cm without deflating the
cuff and repositioned: “up-down” maneuvre) or size
change5 combined with maneuvers to adjust patient’s
position for alignment with the glottis (optimizing
head-neck position, applying mild laryngeal pressure).
ILMA size change and the up-down maneuver
according to the depth (measured from the black
transverse marker on the tracheal tube) resistance was
encountered. If resistance was at less than 1.5 cm or at
more than 4 cm a smaller size ILMA used. If resistance
was between 2-4 cm a larger size of ILMA was used. If
resistance was between 1.5-2 cm an up-down maneuver
was performed.
IDG-3: unsuccessful second attempt for blind
intubation or esophageal intubation at either attempt.
Between intubation attempts patients were ventilated
via the ILMA with 100% oxygen and additional
boluses of propofol (20-40 mg) were given to ensure
adequate anesthetic depth. If blind intubation failed,
direct laryngoscopy was the alternative approach.
Complications such as desaturation (SpO2<90%),
regurgitation or aspiration, severe bronchospasm and
oropharyngeal or dental trauma, occurring at insertion
of the ILMA or at blind intubation, were recorded.
555
distributions, while Mallampati classification, mouth
opening, Cormack-Lehane grade, number of insertion
attempts and IDG did not follow normality. Chi square
test was used for association between Mallampati
classification or Cormack-Lehane Grade and insertion
attempts and between Mallampati classification or
Cormack-Lehane Grade and IDG. To analyze bivariate
correlations between BMI, thyromental distance or
mouth opening and insertion attempts or IDG, the
Spearman non parametric correlation coefficient was
used, corrected for the number of possible correlations.
Statistical significance was considered when P<0.05
for Chi Square test and when P<0.016 for Spearman
correlation coefficient.
Results
Patient characteristics are shown in Table 1.
Table 1
Patients characteristics: Age (yrs), Height (cm), BMI (Kg.m-2)
and Thyromental distance (cm).
Values are mean (SD). Mallampati, mouth opening
(number of fingers),
Cormack Lehane Grade, insertion attempts and IDG.
Values are median (min-max).
Age (yrs)
53(15)
Height (cm)
165(7)
BMI (Kg.m-2)
26(4)
Mallampati
2(1-3)
Thyromental distance (cm)
8.5(1)
Mouth opening (number of fingers)
3(2-4.5)
Cormack-Lehane Grade
1(1-3)
Insertion attempts
1(1-2)
IDG
1(1-3)
The overall rate in successful insertion of ILMA
was 100%, (91.4% at first attempt and 8.6% at second
attempt).
Statistics
The overall rate in successful blind intubation with
the ILMA was 92.6%. Of the successfully intubated
patients sixty three (77.8%) had IDG-1, 10 (12.3%)
had IDG-2, and eight (9.9%) patients had IDG-3.
Data were analyzed using the SPSS 15.0
statistical program (SPSS INC., Chicago, IL, USA).
According to Kolmogorov-Smirnov test, age, height,
BMI and thyromental distance followed normal
Seventy one patients (71/81) had Cormack
–Lehane grade I or II, 10 patients (10/81) had a
Cormack-Lehane grade III and no patient had grade
IV. The rate in successful blind intubation for patients
M.E.J. ANESTH 20 (4), 2010
556
C. Staikou et. al
with Cormack Lehane grade III was 70% (7/10), with
a 60% success (6/10) at first attempt.
Eight of the 81 patients (9.9%) were not intubated
with the ILMA at either attempt. Seven of them (7/8)
had a Cormack-Lehane grade I or II and were easily
intubated under direct laryngoscopy. One patient
(1/10) had a Cormack-Lehane grade III and could not
be intubated under direct laryngoscopy, despite the
use of a gum elastic boogie and the McCoy blade and
surgery proceeded with an LMA proseal.
There was no difference between Mallampati
classification or Cormack-Lehane Grade and insertion
attempts or IDG (table 2). No correlation was found
between thyromental distance, or mouth opening and
insertion attempts or IDG (table 2).
Table 2
Insertion attempts and IDG in relation to Mallampati score,
mouth opening (number of fingers)
thyromental distance (cm) and Cormack-Lehane Grade.
Insertion
attempts
IDG
Mouth opening (number of
fingers)
P= 0.480
r = -0.080
P= 0.219
r = -0.138
Mallampati
P= 0.296
X2=2.433
P= 0.698
X2=2.205
Thyromental distance (cm)
P = 0.150
r = -0.161
P = 0.214
r = -0.139
Cormack-Lehane grade
P = 0.588
X2 = 1.936
P = 0.75
X2 = 5.19
* P<0.05 for Chi Square (level of statistical significance).
** P<0.016 for Spearman coefficient (level of statistical
significance)
Complications, such as desaturation (SpO2<90%),
regurgitation or aspiration, severe brochospasm and
oropharyngeal or dental trauma, at insertion of the
ILMA or at blind intubation, were not recorded.
Disscusion
According to our results successful insertion
of ILMA and intubation with the device has been
accomplished in 100% and 92.6% of patients
respectively No relationship was found between factors
predicting or assessing difficult airway and easiness of
the ILMA use.
Brain et al, found that tracheal intubation with the
ILMA required fewer adjusting manoeuvers in patients
with a predicted or known difficult airway5. The authors
suggested that in those cases anterior placement of the
larynx favors blind intubation with the ILMA because
of its structure. Combes et al, in a recent study showed
that airway management with the ILMA was simpler in
obese than in lean patients13. Although obesity is related
to difficult intubation14,15, Cormack-Lehane Grade was
not assessed in those patients and the authors suggested
less rotating movement of the ILMA in obese patients
because of less pharyngeal space, a fact not considered
in the definition of difficult airway. Similarly Ferson
et al, in a retrospective study found that in 111 patients
with a Cormack-Lehane Grade IV, intubation with the
ILMA was achieved in 92% of patients and in 63.6%
intubation was successful at first attempt6. Also, Agro
et al, in a prospective study recorded correct insertion
of ILMA in 95% of the patients studied and intubation
at first attempt succeeded in 74% of the patients16.
In this study only 6 patients had known or predicted
difficult airway.
Our results are in accordance with the results of
Roblot et al17, who did not detect in women any impact
of Cormack-Lehane Grade or of a difficult intubation
predicting score (Arne’s score) on ILMA use.
Although bedside tests are considered poor
predictors of difficult intubation, especially if each
of them is used alone18,19, we preferred to investigate
separately the difficult intubation predictive factors,
such as thyromental distance, mouth opening
and Mallampati classification, because a possible
correlation between ILMA use with each factor could
not be revealed, if it was summated in a multifactorial
risk score. Also since we decided to assess directly
the airway by Cormack-Lehane Grade we thought
that at the same time predicting difficult airway was
unnecessary. We decided to make up to two attempts
for blind intubation since according to Difficult Airway
Society (DAS) guidelines up to 4 intubation attempts
are allowed in cases difficult intubation is encountered
after induction20. Similarly Frappier et al, studying
obese patients (BMI >40) did not find any impact
of Cormack-Lehane Grade on the easiness of ILMA
use21.
We are aware of the difficulty to study
prospectively a systematic effect of difficult intubation
A ASSOCIATION BETWEEN FACTORS PREDICTING AND ASSESSING THE AIRWAY AND USE OF INTUBATING
LARYNGEAL MASK AIRWAY
predictive factors and Cormack-Lehane Grade on ILMA
use in general population. A limitation of our study is
a small number of Cormack-Lehane III or IV grade in
general population. Since ILMA appears in the revised
ASA guidelines22 and also in DAS guidelines20 as an
alternative approach to difficult airway, it is important
that further studies will delineate our hypothesis, if
557
ILMA is or is not easier to use in a failed intubation
scenario.
In conclusion, under the present study design,
ILMA use was not associated with mouth opening,
Mallampati classification, thyromental distance, or
Cormack-Lehane Grade.
M.E.J. ANESTH 20 (4), 2010
558
C. Staikou et. al
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2. Combes X, Aaron E, Jabre P, Leroux B, Lefloch AS, Andre JY
et al: Introduction of the intubating Laryngeal Mask Airway in a
prehospital emergency medical unit. Ann Fr Anesth Reanim; 2006,
25:1025-1029.
3. Brimacombe J, Berry A: Mallampati classification and laryngeal
mask insertion. Anaesthesia; 1993, 48:347.
4. Mahiou P, Narchi P, Veyrac P, Germond M, Gory G, Bazin
G: Is laryngeal mask easy to use in case of difficult intubation?
Anesthesiology; 1992, 77:A1228.
5. Brain AI, Verghese C, Addy EV, Kapila A, Brimacombe J: The
intubating laryngeal mask. II: a preliminary clinical report of a new
means of intubating the trachea. Br J Anaesth; 1997, 79:704-709.
6. Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A:
Use of the intubating LMA-Fastrach™ in 254 patients with difficult
to manage airways. Anesthesiology; 2001, 95:1175-1181.
7. Parr MJ, Gregory M, Baskett PJ: The intubating laryngeal mask
use in failed and difficult intubation. Anaesthesia; 1998, 53:343348.
8. Samsoon GL, Young JR: Difficult tracheal intubation: a retrospective
study. Anaesthesia; 1987, 42:487-490.
9. Mallampati SR, Gatt SP, Gugino LG, Desai SP,Waraksa B,
Freiberger D, et al: A clinical sign to predict difficult tracheal
intubation: a prospective study. Can Anaesth Soc J; 1985, 32:429434.
10.Aiello G, Metcalf I: Anaesthetic implications of temporomandibular
joint disease. Can J Anaesth; 1992, 39:610-616.
11.Lewis M, Keramati S, Benumof JL, Berry CC: What is the best way
to determine oropharyngeal classification and mandibular space
length to predict difficult laryngoscopy? Anesthesiology; 1994,
81:69-75.
12.Cormack RS, Lehane J. Difficult intubation in obstetrics.
Anaesthesia; 1984, 39:1105-1111.
13.Combes X, Sauvat S, Leroux B, Dumerat M, Sherrer E, Motamed
C, et al: Intubating laryngeal mask airway in morbidly obese and
lean patients. Anesthesiology; 2005, 102:1106-1109.
14.Rose DK, Cohen MM: The airway: Problems and predictions in
18,500 patients. Can J Anesth; 1994, 41:372-383.
15.Wilson ME, Spiegelhalter D, Robertson JA, Lesser P: Predicting
difficult incubation. Br J Anaesth; 1988, 61:211-216.
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A, Cataldo R: The intubating laryngeal mask (Clinical appraisal
of ventilation and blind tracheal intubation in 110 patients).
Anaesthesia; 1998, 53:1084-1090.
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intubation in apparently normal patients. A meta-analysis of bedside
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intubation. Anaesthesia; 2004, 59:675-694.
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PREOPERATIVE ORAL DEXTROMETHORPHAN
DOES NOT REDUCE PAIN OR
MORPHINE CONSUMPTION AFTER
OPEN CHOLESYCTECTOMY
Hossein Mahmoodzadeh1, Ali Movafegh2
and
Nooshin Moosavi Beigi3
Summary
Background: Dextromethorphan (DM), the D-isomer of the codeine analogue levorphanol, is
a weak, noncompetitive N-Methyl-D-Aspartate (NMDA) receptor antagonist. It has been suggested
that NMDA receptor antagonists induce preemptive analgesia when administrated before tissue
injury occurs, thus decreasing the subsequent sensation of pain.
Method: The study was conducted in the Dr Ali shariati hospital, Tehran University of
Medical Sciences, Tehran, Iran. In this seventy two patients scheduled for elective cholesyctectomy
between February 2005 and December 2006 were randomized into three equal groups to receive as
premedication either oral dextromethorphan 45 mg (Group D45 = 24), dextromethorphan 90 mg
(Group D 90 = 24) or placebo (Group C, n = 24), 120 min before surgery. A visual analogue scale
(VAS) for pain of each patient measured at arrival in the ward and 6 and 24 hours after surgery,
was recorded.
Results: The demographic characteristics of patients, ASA physical status class, duration of
surgery, and the basal VAS pain score were similar in the two groups. There was no significant
difference in the mean of the VAS pain scores measured over time or morphine consumption
between three groups.
Conclusion: Dextromethorphan, 45 and 90 mg orally administrated 2 h before surgery had
no effect on postoperative morphine requirement and pain intensity.
Key words: dextromethorphan, postoperative pain, preemptive analgesia.
1
2
3
From the Departments of Surgery 1, 2 and Anesthesiology and Critical Care, Ali Shariati Hospital, Tehran Univ. of
Medical Sciences, Tehran, Iran.
MD, Assist. Prof. Surgery.
MD, Associate Prof. Anesth. & Critical Care.
MD, Resident Surgery.
Corresponding Author: Ali Movafegh MD, Department of Anesthesiology and Critical Care,
Dr Ali Shariati Hospital, North Karegar Street, Tehran 1411713135, Iran. Tel: +98-912-3021389,
Fax: +98-21-88026017. E-mail Address: [email protected]
559
M.E.J. ANESTH 20 (4), 2010
560
Introduction
Opioids, are frequently administered to patients
undergoing major surgery to alleviate postoperative
pain. However, they may cause adverse effects such
as nausea and vomiting, pruritus, urinary retention and
respiratory depression1.
As the analgesia and side effects of opioids are
dose dependent, a multimodal offset may enhance
analgesia while minimizing the side effects1.
Dextromethorphan (DM), the D-isomer of the codeine
analogue levorphanol, is a weak, noncompetitive
N-Methyl-D-Aspartate (NMDA) receptor antagonist
that has been used as an antitussive drug for more
than 40 years2,3. It has been suggested that NMDA
receptor antagonists induce preemptive analgesia
when administrated before tissue injury occurs, thus
decreasing the subsequent sensation of pain2,3.There
is good evidence from basic scientific literature to
believe that acute postinjury pain states in humans
could be treated usefully with a combination of opioids
and NMDA antagonists46-.
The purpose of the current study was therefore
to determined to find out whether preoperative
administration of 45 and 90 mg of oral DM would
reduce postoperative pain and opioid consumption as
compared to a control group.
Method & Materials
The study was conducted in the Dr Ali shariati
hospital, Tehran University of Medical Sciences,
Tehran, Iran.
The proposal was approved by the Institutional
Ethics Committee and informed written consent was
obtained from the patients. Between February 2005
and December 2006 seventy two patients, 25-50
years, ASA I & II scheduled for open cholesyctectomy
(midline approach) under general anesthesia, were
enrolled in this randomized, double- blinded, and
placebo controlled study.
Patients who received opioids within 48 h of
surgery and sedatives or centrally acting drugs(central
nervous system depressants or antidepressants) during
the 21 days prior to surgery; those with a history
of chronic pain, psychotic disorders or addiction
including opioids, those with any contraindication to
H. Mahmoodzadeh et. al
DM and pregnant or lactating women were excluded
from the study.
All participants were given full explanations of
DM and the visual analog scale for pain (VAS) on the
day before surgery.
All drugs were given by an anesthesiologist who
was not involved in patient observation, thus both
the observer and patients were blinded to the group
assignment. Patients were randomly assigned into
three equal groups (24 each): Patients receiving DM
45 mg (Group 45 DM), (Patients receiving DM 90
mg (Group DM 90, and (Group C) using a computer
generated randomization list.
All patients in the 3 groups received the designated
dose orally 120 min before surgery. Placebo was in
similar capsules containing sucrose.
On arrival to operating room, all patients
were monitored with an electrocardiogram (ECG),
noninvasive blood pressure and pulse oximetry. An 18gauge cannula was inserted and lactated ringer solution
7 ml.kg-1 was administered.
Anesthesia was induced with 2 mg.kg-1 propofol
and 0.3 µg.kg-1 sufentanyl; and endotracheal intubation
was facilitated with 0.15 mg.kg-1 cisatracurium. After
tracheal intubation, anesthesia was maintained by
isoflurane and N2O (50%); 0.05 mg.kg-1 cisatracurium
and 0.2 µg.kg-1 sufentanyl were administered
half hourly. Ventilation was adjusted to maintain
normocapnia (end-tidal carbon dioxide partial pressure
4.7-5.3 kPa). Patients were actively warmed to keep
core temperature (esophageal) normothermic. At the
beginning of the skin sutures, drugs administration was
stopped and neuromuscular block was antagonized by
IV administration of 2.5 mg of neostigmine along with
1.25 mg atropine. Patients were considered awake
when they opened their eyes on demand or after gentle
tactile stimulation; they were later extubated.
The severity of postoperative pain was measured
and recorded using a 10-cm visual analog scale (VAS),
(0 = no pain and 10 = the worst possible pain). Patients
were asked to score the pain during coughing or
movement at arrival in the ward and 6 and 24 hours
after surgery. Patients could request rescue analgesia at
any time. Morphine, 0.1 mg/kg-1 was given as rescue
analgesia at 8-h intervals.
PREOPERATIVE ORAL DEXTROMETHORPHAN DOES NOT REDUCE PAIN OR MORPHINE CONSUMPTION
AFTER OPEN CHOLESYCTECTOMY
According to the previous studies, a sample
size of 24 in each group would be sufficient to detect
a difference of 3 scores in the mean of pain score,
estimating a power of 80%, and a significance level
of 5%. Statistical analysis was performed using SPSS
package (SPSS Inc., Chicago, IL, USA), version 11.5.
Normality of distribution was checked as needed.
For statistical analysis of demographic data and for
comparison of groups one way ANOVA, repeated
measure analysis of variance, Fishers exact or Chisquare tests where appropriate. Tow tailed P<0.05 was
taken as significant.
Results
Seventy two patients were randomized. Three
patients were excluded from the study because the
surgical complications (two from C group and one
from D45 group).
Demographic characteristics of patients, ASA
physical status class, and surgery time (min) were
similar in the two groups (Table 1).
Table 1
Demographic characteristics
Group
Control
(n = 22)
Group DM
45
(n = 23)
Group DM
90
(n = 24)
48.3 ± 14.5 48.2 ± 14.3 46.2 ± 23.3
Age (yr)*
13/9
13/10
14/10
Sex (F/M)
Surgery Time (min)* 98 ± 25.6 104 ± 23.2 112 ± 13.2
10/12
12/11
11/13
ASA class (I/II)
78.3 ± 7.5 80.1 ± 10.4 75.1 ± 8.3
Weight (kg)*
* Values are expressed as mean ± SD.
** There are no significant differences among the groups.
There were no significant differences in the mean
of the morphine consumption (12.39 ± 5.24 mg in DM
45 group and 13.71 ± 4.28 mg in DM 90 group, versus
11.88 ± 5.29 in C group) and the time to first morphine
request (3.1 ± 1.7 h in DM 45 group and 3.2 ± 1.9 in DM
90 group, versus 2.9 ± 1.1 in control group) (Table 2).
There was no significant difference in the mean
of VAS pain scores measured over time between three
groups(5.55 ± 1.38, 4.83 ± 2.39, 3.62 ± 2.92 in group C;
4.73 + 2.14, 4.22 + 2.36, 4.00 + 2.50 in group DM 45;
and 5.18 ± 2.81, 4.12 ± 2.80, 3.24 ± 2.95 in group DM
90, repeated-measures analysis of variance, betweensubjects effects) (Table 2).
561
Table 2
VAS for pain, morphine consumption and time to first
morphine injection in the three groups.
Group
Control
Group DM
45
Group DM
90
3.1 ± 1.7
3.2 ± 1.9
Total Morphine 11.88 ± 5.29
Consumption
(mg)*
Time to First
2.9 ± 1.1
12.39 ± 5.24 13.71 ± 4.28
Morphine
Injection (h)*
Visual Analogue
Scale for pain*
5.55 ± 1.38 4.73 + 2.14 5.28 ± 2.81
- Arriving
Ward
4.83 ± 2.39 4.22 + 2.36 4.12 ± 2.80
-6h
- 24 h
3.62 ± 2.92 4.00 + 2.50 3.24 ± 2.95
* Values are expressed as mean ± SD.
** There are no significant differences among the groups.
Discussion
This study demonstrated that in patient undergoing
open cholecystectomy, oral premedication with 45
or 90 mg DM did not decrease post-operative pain
intensity or morphine consumption when compared
to patients who received placebo. Our findings are not
consistent with earlier reports that dextromethorphan
reduces pain and analgesic requirement after various
surgeries7-10.
N-methyl-D-aspartate receptor antagonism
inhibits wind up or central hypersensitivity of dorsal
horn neurons in response to noxious stimulation2-11.
Dextromethorphan, an NMDA receptor antagonist
has been shown to reduce secondary hyperalgesia but
have no effect on primary hyperalgesia on healthy
adult male volunteers2,12,13.Other investigators have
been unable to demonstrate that DM, in clinically
relevant dose, has any effect on primary or secondary
hyperanalgesia14,15.
The ability of DM to attenuate pain is controversial.
Not all investigators agree that DM reduces opioid
consumption or acute pain. Although DM have been
used successfully as premedication for postoperative
pain and morphine consumption reduction in some
investigations6-10, other studies have not corroborated
these reports16-19.
Ilkjaer et al studied 50 patients undergoing nonmalignant elective abdominal hysterectomy. The study
was a double-blinded, randomized designed to compare
M.E.J. ANESTH 20 (4), 2010
562
post-operative analgesia requirements and pain scores
in patients who received preoperative DM or placebo.
DM reduced morphine requirements in this sample and
a modest (but non-significant) reduction in pain scores
was found. They found that oral dextromethorphan 150
mg reduced PCA morphine consumption immediately
(0-4 h) after hysterectomy, without prolonged effects
on pain or wound hyperalgesia18.
Thematic of the controversy surrounding the
role of DM in acute pain management, Wadhaw et al.
failed to demonstrate the specific opioid sparing effect
expected with DM administration. In this 66 patient
experimental sample, the investigators concluded that
DM dose not improve acute pain scores even at high
doses19.
Many surgical procedures were included in both
positive and negative studies, and there did not appear
to be one specific procedure that yielded more benefit
than any other. In the dextromethorphan studies, four
negative studies used the oral route, and in two of these
trials at smaller doses of drug, there was no direct
analgesic effect of the intervention16-19.
H. Mahmoodzadeh et. al
The NMDA blocking properties of DM are likely
less potent compared to ketamine2. It is possible that
only subset of individuals will benefit from the NMDA
properties of DM.
As well it may be that DM should be administered
parenterally in a dose of at least 1 mg/kg-1 for maximal
preventive effect2.
Further investigations are required to determine
whether larger doses or repeated doses of oral
dextromethorphan attenuate post operative pain.
However, undesirable side effects of dextromethorphan,
including sedation and ataxia, are common in adults
when the dose is increased above that recommended
for antitussive therapy and may limit its usefulness17.
The power analysis for this study indicated that
there were sufficient numbers of patients in each group
to detect 25% reduction in morphine use and 30 mm
reduction in VAS for pain on moving.
In conclusion, dextromethorphan, 45 and 90 mg
orally administrated 2 h before surgery had no effect
on postoperative morphine requirement and pain
intensity.
PREOPERATIVE ORAL DEXTROMETHORPHAN DOES NOT REDUCE PAIN OR MORPHINE CONSUMPTION
AFTER OPEN CHOLESYCTECTOMY
563
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13.Ilkjaer S, Driks J, Brennum J, Werenberg M, Dahi JB: Effect of
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on primary and secondary hyperalgesia in humans. Br J Anaesth;
1997, 79:600-5.
14.Kinnman E, Nygrads EB, Hansson P: Effects of dextromethorphan
in clinical doses on capsaicin-induced ongoing pain and mechanical
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15.Kauppila T, Gronroos M, Petrovaara A: An attempt to attenuate
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16.Fisher K, Coderre TJ, Hagen NA: Targeting the N-methyldaspartate receptor for chronic pain management: preclinical animal
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Pain Symptom Manage; 2000, 20:358-73.
17.Rose JB, Romulo C, Cohen DE, Scheriner MS: Preoperative oral
dextromethorphan dose not reduce pain or analgesic consumption in
children after adenotonsilectomy. Anesth Analg; 1999, 88:749-53.
18.Ilkjaer S, Bach LF, Nielsen PA, Wernberg M, Dahl JB: Effect
of preoperative oral dextromethorphan on immediate and late
postoperative pain and hyperalgesia after total abdominal
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M.E.J. ANESTH 20 (4), 2010
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H. Mahmoodzadeh et. al
DEXAMETHASONE WITH EITHER GRANISETRON
OR ONDANSETRON FOR POSTOPERATIVE
NAUSEA AND VOMITING IN
LAPAROSCOPIC SURGERY
Alia S. Dabbous*, Samar I. Jabbour-Khoury**,
Viviane G Nasr***, Adib A Moussa***, Reine A Zbeidy***,
Nabil E Khouzam***, Mohamad F El-Khatib**,
Anis S Baraka****
Abstract
In a prospective randomized double-blind study, we compared the effectiveness of
dexamethasone 8 mg with either granisetron 1 mg or ondansetron 4 mg in the prevention of
postoperative nausea and vomiting in patients undergoing laparoscopic surgery. Hundred ASA
I and II patients scheduled for laparoscopic surgery were enrolled in the study and 84 patients
completed it. Following induction of anesthesia, group I (n = 42) received granisetron 1 mg and
dexamethasone 8 mg, group II (n = 42) received ondansetron 4 mg and dexamethasone 8 mg.
Nausea and vomiting episodes, pain scores as well as side effects were recorded during the first
hour and subsequently during the first 6 and 24 hours postoperatively. Satisfaction scores were
obtained at discharge. There was no statistically significant difference between the 2 groups
during the 1st 24 hours following surgery in regards to pain scores, satisfaction and side effects
manifestations. At 0-1 hour interval, 100% of patients in group I and 97.6% in group II had no
vomiting. Total response (no moderate or severe nausea and no rescue antiemetics) was 83.3% in
group I and 80.95% in group II, and metoclopramide was used in 7.1% of patients in both groups.
At 1-6 hours interval, 97.6% of patients in group I and 100% in group II had no vomiting. Total
response was 92.8% in group I and 90.9% in group II, and metoclopramide was used in 4.76% of
patients in group I and 2.38% in group II. At 6-24 hours no vomiting occurred in 97.6% of patients
in group I and 100% in group II. Total response was 95.2% in both groups, and metoclopramide
was used in 2.38% of patients in both groups. In conclusion, the combination of dexamethasone 8
mg with either granisetron 1 mg or ondansetron 4 mg following induction of anesthesia in patients
undergoing laparoscopic surgery showed no statistically significant difference in antiemetic
efficacy with minimal side effects and excellent patient satisfaction.
Key Words: Postoperative nausea and vomiting, Granisetron, Ondansetron, Dexamethasone,
Laparoscopy.
*
Assistant Professor.
** Professor.
*** Resident.
****Professor Emeritus, Department of Anesthesiology, American University of Beirut-Medical Center, Beirut, Lebanon.
Address correspondence to: Alia Dabbous, MD, Assistant Professor, Department of Anesthesiology American University
of Beirut. P.O. Box: 11-0236, Beirut 1107-2020, Lebanon. E-mail:[email protected]
565
M.E.J. ANESTH 20 (4), 2010
566
Introduction
Postoperative nausea and vomiting (PONV) are
two of the most common and unpleasant side effects
following anesthesia and surgery1. Laparoscopic
surgery is associated with a high incidence of nausea
and vomiting2,3. In a recent review on postoperative
recovery profile after laparoscopic cholecystectomy,
PONV was seen in 11% of patients and severe
PONV in 2% of patients despite prophylaxis with
dexamethasone, ondansetron and the use of total
intravenous anesthesia technique4. PONV remains
to be a predictor of complicated recovery profile
and deserves further attention. The combination of
ondansetron plus dexamethasone was more effective
in the prevention of postoperative nausea and vomiting
than ondansetron alone5. Also, the combination
of granisetron 40 µg/kg and dexamethasone 8 mg
produced 98% PONV free in patients undergoing
laparoscopic cholecystectomy versus 83% PONV
free with granisetron alone6. In another study, the
same combination produced 95% PONV free versus
83% for granisetron alone7. Although the combination
of dexamethasone and 5-hydroxytryptamine type 3
(5HT3) antagonists has been previously described,
our report is the first to compare the combination of
granisetron 1 mg and dexamethasone 8 mg versus
ondansetron 4 mg and dexamethasone 8 mg for PONV
prophylaxis in patients undergoing laparoscopic
cholecystectomy and herniorraphy.
The aim of this study is to compare the effectiveness
of granisetron 1 mg and dexamethasone 8 mg (group
I) versus ondansetron 4 mg and dexamethasone 8 mg
(group II) in the prevention of early and late PONV in
patients undergoing laparoscopic cholecystectomy and
herniorraphy.
Materials and Methods
After obtaining our institutional review board
(IRB) approval and informed written consents from all
human subjects, 100 patients, ASA I or II, scheduled
for laparoscopic cholecystectomy or herniorraphy
were enrolled in this prospective randomized doubleblinded study. 84 patients completed the study (42 in
group I and 42 in group II). Exclusion criteria included:
Known allergies or hypersensitivity to the study drugs,
history of chronic nausea and vomiting or experienced
A. S. Dabbous et. al
nausea and vomiting in the past 24 hours prior to
anesthesia, had received any antiemetics or any drug
with antiemetic properties during the 24 hours before
anesthesia, had a body mass index ≥35 kg/m2, aged
>70 years, were pregnant or breast feeding or had a
condition requiring chronic opioid use.
Using a computer generated randomization
method; Patients were randomized into 2 groups.
Group I received granisetron 1 mg and dexamethasone
8 mg while group II received ondansetron 4 mg and
dexamethasone 8 mg. The study medications were
prepared by a resident, who was not involved in any
other part of the study, and were presented to blinded
investigators as identical 2 ml filled syringes.
After standard monitoring techniques consisting
of EKG, pulse oximetry, and blood pressure, patients
received 1 mg of midazolam intravenously as a
premedication. General anesthesia was induced with
intravenous (IV) propofol 2 mg/kg, lidocaine 1 mg/Kg,
fentanyl 2 µg/kg, and muscle relaxation was achieved
with rocuronium 0.6 mg/kg to facilitate endotracheal
intubation. Maintenance of anesthesia was achieved by
sevoflurane, oxygen: air mixture (1:1), additional doses
of fentanyl up to 4 µg/kg and rocuronium as needed to
keep a train of four ratio <0.7. The study medications
dexamethasone and granisetron or dexamethasone
and ondansetron were administered immediately after
induction of anesthesia in both treatment groups.
Neuromuscular blockade was reversed at the end
of surgery with IV neostigmine (0.05 mg/kg) and
glycopyrrolate (0.01 mg/kg). Patients were transferred
to the post anesthesia care unit (PACU) and the PACU
team was instructed to assess pain scores according
to the visual analogue scale VAS. If pain score >5 the
patients were given either paracetamol (Prodafalgan™)
1 g IV drip or demerol 20 mg IV bolus. The time of
each vomiting episode and the time and intensity of
each nausea episode were collected from the nursing
chart upon arrival to PACU, at 1 hour, 6 and 24 hours
postoperatively. An episode of vomiting was defined as
expulsion of stomach contents with no relief of nausea
symptoms. The intensity of each nausea episode was
graded as mild (discomfort noticed but no disruption
of anticipated normal activity), moderate (discomfort
sufficient to reduce or affect anticipated normal
activity) or severe (inability to perform anticipated
DEXAMETHASONE WITH EITHER GRANISETRON OR ONDANSETRON FOR POSTOPERATIVE
NAUSEA AND VOMITING IN LAPAROSCOPIC SURGERY
normal activity). The initial rescue medication was
metoclopramide 10 mg administered as a single IV
bolus dose and was given if the patients vomited,
complained of moderate or severe nausea and if
they requested the treatment medication. Nausea and
vomiting assessments were made up to 30 minutes
following rescue medication administration and
response was defined as improvement or resolution of
PONV symptoms. Adverse events were evaluated and
recorded by a resident who was blinded to the study
drugs used. Postoperative pain was also followed up at
1, 6 and 24 hours postoperatively. Patient satisfaction
was recorded just before discharge.
Statistical Analysis
All values were reported as means ± standard
deviation, or numbers and percentages. Data were
analyzed using independent sample t-test and chisquared test. A P value less than 0.05 was considered
statistically significant.
Results
Of the 100 patients initially signing the informed
consent, 84 patients (42 in group I, 42 in group
II) completed the study. There was no statistically
significant difference between the two groups in regards
to gender, history of PONV and history of motion
sickness, age, weight, type of surgery (laparoscopic
cholecystectomy or laparoscopic herniorraphy),
duration of surgery, history of prolonged gastric
emptying, and smoking history (Table 1).
Table 1
Demographic data
Granisetron + Ondansetron +
Dexamethasone Dexamethasone
(n = 42)
(n = 42)
Age (years)
Gender (male/female)
Weight (kilograms)
46.5 ± 11.7
47.4 ± 14.2
22/20
20/22
75.8 ± 16.1
77.5 ± 14.1
Type of surgery:
Lap cholecystectomy
Lap Herniorraphy
31
11
30
12
History of PONV
5
4
History of motion
sickness
1
2
History of delayed gastric
emptying
4
5
History of smoking
Duration of surgery (min)
20
18
61 ± 8.4
62 ± 7.4
567
There was no statistically significant difference
between the two groups at the three time intervals (0-1,
1-6, 6-24 h) with respect to total response, number
of patients who vomited and the use of antiemetics
(metoclopramide) (P>0.05) (Table 2).
Table 2
Efficacy outcome
Granisetron +
Dexamethasone
(n = 42)
Ondansetron +
Dexamethasone
(n = 42)
No Vomiting
0-1 hr
1-6 hrs
6-24 hrs
42 (100%)
41 (97.6%)
41 (97.6%)
41 (97.6%)
42 (100%)
42 (100%)
Total response
0-1 hr
1-6 hrs
6-24 hrs
35 (83.3%)
39 (92.8%)
40 (95.2%)
34 (80.95%)
38 (90.9%)
40 (95.2%)
Metoclopramide
0-1 hr
3 (7.1%)
3 (7.1%)
1-6 hrs
2 (4.76%)
1 (2.38%)
6-24 hrs
1 (2.38%)
1 (2.38%)
Total response = no moderate nausea, no severe nausea and no
rescue antiemetic use.
All patients who received metoclopramide once
were satisfied and did not receive any other antiemetics.
In this randomized double-blind study, granisetron 1 mg
plus dexamethasone 8 mg was shown to be as effective
as ondansetron 4 mg plus dexamethasone 8 mg; At 0-1
hour, 100% of patients in group I had no vomiting and
97.6% of patients in group II had no vomiting. Total
response (i.e. no moderate or severe nausea and no
rescue antiemetic use) was present in 83.3% in group I
and 80.95% in group II. The percentage of patients who
received metoclopramide was 7.1% in both groups at
0-1 hour interval as well. At 1-6 hours interval, 97.6%
of patients in group I and 100% in group II had no
vomiting. Total response was 92.8% in group I and
90.9% in group II, and metoclopramide was used in
4.76% of patients in group I and 2.38% in group II. At
6-24 hours no vomiting occurred in 97.6% of patients
in group I and 100% in group II. Total response was
95.2% in both groups, and metoclopramide was used
in 2.38% of patients in both groups. Two out of 42
patients in group I, and 2 out of 42 patients in group
II complained of dizziness in the PACU; 3 out of 42
patients in group I and 3 out of 42 patients in group II
complained of headache in the PACU; one out of 42
M.E.J. ANESTH 20 (4), 2010
568
patients in group I and 3 out of 42 patients in group
II were sedated in the PACU; 38 out of 42 patients
in group I and 37 out of 42 patients in group II were
satisfied with the antiemetic prophylaxis. Pain scores
in group I at 0-1 hour were 5 ±1.1 , at 1-6 hours 4.8
±0.5 and at 6-24 hours 2 ± 0.4. Pain scores in group
II at 0-1 hour were 4.7 ± 0.5, at 1-6 hours 4.4 ± 0.4
and at 6-24 hours 2.3 ± 0.4. There was no significant
difference between the two groups concerning the side
effects and the pain scores.
Discussion
Laparoscopic surgery without antiemetics
prophylaxis is associated with a high incidence of
nausea and vomiting2,3. Studies have shown that
substituting propofol for a volatile anesthetic reduces
the risk of postoperative nausea and vomiting by
about 19%, whereas substituting nitrogen for nitrous
oxide reduces the risk by about 12%8. Combining
these two anesthetic management strategies (i.e., total
intravenous anesthesia) reduces the risk by about as
much as any single antiemetic8. A 70 percent reduction
in the relative risk of postoperative nausea and
vomiting is the best that can be expected, even when
total intravenous anesthesia is used in combination with
three antiemetics8. Therefore, combination therapy
using antiemetics acting at different neuroreceptor sites
is more effective than using individual components
alone. This is particularly true when dexamethasone is
combined with a serotonin receptor antagonist such as
granisetron or ondansetron.
In this prospective randomized double-blind
study, we found no statistically significant difference
in the incidence of PONV, during the first 24 hours
following surgery, when dexamethasone was
combined with either granisetron or ondansetron.
Multiple previous studies had shown that combination
regimens of antiemetics provide significantly better
PONV prophylaxis compared with a single antiemetic
therapy. Of note, the combination of dexamethasone
and ondansetron was better than ondansetron alone5
also, dexamethasone and granisetron was better than
granisetron alone6,7. Furthermore, different combination
therapies had been proven to be similar in outcome and
efficacy8. Our results confirms the results published by
Apfel et al where different antiemetic interventions are
A. S. Dabbous et. al
found to be similarly effective and different antiemetic
combinations are found to be similar in outcome and
efficacy8. Another meta-analysis found no statistically
significant difference in the incidence of early or
overall PONV when a 5-HT3 receptor antagonist was
combined with either droperidol or dexamethasone.
Both combination regimens provided significantly
better PONV prophylaxis compared with 5-HT3
receptor antagonists alone9. Gan et al reported a similar
study to ours using different dosages and different
timing of administration for abdominal hysterectomy.
They also found that both combinations were equally
effective in preventing PONV in the first two hours
postoperatively10. Our study however extends the
observation period to 24 hours postoperatively.
Dexamethasone is a glucocorticoid that produces
strong antiemetic effect, by an undetermined mechanism.
It may act through prostaglandin antagonism, serotonin
inhibition in the gut and by releasing endorphins. The
prophylactic antiemetic effect of dexamethasone has
been documented in laparoscopic surgery11-14. There
are no reports of dexamethasone related adverse effects
in the doses used for management of PONV although
even meta-analyses and systemic reviews may have
insufficient power to detect rare complications15,16.
When dexamethasone is used alone, late efficacy
seems to be most pronounced11.
The prophylactic antiemetic effect of ondansetron17
and granisetron18 has been documented in laparoscopic
surgery. The 5HT3 receptor antagonists are highly
specific and selective for nausea and vomiting1.
Members of this group exert their effects by binding
to the serotonin 5HT3 receptor in the chemorecptor
trigger zone (CTZ) and at vagal afferents in the
gastrointestinal tracts1. Granisetron is highly selective
in its ability to bind the 5HT3 receptors 1000:1 to
other receptors such as (5HT1A, 5HT1B, 5HT1C,
5HT1, 5HT2) or α1 and α2 adrenergic, dopamine D2,
histamine H1, benzodiazepine, β adrenergic, and opioid
receptors, while the selectivity for ondansetron is only
250-400:119. We did not find any difference between
the two groups when we compared early versus late
in terms of antiemetic efficacy, total response and side
effects.
A review of the role of dexamethasone for the
prevention of postoperative nausea and vomiting
DEXAMETHASONE WITH EITHER GRANISETRON OR ONDANSETRON FOR POSTOPERATIVE
NAUSEA AND VOMITING IN LAPAROSCOPIC SURGERY
compared to placebo shows that dexamethasone
treatment, reduced early PONV by 35%, and late
PONV by 50%15. The dose most frequently used was
8 or 10 mg IV. The combination of dexamethasone
with ondansetron or granisetron further decreased
the risk of PONV11,15. The best prophylaxis available
is achieved by combining dexamethasone with 5HT3
receptor antagonist11,15.
Our report showed that administration of
granisetron 1 mg and dexamethasone 8 mg or
ondansetron 4 mg and dexamethasone 8 mg following
induction of anesthesia in patients undergoing short
569
laparoscopic operations, prevented PONV in a high
percentage of patients with minimal side effects and
excellent patient satisfaction.
In conclusion, dexamethasone 8 mg in
combination with granisetron 1 mg or ondansetron
4 mg was found to prevent nausea and vomiting in a
high percentage of patients undergoing laparoscopic
cholecystectomy and herniorraphy, with minimal side
effects and excellent patient satisfaction. There was
no statistically significant difference between the two
combinations concerning its efficacy or side effects.
M.E.J. ANESTH 20 (4), 2010
570
A. S. Dabbous et. al
References
1. Habib AS, Gan TJ: Pharmacotherapy of postoperative nausea and
vomiting. Expert Opin Pharmacother; 2003, 4:457-73.
2. Fortier J, Chung F, Su J: Unanticipated admission after ambulatory
surgery-a prospective study. Can J Anaesth; 1998, 45:612-9.
3. Gerges FJ, Kanazi GE, Jabbour-Khoury SI: Anesthesia for
laparoscopy: a review. J Clin Anesth; 2006 Feb, 18(1):67-78.
4. Jensen K, Kehlet H, Lund CM: Post-operative recovery profile after
laparoscopic cholecystectomy: a prospective, observational study of
a multimodal anesthetic regime. Acta Anaesthesiol Scand; 2007,
51:464-71.
5. McKenzie R, Tantisira B, Karambelkar DJ, et al: Comparison of
ondansetron with ondansetron plus dexamethasone in the prevention
of postoperative nausea and vomiting. Anesth Analg; 1994,
79(5):961-4.
6. Fujii Y, Saitoh Y, Tanaka H, Toyooka H: Granisetron/dexamethasone
combination for the prevention of postoperative nausea and vomiting
after laparoscopic cholecystectomy. Eur J Anaesthesiol; 2000,
17:64-8.
7. Biswas BN, Rudra A: Comparison of granisetron and granisetron
plus dexamethasone for the prevention of postoperative nausea and
vomiting after laparoscopic cholecystectomy. Acta Anaesthesiol
Scand; 2003, 47:79-83.
8. Apfel CC, Korttila K, Abdalla M, et al: A factorial trial of six
interventions for the prevention of postoperative nausea and
vomiting. N Engl J Med; 2004, 350:2441-51.
9. Habib AS, El-Moalem HE, Gan TJ: The efficacy of the 5-HT3
receptor antagonists combined with droperidol for PONV
prophylaxis is similar to their combination with dexamethasone. A
meta-analysis of randomized controlled trials. Can J Anaesth; 2004,
51:311-9.
10.Gan T, Coop A, Philip B: A randomized, double blind study
of granisetron plus dexamethasone versus ondansetron plus
dexamethasone to prevent postoperative nausea and vomiting in
patients undergoing abdominal hysterectomy. Anesth Analg; 2005,
101:1323-9.
11.Elhakim M, Nafie M, Mahmoud K, Atef A: Dexamethasone 8mg
in combination with ondansetron 4mg appears to be the optimal
dose for the prevention of nausea and vomiting after laparoscopic
cholecystectomy. Can J Anaesth; 2002, 49:922-6.
12.Bisgaard T, Klarskov B, Kehlet H, Rosenberg J: Preoperative
dexamethasone improves surgical outcome after laparoscopic
cholecystectomy: a randomized double-blind placebo-controlled
trial. Ann Surg; 2003, 238:651-60.
13.Feo CV, Sortini D, Ragazzi R, De Palma M, Liboni A: Randomized
clinical trial of the effect of preoperative dexamethasone on nausea
and vomiting after laparoscopic cholecystectomy. Br J Surg; 2006,
93:295-9.
14.Waknine Y: Preoperative dexamethasone improves outcome of
laparoscopic cholecystectomy. Medscape medical news; 2003.
15.Henzi I, Walder B, Tramer M: Dexamethasone for the prevention of
postoperative nausea and vomiting: A quantitative systemic review.
Anesth Analg; 2000, 90:186-94.
16.Carlisle JB, Stevenson CA: Drugs for preventing postoperative
nausea and vomiting. Cochrane Database Syst Rev; 2006,
19:3:CD004125.
17.Koivuranta MK, Laara E, Ryhanen PT: Antiemetic efficacy
of prophylactic ondansetron in laparoscopic cholecystecmoy. A
randomized, double-blind, placebo-controlled trial. Anaesthesia;
1996, 51:52-5.
18.Fujii Y, Tanaka H, Toyooka H: Granisetron reduces the incidence and
severity of nausea and vomiting after laparoscopic cholecystectomy.
Can J Anaesth; 1997, 44:396-400.
19.Blower PR: Granisetron relating pharmacology to clinical efficacy.
Support care cancer; 2003, 11:93-100.
case reports
PERSISTENT POSTOPERATIVE HYPERTENSION
FOLLOWING POSTERIOR FOSSA SURGERY
- A Case Report-
Zulfiqar Ali*, Hemanshu Prabhakar*
and G irija P R ath *
Abstract
We report a case of a 20 month old male child who underwent surgery for posterior fossa
tumor. Post operatively the child developed persistent hypertension. No active intervention was
done as it could have compromised cerebral perfusion pressure. The possible cause is discussed.
Key Words: posterior fossa tumor; postoperative; persistent hypertension; reactionary edema;
cerebral perfusion pressure.
Introduction
Postoperative complications are often reported following surgery in the posterior fossa. These
are usually of transient nature. They can be devastating if persistent or continue for a long time. We
report a case where the patient developed persistent hypertension in the postoperative period.
Case History
A 20-months-old male child, weighing 9 kg presented with persistent vomiting for 4 months,
associated with decreased visual acuity and delayed milestones. Computed tomography revealed
a large posterior fossa tumor, composed of solid and cystic components, arising from the vermion
and extending to supratentorial compartment.
On admission the child was drowsy, had papilloedema and hydrocephalus for which a medium
pressure right ventriculoperitoneal shunt insertion was done. A week later, the child was scheduled
for elective midline suboccipital craniectomy and tumor decompression.
All routine investigations were within normal limits. Adequate fluids and packed red blood
cells were given to replace the blood loss of approximately 700 ml.
The resection of the tumor adherent to brain-stem led to multiple episodes of severe bradycadia
with heart rate decreasing from 130 to 64 bpm. These episodes were resolved on cessation of the
surgical stimulus. After tumor excision, it was observed that patient’s blood pressure gradually
increased from systolic 70 mmHg to 135 mmHg and the heart rate decreased from 150 to 110 bpm.
Methylprednisolone infusion was started and continued for 24 hours.
*
Department of Neuroanaesthesiology Neurosciences Center, 7th floor. All India Institute of Medical Sciences,
New Delhi, India.
Address for Correspondence: Dr. Hemanshu Prabhakar, Department of neuroanesthesiology, Neurosciences Center,
7th floor. All India Institute of Medical Sciences, New Delhi, India-110029. Phone no.: +91-11-26588500-4849/4847,
Fax: 91-11-26588663, E-mail: [email protected].
571
M.E.J. ANESTH 20 (4), 2010
572
At the end of an 8 hours surgery, the blood
pressure remained high between systolic 130 to 140
mmHg and heart rate in the range of 100 to 110 bpm.
In view of manipulation of brain stem structures,
it was decided to electively ventilate the child in the
postoperative period with adequate sedation and
analgesia. However, the hypertension and relative
bradycardia persisted for the next 24 hours. The
systolic blood pressure returned gradually to the
preoperative values of 70-80 mmHg over next 36 hours.
The postoperative course was further complicated
by pneumothorax secondary to subclavian venous
cannulation on the right side. This was successfully
managed by inserting an intercostal drain. Trachea was
extubated on the seventh postoperative day. At the time
of discharge from ICU, the child had no respiratory
problems or any fresh neurological deficits.
Discussion
Surgery on the posterior fossa is attended by
transient complications related to respiratory and
cardiovascular systems in the postoperative period1.
However, such complications if persistent occur due
to brain stem compression, ischemia, or hematoma2.
It has been postulated that compression on the pressor
centre at the rostral ventrolateral medulla results in
stimulation of the sympathetic nervous system, leading
Z. Ali et. al
to systemic hypertension3.
A postoperative computed tomographic scan of
our patient did not reveal any hematoma. He developed
persistent hypertension postoperatively, possibly
due to brain-stem edema as a result of intraoperative
manipulation. As the edema subsided over the next 36
to 48 hours the blood pressure normalized. Any effort
to reduce the pressure could possibly compromise the
cerebral perfusion pressure in the presence of edema.
In this situation we believe that the increase in blood
pressure was a reactionary phenomenon to maintain
an adequate perfusion of the edematous brain stem.
No active measures to decrease the blood pressure in
the postoperative period were taken, as such measures
could have resulted in ischemia and infarction of the
vital structures of the brainstem. Since such elevated
blood pressure could possibly lead to a deranged
autoregulation and cerebral hyperemia, hourly
neurological examinations were carried out. Fortunately,
our patient recovered without any neurological deficit
or respiratory or cardiac complication.
In conclusion, we believe that under vigilant
monitoring, postoperative hypertensive response
following posterior fossa surgery need not be treated
aggressively, as this response could be a reactionary
response to brain edema.
References
1. Artru AA, Cucchiara RF, Messick JM: Cardiorespiratory and
cranial-nerve sequelae of surgical procedures involving the posterior
fossa. Anesthesiology; 1980, 52:83-86.
2. Smith DS, Osborn I: Posterior fossa: Anesthetic considerations. In:
Cottrell JE, Smith DS, eds. Anesthesia and Neurosurgery. St. Louis:
Mosby, Inc., 2001, 335-351.
3. Kan P, Couldwell WT: Posterior fossa brain tumors and arterial
hypertension. Neurosurg Rev; 2006, 29:265-269.
GRANULAR CELL MYOBLASTOMA OF
TONGUE: A RARE CAUSE OF UNANTICIPATED
DIFFICULT INTUBATION
Lenin Babu Elakkumanan*, Anjolie Chhabra*,
Somnath Bose* and Kiran Sharma*
Implication statement: We discuss the clinical presentation of a patient with granular cell
myoblastoma and the management of an unanticipated difficult intubation with this rare condition.
Literature review of similar cases of difficult intubations due to supraglottic masses was performed
and the various methods of management have been enumerated.
Abstract
Introduction: Intubation with direct laryngoscopy may be impossible in 0.05%-0.35%
patients due to an undetected supraglottic mass despite an apparently normal pre-operative
airway assessment. We report a case of granular cell myoblastoma of the tongue, as a cause of an
unanticipated impossible intubation.
Case report: A 55-year-old ASA III male weighing 75 Kg was taken up for emergency
exploratory laparotomy with perforation peritonitis. On preoperative airway examination there
was no indication of difficult intubation. After induction of anesthesia (rapid sequence with
rocuronium) we performed direct laryngoscopy. There was a mass arising from the base of the
tongue because of which no recognizable epiglottis or glottic structure could be identified. Despite
repeat laryngoscopy, optimal external manipulation and direct laryngoscopy performed by an ENT
surgeon, the airway could not be secured. As no fibreoptic laryngoscope was available, a surgical
tracheostomy had to be performed.
*
Department of Anaesthesiology and Intensive care, All India Institute of Medical Sciences, New Delhi, India-110029.
Corresponding author: Dr. Anjolie Chhabra, 13/61, West Punjabi bagh, New Delhi, India-110026.
Mobile no: 91-9868397814, 91-9810104383, Fax no: 91-11-26588641. E-mail ID: [email protected]
Conflicts of interest: Nil.
Sources of fund: Solely from institutional sources.
573
M.E.J. ANESTH 20 (4), 2010
574
Introduction
Direct laryngoscopy and intubation may be
impossible in 0.05%-0.35% of patients despite an
apparently normal pre-operative airway assessment1.
Supraglottic masses such as lingual tonsils2, 3,
epiglottic cysts4,5 and vallecular cysts6 have been
reported to be responsible for inability to visualize the
glottis on laryngoscopy. We report a case of granular
cell myoblastoma of the tongue which resulted in an
unanticipated difficult intubation in a full stomach
patient scheduled for an emergency laparotomy.
Case Report
A 55-year-old ASA grade III male patient,
weighing 75 kg was taken up for emergency
laparotomy with suspected perforation peritonitis. The
patient was a known case of alcoholic liver cirrhosis
with prolonged prothrombin time (Pt = 28/control =
13). Other investigations were within normal limits.
Airway examination revealed normal mouth
opening with a modified Mallampatti class II
oropharyngeal view. The thyromental, sternohyoid
distances, mandibular length and range of neck
movements, were all within normal limits. No external
mass or distortion of airway was apparent externally.
Rapid sequence induction with cricoid pressure was
planned. No adventitious breath sounds could be
heard even with the patient taking deep breaths during
preoxygenation.
Anesthesia was induced with 250 mg IV
thiopentone followed by 50 mg of rocuronium. On
direct laryngoscopy with size 3 McIntosh blade, a soft
friable brownish yellow mass of 2 X 3 cm was seen
suspended from the base of the tongue. No identifiable
epiglottis, glottic cartilage or chink could be seen. The
glottis could not be visualized on second laryngoscopy
by an experienced anesthesiologist.
There was no difficulty on mask ventilation
while maintaining the cricoid pressure, with peak
airway pressures of 15 cm of H2O. Repeat attempts
at laryngoscopy including the McCoy laryngoscope
were unsuccessful despite optimal external laryngeal
manipulation. A fibreoptic laryngoscope was not
available at that time. An otolaryngologist, present in the
operating room, did a direct laryngoscopy with a light
L. B. Elakkumanan et. al
source, which also did not facilitate the visualization of
any part of the epiglottis or glottis. As the patient was
full stomach scheduled for an emergency surgery, had
a deranged coagulation profile and an unidentifiable
mass surgery, prolonged airway or mass manipulation
was ruled out. After taking consent from the next of kin,
an emergency tracheostomy was performed. Tracheal
suctioning showed no evidence of aspiration.
Repeat direct laryngoscopy by the otolaryngologist
and attempt to circumvent the mass resulted in it
accidentally getting sheared off. Minimal bleeding was
controlled with packing. The subsequent glottic view
was Cormack Lehane grade II.
Surgery was uneventful. The chest skiagram
done on the first postoperative day was found to
be normal. Even on retrospective questioning, the
patient denied any symptoms including difficulty in
swallowing. Postoperatively, patient developed sepsis
and disseminated intravascular coagulopathy. He
expired on the 10th post operative day.
Discussion
Myoblastoma is a rare tumour of unclear etiology
and histogenic origin which was first described by
Abrikossoff in 19267. It occurs most frequently in
subcutaneous tissues, tongue, skin, breasts and skeletal
muscles. More than 50% of the lesions are situated in
the oral cavity and 35% in the tongue. Most often, it
occurs between 20-50 years of age. The incidence is
equal in both sexes, and it is more frequently found in
the black race. The tumour has a characteristic slow
growth and generally in the intraoral tissues it never
grows larger than 0.5 cm in diameter intraorally. In
extra-oral tissues it never grows larger than 2 cm8. It
usually forms a circumscribed painless mass. As the
tumor is slow growing and painless with minimal
effects on swallowing, breathing and speaking,
patients frequently overlook it and diagnosis is usually
made during some coincidental illness or on routine
otolaryngological examination.
In a series of nine cases of pre-epiglotttic cysts,
three patients (33%) reported difficulty in swallowing,
three (33%) had inspiratory stridor, one had vague
symptoms and two patients (20%) had no symptoms
at all9. Our patient had no symptom at all, even though
GRANULAR CELL MYOBLASTOMA OF TONGUE: A RARE CAUSE OF UNANTICIPATED
DIFFICULT INTUBATION
the tumor was larger than the usually reported size.
All bedside tests to assess ease of intubation
could not predict difficult intubation in an
asymptomatic patient with a supraglottic mass. Upon
reviewing literature on supraglottic masses, especially
myoblastomas, we realized that we should have
pointedly asked the patient for history of difficulty
in swallowing a symptom which could have given a
clue about the presence of a supraglottic mass. Routine
preoperative indirect laryngoscopy could also have
helped in detecting such a mases.
In a study carried out to assess efficacy of
preoperative tests for detecting difficult intubations
Yanamoto et al found out a positive predictive value
of 31% for indirect laryngoscopy compared with 5.9%
for the Wilson risk sum and 2.2% for the Mallampati
test10.
Various methods have been used for the
management of unanticipated difficult intubation
due to supraglottic masses. In a report of six cases of
vallecular cyst, Cheng et al successfully managed two
cases with right and left paraglossal laryngoscopy.11
Kamble et al successfully intubated the trachea by
manipulation of the cyst with a styletted endotracheal
tube6. In our patient, we feared that manipulation of the
pedunculated friable tumor may cause it to break and
slip into the trachea, leading to airway obstruction. As
our patient was full stomach, prolonged laryngoscopy
and mass manipulation was not done.
575
Aspiration of a preepiglottic and vallecular cyst
followed by successful endotracheal intubation has
been also been done9,11. The external appearance of the
mass in our patient was not suggestive of a cyst, so
aspiration was not attempted.
Fibreoptic intubation is the most effective
technique in an unanticipated difficult intubation. In
an anesthetized full stomach patient howerver, this
technique may be as difficult as direct laryngoscopy
especially in an unprepared emergency at night2. In
addition, as advancement of the endotracheal tube over
the fibreoptic scope is blind, we feared it could impact
on the pedunculated tumour and cause it to shear off
and migrate down the tracheobronchial tree.
Therefore securing the airway by performing
a surgical tracheostomy was considered the safest
option in this patient. In conclusion we would like
to emphasize that during airway assessment, pointed
questions should be asked about any difficulty in
swallowing, as one third of patients with painless
supraglottic masses may provide such a history. Though
various airway management devices, such as laryngeal
mask airways, are available to deal with difficult
intubation in patients with no anatomical distortion of
the airway, none could have been safely used in our
patient. Therefore indirect laryngoscopy which has
better positive predictive value in the detection of such
masses, should be incorporated as routine preoperative
airway assessment by anesthesiologists.
M.E.J. ANESTH 20 (4), 2010
576
L. B. Elakkumanan et. al
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2. Davies S, Ananthanarayan C, Castro C: Asymptomatic lingual
tonsillar hypertrophy and difficult airway management: a report of
three cases. Can J Anaesth; 2001, 48:1020-4.
3. Ovassapian A, Glassenberg R, Randel GI, Klock A, Mesnick
PS, Klafta JM: The unexpected difficult airway and lingual
tonsil hyperplasia: a case series and a review of the literature.
Anesthesiology; 2002, 97:124-32.
4. Ghabash M, Matta M: An asymptomatic epiglottic mass as a cause
of difficult intubation - a case report. Middle East J Anesthesiol;
1994, 12:497-500.
5. Mason DG, Wark KJ: Unexpected difficult intubation. Asymptomatic
epiglottic cysts as a cause of upper airway obstruction during
anaesthesia. Anaesthesia; 1987, 42:407-10.
6. Kamble VA, Lilly RB, Gross JB: Unanticipated difficult intubation
as a result of an asymptomatic vallecular cyst. Anesthesiology; 1999,
98:72-3.
7. Becelli R, Perugini M, Gasparini G, Cassoni A, Fabiani F.
Abrikossoff’s tumor. J Craniofac Surg; 2001, 12:78-.81.
8. Filipovic I, Seiwerth S, Manojlović S, Susic M. Granular
Myoblastoma: A case presentation and review of literature. Acta
Stomatol Croat; 2000, 34:203-205.
9. Keenleyside HB, Greenway RE: Management of pre-epiglottic
cysts: a report of nine cases. Can Med Assoc J; 1968, 99:645-9.
10.Yamamoto K, Tsubokawa T, Shibata K, Ohmura S, Nitta S, Kobayashi
T. Predicting difficult intubation with indirect laryngoscopy.
Anesthesiology; 1997, 86:316-21.
11.Cheng KS, Ng JM, Li HY, Hartigan PM. Vallecular cyst
and laryngomalacia in infants: report of six cases and airway
management. Anesth Analg; 2002, 95:1248-50.
USE OF REMIFENTANIL IN A PATIENT
WITH EISENMENGER SYNDROME REQUIRING
URGENT CESAREAN SECTION
Ates Duman*, Gamze Sarkilar*, Mürüvvet Dayioglu*,
Mine Özden** and Niyazi Görmüs**
Abstract
We describe a case of 41 yr old multigravida at 35 weeks gestation, with a diagnosis of
Eisenmenger syndrome, requiring urgent Cesarean section. The parturient had signs and symptoms
of respiratory distress due to high pulmonary artery pressure, and the pregnancy was complicated
by preeclampsia. A general anesthetic consisting of ketamine and etomidate and an intravenous
infusion of remifentanil were used to provide stable anesthesia and analgesia for a successful
delivery. The baby was delivered with high Apgar scores. The potential benefits and safety of the
use of remifentanil in parturients with high pulmonary artery pressures are discussed.
Key Words: Cesarean section; Eisenmenger`s syndrome; remifentanil.
Introduction
Eisenmenger syndrome occurs when a congenital or surgically created shunt between the
left and right sides of the heart causes an increase in pulmonary vascular resistance (PVR) that
surpasses systemic vascular resistance (SVR) resulting in a reversal of left to right shunt to right to
left shunt or bidirectional shunt. Maternal mortality rate in Eisenmenger syndrome is reported to
be 50-65% with Cesarean section1,2. For successful outcome, factors that increase PVR or decrease
SVR should be avoided during the anesthetic management. Together with appropriate vasoactive
or inotropic drugs, opioids are useful for controlling hemodynamic fluctuations during induction
of general anesthesia in cardiac patients. Unfortunately, however, opioids are generally omitted
during induction of general anesthesia in patients undergoing Cesarean sections because of risk of
neonatal respiratory depression.
There are a number of case reports in literature describing the successful use of remifentanil
for high-risk cardiac patients undergoing Cesarean delivery3-7. In two recent randomized, controlled,
blind studies Draisci et al.8 and Bouattour et al.9 showed that remifentanil (0.5 µg.kg-1min-1) can be
used safely during anesthesia induction without subsequent neonatal depression whilst providing
stable hemodynamics in healthy elective parturients8,9.
Data in the literature are incomplete on the use of remifentanil in parturients with high
pulmonary artery pressures such as in Eisenmenger syndrome. In this case report we used
remifentanil as a part of induction and maintenance of general anesthesia in a parturient with
Eisenmenger syndrome undergoing emergency Cesarean section.
Departments of * Anesthesiology and Intensive Care and ** Cardiovascular Surgery, Meram Medical Faculty,
Correspondence to author: Dr A. Duman, Selcuk Universitesi, Tip Fakultesi, Anestezi ve Reanimasyon AD,
Konya, Turkey, 42080. Tel: +905334362823, Fax: +903322232643. E-mail: [email protected]
577
M.E.J. ANESTH 20 (4), 2010
578
A. Duman et. al
of anesthesia. She remained cardiovascularly stable
during induction and surgery (Fig. 1).
Case Report
A 41-year-old female, 35 weeks gestation,
recently diagnosed as Eisenmenger syndrome due
to atrial septal defect, was admitted to our Cardiac
Anesthesia Department for emergency Cesarean section
due to fetal distress. She had four prior normal vaginal
deliveries. During this pregnancy she was diagnosed
with serious cardiac disease and preeclampsia. On
admission she was dyspneic and cyanosed with
clubbing. The electrocardiogram (ECG) demonstrated
sinus tachycardia with right bundle branch block and
non specific ST segment and T wave changes.
Fig. 1
Hemodynamic data of the parturient during anaesthesia.
Figure 1: Hemodynamic data of the parturient during anaesthesia. SAP: systolic artery
SAP: systolic
pressure
(mmHg),
DAP: diastolic
artery
pressure
(mmHg), artery
DAP: diastolic
artery
pressure(mmHg),
HR: heart
rate (beat/min).
pressure(mmHg), HR: heart rate (beat/min)
Hemodynamic data
170
160
150
140
130
120
110
100
90
80
SAP
DAP
Re
m
if e
B
nt as
an e l
il i in e
nf
u
In sio
tu
ba n
t io
1s n
tm
2n in
d
m
5t in
h
m
10 in
th
m
15 in
th
m
20 in
th
m
25 in
th
m
30 in
th
m
35 in
th
m
in
HR
Preoperative
echocardiography
showed;
prominent right-to-left shunt with an estimated systolic
pulmonary artery pressure of 114 mmHg, ejection
fraction of 48%, moderate mitral regurgitation and
moderate to severe tricuspid regurgitation.
No premedication was given. On arrival to the
theatre, two peripheral venous and one radial artery
catheters were inserted. Oxygen saturation (SpO2)
on arrival was 79% on room air and 96% after preoxygenation. Her baseline systemic blood pressure
was 147/94 mmHg and her heart rate was 92 per min.
Baby was delivered 6 min after induction with an
Apgar scores at 1st and 5th min of 7 and 9 respectively.
After delivery, intravenous oxytocin 20 units was
administered over 20 min. Duration of surgery and
anesthesia were 27 min and 35 min respectively.
Mother was extubated in the theatre and remifentanil
was discontinued after extubation. umbilical cord
arterial pH was 7.4 (Table 1).
Induction agents were administered intravenously
using, remifentanil 0.5 µg.kg-1 infused in 60 sec
followed by slow boluses of ketamine 75 mg and
etomidate 10 mg. Tracheal intubation and intermittent
positive pressure ventilation were facilitated with
suxamethonium 80 mg. Sevoflurane to an end-tidal
concentration of 1.2% and remifentanil 0.2 µg.kg-1min-1
in 100% oxygen were administered for maintenance
The mother’s initial blood gas measurement
showed hypoxemia. Her arterial oxygen saturation
Pediatricians commented on the lack of respiratory
depression in view of the opioid given to the mother
and no naloxone was given to the baby. The baby was
transferred to the neonatal ward for routine care and
the mother was moved to the Cardiac Intensive Care
for further management.
Table 1
Arterial blood gas measurements of the parturient and the newborn
Maternal
Maternal
Maternal
Fetal
preoperative
after intubation
after extubation
umbilical cord
(in room air)
(100% oxygen)
(100% oxygen)
7.47
7.43
7.39
7.40
PO2 (mmHg)
36
49.5
80.6
36.1
PCO2 (mmHg)
27
25.9
32.8
36.9
SpO2 (%)
74
87
95.6
69.5
HCO3 (mmol/L)
22
20.2
21
22.2
BE (mmol/L)
-4
-5
-4
-1.8
Blood gases
pH
USE OF REMIFENTANIL IN A PATIENT WITH EISENMENGER SYNDROME REQUIRING URGENT CESAREAN SECTION
improved after induction and ventilation (Table 1).
Postoperative analgesia was managed with
intravenous 4 mg morphine and 1 g paracetamol.
Regular antibiotic therapy was continued according to
microbiological advice. The mother’s stay in the ICU
was uneventful. Her postoperative echocardiography
showed diminished and persistent right to left shunt with
moderate mitral and tricuspid regurgitations. Systolic
PAP was 85 mmHg. The mother was discharged to the
cardiology ward the following day.
Discussion
Although there are reports of successful use of
remifentanil in Cesarean deliveries for compromised
cardiac patients10, our case is the first case report
describing the use of remifentanil during general
anesthesia for emergency Cesarean section, in a patient
with Eisenmenger syndrome. The anesthetic technique
of induction and maintenance used was safe for the
neonate and the hemodynamically compromised
mother.
The incidence of congenital heart disease
is approximately 1%. About 8% of patients with
congenital heart disease and 11% of those with leftto-right intra-cardiac shunting develop Eisenmenger
syndrome if untreated11.
Eisenmenger syndrome is characterized by
elevated pulmonary vascular resistance and rightto-left shunting of blood through a systemic-topulmonary circulation connection. Patients diagnosed
with Eisenmenger syndrome in adulthood, have high
perioperative mortality rates1,12. Eighteen percent of
anatomic defects of Eisenmenger syndrome reported
by Weiss et al consisted of isolated atrial septal defects1.
Our patient was diagnosed as Eisenmenger syndrome
due to isolated atrial septal defect by angiography and
echocardiography shortly during the third trimester of
her pregnancy.
Although no randomized controlled trials
comparing the safety of general and regional anesthesia
for non-cardiac surgery in exist this group of patients,
both techniques have been used successfully in
patients Eisenmenger syndrome13,14. If general
anesthesia is to be used, the anesthetic technique
least likely to decrease the patient’s systemic blood
579
pressure and vascular resistance, should be chosen
because such changes increase the magnitude of rightto-left shunting and cyanosis. Many agents used for
induction and maintenance of general anesthesia do
depress myocardial function and reduce systemic
vascular resistance15. Opioids are effective in blunting
sympathetic discharges during anesthesia and surgery
with minimal or no myocardial depression16,17. We
decided to use ketamine together with etomidate
in order to preserve peripheral vascular resistance
and cause minimal myocardial depression during
induction.
The main concern with opioids for Caesarean
section is placental transfer. Remifentanil, a short acting
opioid has similar properties to other semi-synthetic
opioids in preventing maternal vasopressor responses.
Remifentanil is known to be rapidly metabolized by
non-specific plasma esterases, therefore it has a very
short context-sensitive half life. Remifentanil has been
described to provide safe anesthesia in Eisenmenger
syndrome patients undergoing non-cardiac surgery13.
Although remifentanil is rapidly metabolized
and/or redistributed by the newborn18, it seems not to
be devoid of side effects. In a study which compared
remifentanil with placebo for general anesthesia in
patients undergoing Cesarean delivery, Draisci et al.
demonstrated that there were significant differences in
the mean Apgar score and umbilical cord pH values,
indicating depression in the remifentanil group. The
authors stated that neonates of remifentanil treated
mothers had a greater need for resuscitation in the first
minutes after birth, but no case showed evidence of
prolonged insult and damage7. Recently in 2008 Palacio
et al19, published the utility and safety of 1 µg.kg
remifentanil bolus for hemodynamic control during
cesarean section in 12 high-risk patients ineligible
for spinal anesthesia. Patients were undergoing
surgery because of placenta abruptio, subarachnoid
hemorrhage, HELLP syndrome, or preeclampsia.
Palacio encountered no cases of neonatal rigidity and
there was no need for naloxone. The authors concluded
that, because of potential risk of neonatal depression,
remifentanil should be used selectively and the means
for neonatal resuscitation should be available.
the main concern in our case, was to provide a
smooth induction and stable hemodynamics for the
M.E.J. ANESTH 20 (4), 2010
580
mother. In view of Palacio’s result on and consideration
of the risk/benefit ratio, remifentanil was used,
provided resuscitation measures for the newborn were
available.
Earlier case reports on the use of remifentanil
for Cesarean section in cardiovascularly compromised
parturients report different patient and neonatal
outcomes. The remifentanil infusion rate in the case
reports varied from 0.2 µg.kg-1min-1 to 2 µg.kg-1min-1
3-6
. Wadsworth et al. used 0.5 µg.kg-1min-1 remifentanil
for two high risk cardiac patients. First case was 36
weeks gestation, left ventricular failure due to severe
aortic regurgitation with stenosis and the second case
was 28 weeks gestation hypertrophic obstructive
cardiomyopathy. Both neonates required short term
respiratory support after delivery6. In a patient with
recurrent aortic coarctation, Manullang et al. started
remifentanil infusion at 0.05 to 0.1 µg.kg-1min-1 before
induction and increased it to 0.2 µg.kg-1min-1 for
A. Duman et. al
induction. The patient was hemodynamically stable
and the newborn was in excellent condition at delivery3.
Likewise, no respiratory depression occurred in the
baby when Scott et al. used 2 µg.kg-1min-1 remifentanil
in a 38 weeks gestation parturient diagnosed as mixed
mitral valve disease2. In our case the baby was born
with excellent Apgar scores and umbilical blood gas
results, despite continuing remifentanil infusion until
clamping of the cord.
Results of this and previous cases lead us to
consider that remifentanil is effective in controlling
hemodynamic fluctuations during induction and
maintenance of general anesthesia of parturients with
Eisenmenger syndrome and high pulmonary artery
pressures. Although previous reports suggest a potential
requirement for neonatal resuscitation, remifentanil
may be useful in cases when maternal risk exceeds the
concern of neonatal respiratory depression.
References
1. Weiss BM, Zemp L, Seifert B, Hess OM: Outcome of pulmonary
vascular disease in pregnancy: a systematic overview from 1978
through 1996. J Am Coll Cardiol; 1998, 31:1650-7.
2. Makaryus AN, Forouzesh A, Johnson M: Pregnancy in the patient
with Eisenmenger’s syndrome. Mt Sinai J Med; 2006, 73:1033-6.
3. Scott H, Bateman C, Price M: The use of remifentanil in general
anaesthesia for Caesarean section in a patient with mitral valve
disease. Anaesthesia; 1998, 53:695-7.
4. Manullang TR, Chun K, Egan TD: The use of remifentanil for
Cesarean section in a parturient with recurrent aortic coarctation.
Can J Anaesth; 2000, 47:454-9.
5. Mertens E, Saldien V, Coppejans H, Bettens K, Vercauteren M:
Target controlled infusion of remifentanil and propofol for caesarean
section in a patient with multivalvular disease and severe pulmonary
hypertension. Acta Anaesthesiol Belg; 2001, 52:207-9.
6. McCarroll CP, Paxton LD, Elliot P, Wilson DB: Use of
remifentanil in a patient with peripartum cardiomyopathy requiring
Caesarean section. Br J Anaesth; 2001, 86:135-8.
7. Wadsworth R, Greer R, MacDonald JMS, Vohra A: The use of
remifentanil during general anaesthesia for caesarean delivery in
two patients with severe heart dysfunction. Int J Obstet Anesth;
2002, 11:38-43.
8. Draisci G, Valente A, Suppa E, Frassanito L, Pinto R, Meo F, De
Sole P, Bossù E, Zanfini BA: Remifentanil for cesarean section
under general anesthesia: effects on maternal stress hormone
secretion and neonatal well-being: a randomized trial. Int J Obstet
Anesth; 2008, 17:130-6.
9. Bouattour L, Amar HB, Bouali Y, Kolsi K, Gargouri A,
Khemakhem K, Kallel N, Trabelsi K, Guermazi M, Rekik A,
Kuroui A: Maternal and neonatal effects of remifentanil for general
anesthesia for Cesarean delivery. Ann Fr Anesth Reanim; 2007,
26:299-304.
10.Bilehjani E, Kianfar AA, Toofan M, Fakhari S: Anesthesia with
etomidate and remifentanil for cesarean section in a patient with
severe peripartum cardiomyopathy-a case report. Middle East J
Anesthesiol; 2008, 19:1141-9.
11.Vongpatanasin W, Brickner ME, Hillis LD, Lange RA: The
Eisenmenger Syndrome in Adults. Ann Inter Med; 1998, 128:74555.
12.Oya H, Nagaya N, Uematsu M, Satoh T, Sakamaki F, Kyotani S,
Sato N, Nakanishi N, Miyatake K: Poor prognosis and related
factors in adults with Eisenmenger syndrome. Am Heart J; 2002,
143:739-44.
13.Kopka A, McMenemin IM, Serpell MG, Quasim I: Anaesthesia
for cholecystectomy in two non-parturients with Eisenmenger’s
syndrome. Acta Anaesthesiol Scand; 2004, 48:782-6.
14.Ghai B, Mohan V, Khetarpal M, Malhotra N: Epidural anesthesia
for cesarean section in a patient with Eisenmenger’s syndrome. Int J
Obstet Anesth; 2002, 11:44-7.
15.Jones P, Patel A: Eisenmenger’s syndrome and problems with
anaesthesia. Br J Hosp Med; 1995, 54:214.
16.Duman A, Sahin AS, Atalik EK, Öztin Ogun C, Basri Ulusoy H,
Durgut K, Ökesli S: The in vitro effects of remifentanil and fentanyl
on isolated human right atria and saphenous veins. J Cardiothorac
Vasc Anesth; 2003, 17:465-9.
17.Hanouz JL, Yvon A, Guesne G, Eustratiades C, Babatasi G,
Rouet R, Ducouret P, Khayat A, Bricard H, Gerard JL: The in
vitro effects of remifentanil, sufentanil, fentanyl, and alfentanil on
isolated human right atria. Anesth Analg; 2001, 93:543-9.
18.Kan RE, Hughes SC, Rosen MA, Kessin C, Preston PG, Lobo EP:
Intravenous remifentanil: placental transfer, maternal and neonatal
effects. Anesthesiology; 1998, 88:1467-74.
19.Placio FJ, Ortiz-Gomez JR, Fortnet I, Lopez MA, Morillas P:
Remifentanil bolus for cesarean section in high-risk patients: study
of 12 cases. Rev Esp Anestesiol Reanim; 2008, 55:86-9.
COMBINED SPINAL EPIDURAL ANESTHESIA
FOR CESAREAN SECTION IN A PREGNANT
PATIENT WITH RARE INTRACRANIAL NEOPLASM
Anjolie Chhabra*, Neeraj Kumar*, Ashwini Kumar*,
Neena Singh** and B.S. Sharma***
Introduction
There are several reports of obstetric emergencies in pregnant patients with malignant
intracranial tumors precipitated by worsening of the mother’s neurological status which necessitate
an early delivery of the fetus before definite therapy can be administered to the mother1-3.
We describe a patient with a sphenoid sinus tumor who developed loss of vision due to rapid
tumor progression necessitating an early delivery of her twin fetuses by cesarean section. The
patient had co morbidities and requested to be awake during the surgery, she was managed using
a combined spinal epidural anesthesia. The advantages of combined spinal epidural anesthesia as
compared to a single shot subarachnoid block, epidural block or general anesthesia are discussed
in a pregnant patient with decrease in intracranial compliance.
Key words: Combined Spinal Epidural, Cesarean section, intracranial neoplasm.
Case Report
A 30 year old multigravida (G3 P1+0+1+1) at 35 weeks of gestation with twin pregnancy
(diamniotic dichorionic) and an intracranial space occupying lesion (ICSOL) was referred to the
Neurosurgery Department of our tertiary care hospital from a peripheral health center with total loss
of vision in the right eye which had progressed over two weeks. A month prior she had developed
ptosis of the left eye, which recovered spontaneously. The patient gave history of bilateral frontal
headaches, on and off, for last 4-5 years. The headaches were associated with vomiting and had
been increasing in intensity for the last two months.
On evaluation she was found to have right second, third, sixth cranial nerve palsy, bilateral
disc pallor and no papilledema.
*
Departments of Anesthesiology, ** Obstetrics and Gynecology, *** Neurosurgery, All India Institute of Medical Sciences,
New Delhi, India.
Corresponding author: Dr. Neeraj Kumar, Senior Resident, Department of Anaesthesiology, All India Institute
of Medical Sciences, New Delhi 110029, India. E-mail: [email protected]
581
M.E.J. ANESTH 20 (4), 2010
582
A. Chhabra et. al
Magnetic resonance imaging (MRI) of the head
showed a homogeneous, enhancing midline mass of
4.2-3.0 cm size in the spheno – occipital region (clivus),
anteriorly obliterating the sphenoid sinus, posteriorly
extending up to the pre-pontine cistern and superiorly
thinning the bone of the hypophyseal fossa. Bilaterally
it was extending in to the cavernous sinus encasing the
intracavernous portion of internal carotid artery, more
on the left. The optic tracts and chiasma appeared to be
normal. The findings were suggestive of a chordoma
of the clival region. The ventricular system was normal
and no parenchymal hypodensity or midline shift was
visible (Fig. 1).
of 140/80 mm Hg. Airway examination revealed
normal mouth opening, Mallampatti grade III view
of the oropharynx and normal neck movements. After
discussion with obstetrician and neurosurgeon it was
decided to perform cesarean section under combined
spinal epidural (CSE) anesthesia for which the patient
was willing.
Fig. 1
After preloading with 500 ml of Ringer lactate
and administering local anesthetic, under strict asepsis a
CSE block was performed at lumbar 3rd – 4th interspace
in the left lateral position with a needle through needle
technique using an 18 G Tuohy and 27G pencil point
spinal needle (PortexR CSE set). 1ml of 0.5% heavy
bupivacaine and 25 µg of fentanyl was administered
intrathecally. The epidural catheter was threaded 5 cm
into the epidural space. After ten minutes, the sensory
block extended from T8 to T12. 5 ml of 2% lignocaine
with 1:200000 adrenaline was then slowly administered
into the epidural space. 10 minutes later adequate
block was established up to T4 and the obstetricians
were allowed to proceed with surgery.
The patient was also detected to have pregnancy
induced hypertension (PIH) (150/100mmHg right upper
limb, supine). Oral methyldopa, 500 mg 8 hourly was
started. The serum bilirubin (1.5 mg/dL), liver enzymes
(SGOT / SGPT – 92/101 IU) and alkaline phosphatase
(792 IU) were raised with negative markers for viral
hepatitis, suggestive of intrahepatic cholestasis of
pregnancy. The prothrombin time and remaining
investigations were normal. An early delivery of the
fetuses was planned to enable transphenoidal debulking and biopsy of the tumor at a later stage.
On pre anesthetic evaluation the patient was fully
conscious with a Glasgow coma scale of 15, anxious
about her ailment and keen not to be made unconscious
for the cesarean section. She was 150 cm tall, 65 kg
with a pulse rate of 80 beats/minute, blood pressure
The patient was kept nil per os for solids for 8 hours
and allowed sips of water till 3 hours preoperatively. On
the morning of surgery metoclopramide, ranitidine and
methyldopa were administered. Standard monitoring
(EKG, pulse oximetry and noninvasive blood pressure)
was started.
Seven minutes after skin incision a 2.5 kg female
baby (Apgar scores of 8 and 9 at 0 and 5 minutes) and
two minutes later a 1.8 kg male baby (Apgar scores of
9 and 10 at 0 and 5 minutes) were delivered.
Intraoperatively, the BP increased to 140/105
mmHg at the time of positioning for the cesarean.
The blood pressure fell 30 min after the epidural drug
administration to 84/50 mmHg, which responded to 6
mg bolus of mephentermine and crystalloids. Surgery
lasted for 50 mins, the intraoperative period was
uneventful. Sensory block receded to T10 level in 155
min, the motor block wore off in 290 minutes.
A single dose of 1.5 mg epidural morphine
provided pain relief for the first 48 hours
postoperatively. Thereafter the epidural catheter was
removed and analgesia provided with oral ibuprofen
500 mg 8 hourly.
One week later, the blood pressure had normalized
COMBINED SPINAL EPIDURAL ANESTHESIA FOR CESAREAN SECTION IN A PREGNANT PATIENT WITH
RARE INTRACRANIAL NEOPLASM
and a transphenoidal tumor decompression and biopsy
was performed under general anesthesia. Histology
reported a giant cell tumor of clivus. After an uneventful
recovery the patient was advised radiotherapy on an
outpatient basis.
Discussion
Malignant tumors of the sphenoid are rare and
have a distinctive clinical presentation. These tumors
are aggressive, locally invasive and produce symptoms
due to compression of vessels and nerves in the
cavernous sinus or orbital fissure leading to multiple
cranial neuropathies, visual loss and headaches.
Though the tumors are in proximity to the pituitary
gland, gland involvement and endocrinopathies are not
commonly reported4. Our patient similarly presented
with headaches, third left cranial nerve palsy which
resolved spontaneously, palsy of the right 2nd, 3rd, 6th
cranial due to direct tumor infiltration into the optic
foramen and cavernous sinus rather than an increase
in ICP Though there were no features of raised ICP
(clinically, on MRI and on fundus examination) in the
presence of the large ICSOL, a decrease in intracranial
compliance was assumed.
As she had a twin pregnancy the obstetricians
preferred a cesarean section to a prolonged induction
and labor for delivery of the fetuses. General
anesthesia is usually chosen for patients with ICSOL
and severe neurological obtundation1-3. As this patient
also had PIH, intrahepatic cholestasis of pregnancy,
the possibility of a difficult intubation and a desire to
remain awake during delivery of her babies, a regional
anesthesia technique was chosen.
We wanted to use a regional anesthesia technique
which would cause minimum alteration in the ICP,
provide safe, titratable intraoperative anesthesia and
postoperative analgesia as well.
Though regional anaesthetic techniques have been
used, there is only one report of a subarachnoid block
being used in a pregnant patient with a glioblastoma
for an emergency section due to fetal distress5.
There are reports of epidural block for labor
analgesia and cesarean section in patients with
intracranial tumors6,7. However, Hilt et al8 demonstrated
that CSF pressure rises significantly even after 10 ml
583
of bupivacaine administration in the epidural space
in patients with reduced intracranial compliance,
necessitating slow administration of 5 ml volumes
at a time. In one of the reports lumbar epidural was
administered to minimize increase in ICP resulting
from bearing down efforts, however, the patient
continued to have headache and features of raised ICP
with uterine contraction even after effective block was
established6.
The advantage of a combined spinal epidural
(CSE) over a single injection subarachnoid block is
that a dural puncture can be easily performed with
a thin pencil point 26/27 G needle which minimizes
the CSF leak. In case CSF seepage persists, the low
volume epidural would help in tamponading the CSF
leak and enable titration of the block without producing
a precipitous fall in blood pressure. In addition
administration of large volumes of local anesthetic in
the epidural space would be avoided and the epidural
catheter would enable us to provide good postoperative
analgesia.
The chance of an accidental dural puncture
with the Tuohy needle is always there, however, the
incidence of this happening with the CSE technique
is documented to be 1.7% as compared to 4.2% with
epidural anesthesia alone9. This may be because
with CSE the epidural space can be more accurately
localized with the aid of the thin pencil point spinal
needle rather than by loss of resistance alone, as is
used for epidural block9.
The use of low dose i.e. 30 µg/kg of epidural
morphine did not cause any nausea, vomiting or
pruritis. The epidural route was chosen and dose was
reduced to minimize the above side effects. Vigilant
monitoring of the patient for worsening headache,
localizing neurological signs or deterioration of the
level of consciousness was done to ensure no untoward
sequelae. The need for absolute asepsis during the CSE
was essential as an intracranial infection in this patient
would have been disastrous.
In conclusion the CSE can be safely used for
cesarean section in patients with intracranial space
occupying lesion (ICSOL) without severe neurological
deficit and in whom general anesthesia may not be
preferred.
M.E.J. ANESTH 20 (4), 2010
584
A. Chhabra et. al
References
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Anesth; 2002, 11:219-21.
4. Esposito F, Kelly DF, Vinters HV, DeSalles AA, Sercarz J,
Gorgulhos AA: Primary sphenoid sinus neoplasm: a report of four
cases with common clinical presentation treated with transsphenoidal
surgery and adjuvant therapies. J Neurooncol; 2006, 76:299-306.
5. Atanassoff PG, Weiss BM, Lauper U: Spinal anaesthesia for
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Caesarean section in a patient with brain neoplasm. Can J Anesth;
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Goroszeniuk T, Howard RS, Wright JT: The management of labour
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malignant cerebral tumor. Anaesthesia; 1986, 41:1128-29.
Finfer S.R: Management of labour and delivery in patients with
intracranial neoplasms. Br J Anaesth; 1991, 67:784-7.
Hilt H, Gramm HJ, Link J: Changes in intracranial pressure associated
with extradural anaesthesia. Br J Anaesth. 1986, 58:676-80.
Norris MC, Grieco WM, Borkowski M, Leighton BL, Arkoosh
VA, Huffnagle HJ, Huffnagle S: Complications of labor analgesia:
epidural versus combined spinal epidural techniques. Anesth Analg;
1994, 79:529-37.
THE USE OF REMIFENTANIL IN GENERAL
ANESTHESIA FOR CESAREAN SECTION IN A
PARTURIENT WITH SEVERE MITRAL STENOSIS AND
PULMONARY EDEMA
Shahram Amini*, Minoo Yaghmaei**
Abstract
Valvular heart diseases have adverse effects on hemodynamic condition in the parturients
during pregnancy. Cesarean section with an opioid based general anesthesia has been used to
alleviate these deleterious effects. We hereby describe the effective application of remifentanil,
for cesarean section under general anesthesia, in a 30 yr old primigravida suffering of severe
multivalvular heart disease and pulmonary hypertension presenting with pulmonary edema who
was in active labor and without neonatal respiratory depression.
Key words: general anesthesia, cesarean section, remifentanil, mitral stenosis, pulmonary
edema.
Introduction
Mitral stenosis is the most common valvular heart disease in parturients, with significant
effects on the mother and neonate especially during labor. General anesthesia is indicated where
regional anesthesia is contraindicated or fails or in case of emergency delivery1.
Systemic opioids are used to blunt the hemodynamic responses during endotracheal intubation
and hormonal stress response during surgery2-4. However, they are associated with unfavorable
effects on the neonate and are therefore avoided until after delivery. Remifentanil might be an
excellent choice for cesarean section under general anesthesia5,6.
We report the use of remifentanil for general anesthesia in a parturient in active labor with
severe multivalvular heart disease requiring emergency cesarean section.
*
Departments of Anesthesiology, ** Obstetrics and Gynecology, Zahedan University of Medical Sciences, Zahedan, Iran.
Corresponding author: Shahram Amini, MD. Ali-ebne Abitaleb Hospital, Department of Anesthesiology, Zahedan, Iran.
Tel: 0098 915 141 7235, Fax: 0098 511 8640535. E-mail: [email protected]
585
M.E.J. ANESTH 20 (4), 2010
586
Case Report
A 30 years old woman (gravid 1 para 0) with a
fetus of 36 weeks gestation, presented to the hospital
with severe respiratory distress and active labor. The
patient had a history of severe mitral stenosis, mitral
regurgitation, tricuspid regurgitation, and pulmonary
hypertension. Her vital signs revealed blood pressure
90/52 mmHg, pulse rate 130bpm, and respiratory
rate 35. Her SpO2 was 85% on room air. She also had
bilateral crackles throughout the lungs, and severe
diastolic and systolic murmurs.
Following preoxygenation, anesthesia was
induced with ketamine 2 mg/ kg, remifentanil 1 µg/
kg, and suxamethonium 1.5 mg/kg to facilitate
endotracheal intubation. Cisatracurium 0.1 mg/kg was
given after endotracheal intubation with remifentanil
infused at 0.1 µg/kg/min until delivery and 0.2-0.4 µg/
kg/min with midazolam 0.1mg/kg for maintenance
of anesthesia after delivery. The patient received 100
percent oxygen throughout surgery.
Standard monitoring included pulse rate,
noninvasive blood pressure, EKG monitoring,
respiratory rate, pulse oxymetry, ET CO2 and
noninvasive cardiac output monitoring using NICO
(Novametrix, Wallingford, CT, USA). The patient’s
cardiac index was 1.5 L/min/m2. Dobutamine was
administered to improve the cardiac output and
compensate any decrease in blood pressure. A live
2950g female infant was delivered 4 minutes after skin
incision with Apgar score of 8 and 9 at 1 and 5 minutes,
respectively with no evidence of respiratory depression.
She was transferred to NICU for postoperative care
where she had an uneventful stay.
At the end of the surgery, residual neuromuscular
block was antagonized with neostigmine and atropine
and the mother was transferred to the ICU while
intubated. Her stay in the ICU was uneventful, she was
extubated at 26 hours and on 3rd day was transferred to
the postpartum ward. She was discharged on the fifth
day postpartum.
Discussion
Rheumatic mitral stenosis is the most common
clinically significant cardiac abnormality seen in
pregnant women worldwide6-8 with increased maternal
S. Amini & M. Yaghmaei et. al
and neonatal mortality9,10. Stenosis of the mitral valve
obstructs left ventricular filling resulting in increased
left atrial pressure (LAP) and reduced cardiac output.
During pregnancy several hemodynamic changes
including increased intravascular volume and increased
heart rate exacerbate the cardiovascular aberrations
associated with mitral stenosis. During natural labor,
cardiac output and blood pressure increase with uterine
contractions. Immediately after delivery cardiac filling
pressures increase dramatically due to vena caval
decompression and return of uterine blood. Critical
mitral stenosis occurs when the opening is reduced to
1 cm2. As the disease progresses, chronic elevation of
LAP leads to pulmonary hypertension, tricuspid and
pulmonary valve incompetence, pulmonary edema,
and secondary right heart failure.
Vaginal delivery under regional anesthesia,
especially epidural anesthesia is the usual approach
in patients with valvular hear disease11,12. However,
since our patient was in active labor with symptoms
of severe heart failure, we decided to use general
anesthesia instead in order to reduce the labor
associated hemodynamic alteration. Moreover, our
patient had also mitral and tricuspid regurgitation, and
pulmonary hypertension, all of which make her more
vulnerable to adverse effects of labor. We used noninvasive cardiac output monitoring to evaluate the
patient’s hemodynamic condition.
Remifentanil was used before delivery to attenuate
the deleterious effects of endotracheal intubation and
surgical pain and to reduce further hemodynamic
compromises during surgery. The patient did not show
significant hemodynamic changes after induction,
before delivery, and throughout the surgery.
Remifentanil crosses the placenta like other
opioids13,14. It undergoes esterase metabolism and has
extremely short duration of action that is independent
of the duration of infusion15.
Use of remifentanil has been associated with stable
hemodynamic variables during general anesthesia in
high risk patients16-18. with no significant respiratory
depression in the neonate6,19,20. However, some have
reported transient neonatal respiratory depression
requiring short period of ventilation support21,22,
transient neonatal chest wall rigidity23 and severe fetal
THE USE OF REMIFENTANIL IN GENERAL ANESTHESIA FOR CESAREAN SECTION IN A PARTURIENT WITH
SEVERE MITRAL STENOSIS AND PULMONARY EDEMA
bradycardia24.
The neonate had no evidence of respiratory
depression after delivery probably attributed to the
low dose of remifentanil administered and the short
incision to delivery time technique used. However,
low bolus doses of remifentanil has been associated
with respiratory depression13,22.
587
In conclusion, we demonstrated the effective
application of remifentanil in general anesthesia in a
parturient in active labor with severe multivalvular
heart disease, pulmonary hypertension and pulmonary
edema requiring cesarean section and without adverse
effects on the neonate.
M.E.J. ANESTH 20 (4), 2010
588
S. Amini & M. Yaghmaei et. al
References
1. Draisci G, Valente A, Suppa E, et al: Remifentanil for cesarean
section under genera anesthesia: effects on maternal stress hormone
secretion and neonatal well-being: a randomized trial. International
J of Obs Anesth; 2008, 17:130-136.
2. Vogl SE, Worda C, Egarter C, et al: Mode of delivery is associated
with maternal and fetal endocrine stress response. Brit J Obst Gyn;
2006, 113:441-5.
3. Morishima HO, Pederson H, Finster M, et al: Influence of maternal
physiologic stress on the fetus. Am J Obstet Gynecol; 1978, 131:28690.
4. Stanely TH, Webster LR: Anesthetic requirements and
cardiovascular effects of fentanyl-oxygen and fentanyl-diazepamoxygen anesthesia in man. Anesth Analg; 1978, 57:411-6.
5. Schuttler J, Albrecht S, Breivik H, et al: A comparison of
remifentanil and alfentanil in patients undergoing major abdominal
surgery. Anesthesia; 1997, 52:307-17.
6. Desai DJ, Golwala MP, Dhimar AA, Swadia VN: Emergency LSCS
in a patient with severe mitral stenosis with pulmonary hypertension
with aortic regurgitation (NYHA-III). Indian J Anesth; 2002,
46(6):483-485.
7. Soler-Soler J, Galve E: Worldwide perspective of valve disease.
Heart; 2000, 83:721-25.
8. Thorne SA. Pregnancy in heart disease. Heart; 2004, 90:450-56.
9. Desai DK, Adanlawo M, Naidoo DP, Moodley J, Kleinschmidt I:
Mitral stenosis in pregnancy: a four year experience at King Edward
VIII hospital, Durban, South Africa. Brit J Obstet Gynecol; 2000,
107:953-58.
10.Sawhney H, Aggrawal N, Suri V, et al: Maternal and perinatal
outcome in rheumatic heart disease. Int J Gynecol Obstet; 2003,
80:9-14.
11.Kuczkowski KM: Labor anesthesia for the parturient with cardiac
disease: what does an obstetrician need to know? Acta Obstet
Ansthesol Belg; 2004, 40:201-5.
12.Kuzczkowski KM, Zundert AV: Anesthesia for pregnant women
with valvular heart disease: the state of the art. Journal of anesthesia;
2007, 21(2):52-57.
13.Nagan KeeW, Khaw KS, Ma KC, Wong AS, et al: Maternal and
neonatal effects of remifentanil at induction of general anesthesia
for cesarean delivery: a randomized, double-blind, controlled trial.
Anesthesiology; 2006, 104:1014-20.
14.Kan R E, Hughes SC, Rosen MA, Kessin C, Preston PG, Lobo EP:
Intravenous remifentanil. Placental transfer, maternal and neonatal
effects. Anesthesiology; 1998, 88:1467-74.
15.Egan TD, Lemmens HJM, Fiset P, et al: The pharmacokinetics
of the new short-acting opioid remifentanil in healthy adult male
volunteers. Anesthesiology; 1993, 79:881-92.
16.More RMLE, Grange CS, Anisworth QP, Grebenik CR: General
anesthesia using remifentanil for cesarean section in parturients with
critical aortic stenosis: a series of four cases. Inter J Obstet Anesth;
2004, 13:183-7.
17.Bedard JM, Richardson MG, Wissler RN: General anesthesia with
remifentanil for cesarean section in a parturient with an acoustic
neuroma. Can J Anesth; 1999, 46(6):576-80.
18.Manullang TR, Chun K, Egan TD: The use of remifentanil for
cesarean section in a parturient with recurrent aortic coarctation.
Can J Anesth; 2000, 47(5): 454-59.
19.Scott H, Bateman C, Price M: The use of remifentanil in general
anesthesia for cesarean section in a patient with mitral valve disease.
Anesthesia; 1998, 53(7):695-7.
20.Molins EJ, Soria GA, Alcala E, Martinez EC, Sanchez CL:
Anesthesia for cesarean delivery in a woman with congenital aortic
stenosis. Res Esp Anestesiol; 2004, 51(4):221-5.
21.Mertens E, Saldien V, Coppejans H, Bettens K, Vercauteren M:
Target controlled infusion of remifentanil and propofol for cesarean
section in a patient with multivalvular disease and severe pulmonary
hypertension. Acta Anesthesiol Belg; 2001, 52(2):207-9.
22.Van de Velde M, Teunkens A, Kuypers M, et al: General anesthesia
with target controlled infusion of propofol for planned cesarean
section: maternal and neonatal effects of a remifentanil-based
technique. Int J Obstet Anesth; 2004, 13:153-8.
23.Carvalho B, Mirikitani EJ, Lyell D, Evans DA, Druzin M, Riley
ET: Neonatal chest wall rigidity following the use of remifentanil
for cesarean delivery in a patient with autoimmune hepatitis and
thrombocytopenia. Int J Obstet Anesth; 2004, 13(1):53-56.
24.Imarengiaye C, Littleford J, Davies S, Thaper K, Kingdom J: Goal
oriented general anesthesia for cesarean section in a parturient with a
large intracranial epidermoid cyst. Can J Anaesth; 2001, 48(9):88489.
INTRAVENOUS REGIONAL ANALGESIA IN
A PATIENT WITH GLANZMANN
THROMBASTENIA
Sitki Goksu*, Rauf Gul*, Onder Ozen*, Mehmet Yilmaz**,
Orhan Buyukbebeci***, Unsal Oner*
Abstract
Glanzmann thrombastenia (GT) is a rare condition of an inherited autosomal recessive gene
characterized with bleeding tendency. The condition is rarely met in the OR. and therefore it is
essential that anesthesiologist be cognizant of the risk involved and be prepared with all necessary
precautionary measures. We present a GT case in a 27 year old male with a mass in the anticubital
region of right wrist that was successfully excised using the non-invasive intravenous regional
analgesia (IVRA).
The use of platelet transfusion and the recombinant factor VIIa, are stressed.
Key words: Glanzmann thrombastenia, Intravenous regional anesthesia, Recombinant factor
VIIa, surgery.
Introduction
Glanzmann thrombastenia (GT) is a rare condition associated with fatal bleeding. Three
hundred such cases have been reported in the literature1. It is a trombocyte aggregation deficiency
inherited autosomal recessive, characterized with bleeding tendency because of the deficiency of
number or function of glycoprotein IIb/IIIa complex found on thrombocyte membrane2. Bleeding
time is significantly increased although platelet count, morphology, prothrombine time (PT) and
activated partial thromboplastin time (aPTT) values are normal2,3. Most commonly seen bleeding
symptoms in these patients are purpura, epistaxis, gingival bleeding and menorrhagia3. Any surgical
or invasive procedures can be high bleeding risk in these patients. Platelet transfusion is the only
way to stop bleeding. It is, ironic however, that excess platelet transfusion may also increase the
bleeding risk due to alloimmunisation4.
We present our experience with intravenous regional anesthesia (IVRA) and share information
on Glanzmann thrombastenia (GT).
From University of Gaziantep, Faculty of Medicine, Gaziantep, Turkey.
*
Department of Anesthesiology & Reanimation
** Department of Hematology.
*** Department of Orthopedic Surgery.
Correspondence to: Rauf Gul, Department of Anaesthesiology and Reanimation, Faculty of Medicine, University of
Gaziantep, 27310 Gaziantep, Turkey. Phone: 00 90 342360 60 60, Fax: 90-342-360 22 44. E-mail: [email protected]
589
M.E.J. ANESTH 20 (4), 2010
590
Case Report
A 27 years-old and 78 kg male, was admitted for
excision of a mass in his right anticubital wrist region.
For the previous 22 years, patient had been diagnosed as
Glanzmann thrombastenia. Except for thrombastenia,
the preanesthetic evaluation was not contributory.
Preoperative laboratory findings revealed: Hct 45%,
Plt 161000/mm3, PT 16.1 sec, INR 1.29, aPTT 32.6
sec, AST 15 U/L, ALT 11 U/L, Glucose 99 mg/dl,
Urea 22 mg/dl, Creatinine 0.82 mg/dl, Factor IX 98%
(normal range 60-150%), Factor VIII 99% (normal
range 60-150%). Radiological examination showed a
32 × 20 mm solid mass with regular borders in the right
wrist anticubital region. A Hematological consultation
emphasized that anesthetic and surgical interventions
could be highly risky because of the diagnosis of GT
and the antibodies formed against platelets in the
patient.
In the operating room (OR), monitoring consisted
of ECG, NIBP and pulse oximetry. An intravenous (iv)
line, 20-gauge cannula, was done at his left arm. Nacl
0.9% infusion at 3 ml/kg/hr started. Premedication
consisted of Midazolam (Dormicum ® roche) 1 mg.
To start the IVRA, a 22-gauge cannula was introduced
in dorsum of right hand. Following exanguination of
blood from right arm using the Esmarch bandage and
double layered tourniquet inflated, 3 mg/kg lidocaine
(Aritmal ® Biosel) (0.9% NaC1 solution was added
to make up a total volume of 40 mL), was given
intravenously.
Vital signs remained normal during surgery. 2400
units rFVIIa (NovoSeven ® Novo Nordisk) was given
1 hour before and at the beginning of the operation.
Bleeding amount was 100 ml approximately. One
apheresis platelet suspension was given during
operation. After tourniquet deflation, there was some
blood leakage from the incision site. After bleeding
stopped, patient was transferred to the service ward
without any problems. A total 7200 units rFVIIa was
given at 2, 6, and 12 hrs postoperatively.
Discussion
Life threatening difficult to stop hemorrhages
mostly develop secondary to trauma or surgical
procedures in Glanzmann thrombastenic (GT) patients.
S. Goksu et. al
The administration of recombinant activated factor VIIa
is safe and effective in such cases. Blood and blood
products (platelet rich plasma, platelet concentrates)
can also be given4,5.
The early diagnosis of GT is most important,
because only platelet transfusion can be life saving.
Platelet agrometria, thromboelastographic techniques,
bleeding time measurements, are the methods for
follow up of platelet function. However, the platelet
agrometria and thromboelastographic techniques are
not commonly used4-7.
Anesthesiologists rarely meet GT in the OR.
All preparation and precautionary measures must be
taken. Without the adequate preparation of patient, all
anesthetics carry risk factors. Tracheal intubation for
one, can cause intractable bleeding and difficulty in
airway management. Nasogastric catheters and other
oral interventions, can cause bleeding5. Central and
peripheral blocks also have bleeding risk.. It is therefore
essential that the advantages and disadvantages of a
central block should be weighed carefully before being
done.
In situations such as the GT, minimally invasive
analgesic techniques should be the procedure of choice
and an IVRA technique should be highly considered.
Literature review revealed that surgery of GT
patients has been done both under general anesthesia
and local anesthesia2,3,5,8,9. However, no IVRA technique
has been reported in such cases.
The IVRA technique used in our case is minimally
invasive and produces bloodless field of the surgical
area. Bleeding risk, however, after tourniquet deflation
is a disadvantage. Due to the high pressure produced
by the IVRA in the tourniquet region, tissue damage
may occur.
No serious bleeding or tissue damage was
observed during and after operation in our patient. It
is probable that having given platelet suspension and
rFVIIa preoperatively, may have a salutary effect in
the prevention of bleeding.. The rFVIIa transfusion
is approved in intractable life threatening bleeding
situation. It must also be realized that although platelet
transfusion is the only accepted treatment in GT, this
platelet transfusion may cause antibody formation
against Glicoprotein IIb/IIIa, and this can inactivate
INTRAVENOUS REGIONAL ANALGESIA IN A PATIENT WITH GLANZMANN THROMBASTENIA
succeeding transfusions4.
It can concluded that intravenous regional
analgesia (IVRA) provides a good non-invasive
591
analgesic technique in the management of patients
with Glanzmann thrombastenia.
References
1. Ranjith A, Nandakumar K: Glanzmann thrombasthenia: a rare
hematological disorder with oral manifestations: a case report. J
Contemp Dent Pract; 2008, 1, 9:107-13.
2. Gunaydın B, Özköse Z, Pezek S: Recombinant Activated Factor
VII and Epsilon Aminocaproic Acid treatment of a patient with
Glanzmann’s thrombasthenia for nasal polipectomy. J1 Anesth,
2007, 21:106-107.
3. Ryckman JG, Hall S, Serra J: Coronary artery bypass grafting in
a patient with Glanzmann’s thrombasthenia. J Card Surg; 2005,
20(6):555-6.
4. Welsby IJ, Monroe DM, Lawson JH, Hoffmann M: Recombinant
activated factor VII and the anaesthetist. Anaesthesia; 2005,
60:1203-12.
5. Uzunlar HI, Eroglu A, Senel AC, Bostan H, Erciyes N: A patient
with Glanzmann’s thrombasthenia for emergent abdominal surgery.
Anesth Analg; 2004, 99:1258-60.
6. Monte S, Lyons G: Peripartum management of a patient with
Glanzmann’s thrombasthenia using Thrombelastograph. Br J
Anaesth; 2002, 88:734-8.
7. Bellucci S, Caen J: Molecular basis of Glanzmann’s Thrombasthenia
and current strategies in treatment. Blood Rev; 2002, 16:193-202.
8. Bay A, Oner AF: Glanzmann thrombasthenia successfully operated
for nasal deformation with recombinant factor VIIA. Indian
Pediatrics; 2006, 43:1094.
9. Nurden AT: Glanzmann thrombasthenia. Orphanet J Rare Dis;
2006, 6, 1:10.
M.E.J. ANESTH 20 (4), 2010
592
Anesthetic Management of 29 Week
Pregnant Patient Undergoing Craniotomy
for Pituitary Macroadenoma
- A Case Report -
Oya Yalcin Cok*, Sule Akin*, Anis Aribogan*,
Meltem Acil*, Bulent Erdogan**, Tayfun Bagis***
Introduction
Intracranial space-occupying lesions are rarely present during pregnancy and these disorders
seldom require immediate surgical attention. The most common among them is pituitary tumor of
which 15-35% has a chance of enlarging during pregnancy1,2. The decision to proceed with surgical
intervention depends on the site, size, and type of the tumor, gestational age and neurological
signs as well as the patient’s wishes. In case of surgery, multidisciplinary approach is essential in
perioperative period.
Maternal alterations during pregnancy may complicate the anesthetic management of patients
and increase monitoring requirements for safety of both mother and fetus3. Unfortunately, this
may become a challenge to all attending physicians, but especially to the anesthesiologists, as the
anesthetic plan must meet the needs of both pregnancy and neurosurgery4.
Here, we present 29-week pregnant patient undergoing craniotomy for pituitary adenoma and
discuss the features of anesthesia providing maternal and fetal safety.
Case Report
A 29 year-old parturient (gravida 3, para 1, D/C 1, C/S 1) at 27 weeks of pregnancy was
presented with blurred vision and headache. She was admitted to the hospital for differential
diagnosis of possible causes such as migraine, infection, hemorrhage and increase in
intracranial pressure. Her past medical history was unremarkable. Her physical examination
disclosed a decreased visual acuity and radiological examination revealed a suprasellar mass
lesion consistent with macroadenoma at magnetic resonance imaging (Fig. 1).
From Baskent Univ., Faculty of Medicine, Ankara, Turkey.
*Department of Anesthesiology and Reanimation.
**Department of Neurosurgery.
***Department of Obstetrics and Gynecology.
Corresponding author: Dr Oya Yalcin Cok, Baskent University, Department of Anesthesiology and Reanimation.
Adana Research and Education Center, Yuregir Adana/Turkey. Tel: +90 322 3272727-1469, Fax: +90 322 3271274.
E-mail: [email protected]
593
M.E.J. ANESTH 20 (4), 2010
594
O. Y. Cok et. al
Fig. 1
MR images showing suprasellar mass lesion
consistent with macroadenoma
(Axial FLAIR and sagittal spin echo T1 weighted images).
The mass was heterogeneous and hyperintense, 3
x 2.7 cm, elevating vascular structure anteriorly with
compression of optic chiasm. After a multidisciplinary
consultation with the neurosurgery, obstetrics and
anesthesiology departments, initial decision was to
delay the surgery until after delivery. However, two
weeks later, a rapid deterioration in patient’s visual
acuity was detected and physical examination disclosed
a total vision loss in the right eye and hemianopsia in
the left eye. She was scheduled for an urgent surgical
intervention after reconsultation.
The preanesthetic assessment revealed a
pregnancy at 29th week and parturient was otherwise
healthy. Fetal cardiotocography and ultrasound
examination revealed that fetus was well and
concordant with its gestational age.
Neurosurgeons preferred a craniotomy for
emergent approach. Intraoperative monitoring included
the routine clinical standards for cranial tumor surgery
such as heart rates 5-lead ECG, invasive arterial
blood pressure, peripheral O2 saturation, end tidal
CO2, central venous pressure acquired by threading
a central venous catheter into subclavian vein, body
temperature and urine output throughout the anesthesia.
Arterial blood gases were checked every twenty
minutes. Furthermore, fetal heart rate (FHR) was
monitored by cardiotocography prior to operation and
throughout the surgery and periodically for 24 hours
postoperatively. A senior resident obstetrician was
ready for assessment of FHR and an urgent caesarean
section (C/S) was planned in case of non-reassuring
fetal stress at the same operating theatre where suitable
set of surgical instruments were also available. In
addition, neonatalogist was informed about the case
and neonatal ICU was available as if the C/S had to be
performed, the baby would have born preterm.
Patient was premedicated with ranitidine 50 mg
and metoclopramide 10 mg IV prior to operation.
Anesthesia was induced with thiopental 400 mg,
fentanyl 100 µg, lidocaine 60 mg and dexamethasone
8 mg intravenously. Intubation was facilitated by
vecuronium 8 mg. The trachea was orally intubated,
7.5 mm at first attempt without any difficulty with
application of cricoid pressure. A left lateral tilt was
accomplished to prevent vena cava compression and
reverse trendelenburg to the operating table to decrease
intracranial pressure. A heated blanket was placed
under the patient to keep normothermia. Anesthesia
was maintained with fentanyl infusion 0.5-3 µg kg-1hr-1,
0.6-0.8 MAC isoflurane and 50% O2 in air. Controlled
ventilation was with a tidal volume 8 mL kg-1 sustaining
an end tidal CO2 values at 30 ± 2 mmHg.
Surgery lasted approximately for 5 hours. The
maternal heart rate and blood pressure remained within
normal limits during operation (Fig. 2A and B). Arterial
blood gases were in normal range and normothermia
was carefully maintained.
Anesthetic Management of 29 Week Pregnant Patient Undergoing Craniotomy for
Pituitary Macroadenoma
Fig. 2A
Maternal and fetal heart rates throughout surgery (Beat/min)
Fig. 2B
Maternal blood pressure values throughout the surgery
(mmHg)
At the end of surgery, the neuromuscular
blockade was reversed and the patient was extubated
fully awake in the operating room and transported to
the ICU uneventfully.
Left temporal anopsia remained unimproved
in her neurological examination at discharge from
hospital, which was her main complaint preoperatively.
Thereafter, she had C/S at 35th week of her pregnancy
because of preterm labor and gave birth to a low birth
weight child (1870 grams).
Discussion
The incidence of brain tumors during pregnancy is
rare5,6. However, this rare problem may require urgent
surgical interventions as brain tumors tend to enlarge
during pregnancy due to fluid retention, increased
blood volume and hormonal changes7. Management
of intracranial tumors in pregnancy is stressful for
everyone involved and it should be individualized for
the patient8,9. The patient’s features and own wishes
have to be considered while providing safety of two
patients, the mother and the fetus9.
The anesthetic management of a parturient
undergoing a non-obstetric surgery includes close
monitorization of maternal hemodynamics and
595
respiratory parameters. Continuous and attentive
monitoring is also essential for follow-up of the
fetus’ well-being during surgery and anesthesia10.
However, necessity of fetal heart rate monitoring is
still a controversial issue8,11,12,13,14. The purpose of FHR
monitoring is to detect fetal hypoxia and metabolic
acidosis, which may result in tissue damage or fetal
death15. The baseline FHR is typically between 120160 beat/minute in a healthy fetus beyond 20 weeks.
Alterations in the baseline rate and variability should
be cautiously interpreted by trained personnel, because
normal variability reliably indicates the absence of fetal
distress, however vice versa does not. Many factors
may mimic fetal stress on fetal heart rate monitoring
such as inhalational anesthetics, opioids, barbiturates,
parasympatholytics, fetal sleep cycles, hypothermia.
The risk of misinterpretation under general anesthesia
always exists and may lead to unnecessary surgery9,16.
In addition, FHR monitoring requires additional trained
personnel in the operating theatre and an emergency
plan must be available in case of urgency. We advocate
the use of FHR monitoring, whenever feasible, since
constant maternal hemodynamics do not assure fetal’s
well-being17,18.
Managing a pregnant patient during craniotomy
requires thorough understanding of physiology and
pharmacology during pregnancy and a comprehensive
knowledge of neurosurgical anesthesia to support
practice3,9,19. The combination of pregnancy and
neurosurgery requires rapid but smooth induction as
advocated for all pregnant patients beyond 20 weeks
of gestation. In pregnancy, functional residual capacity
is decreased by 20% and O2 consumption is higher
than non-pregnant patients. Hypo-and hypercapnia
both reduce uterine blood flow inducing fetal acidosis
and myocardial depression. Thereby, we aimed to
maintain mild hypocapnia during surgery in order
to avoid fetal stress, while avoiding hypoxia and
providing normoventilation throughout surgery10.
Particular attention should be paid to the positioning
of parturient, as there is potential risk of aortacaval
compression during surgery. The common practice
is either to tilt the operation table 20º left laterally or
to place a wedge under patient’s right hip, or both, to
avoid a hypotension that will also affect the fetus9.
The traditional drugs of neurosurgical anesthesia
M.E.J. ANESTH 20 (4), 2010
596
should be reconsidered in a pregnant patient. Opioids
are effective and compatible with neurosurgery and
obstetrics; where as inhalational anesthetics are
favored for uterine relaxation9. Since nitrous oxide
should be avoided in the first trimester because of
its teratogenicity, its aggravating effect on cerebral
vasodilatation when used with potent inhalation agents,
is another concern throughout whole neurosurgery.
In this case, inhalation anesthetics with opioid
supplemetation were preferred for their predictable
effects on fetal well-being. Diuretics and hypotensives
should be used attentively because of feto-maternal
fluid shift and decrease in uteroplacental perfusion9.
Steroids are advantageous by reducing cerebral edema
and accelerating fetal lung maturation. Teratogenicity
O. Y. Cok et. al
and adverse effects of drugs are another concern for
the well-being of the fetus.
We aim to emphasize that a pregnant woman
has a risk of every type of neurosurgical pathology,
that a non-pregnant woman may face. In addition,
pregnancy, itself, may cause neurological disorders
to become symptomatic or may aggravate the present
symptoms2,7. Anesthetists managing patients with both
pregnancy and intracranial neoplasm have to base
their practice on theoretical knowledge of obstetrics
and neurosurgical anesthesia. However, further fetal
safety measures such as fetal heart rate monitoring
should be utilized whenever feasible in the presence of
the fetus as a second patient during all interventions.
References
1. Chandraharan E, Arulkumaran S: Pituitary and adrenal disorders
complicating pregnancy. Curr Opin Obstet Gynecol; 2003,
15:101-6.
2. Swensen R, Kirsch W: Brain neoplasms in women: a review. Clin
Obstet Gynecol; 2002, 45:904-27.
3. Van De Velde M, De Buck F: Anesthesia for non-obstetric surgery
in the pregnant patient. Minerva Anestesiol; 2007, 73:235-40.
4. Smith IF, Skelton V: An unusual intracranial tumour presenting in
pregnancy. Int J Obstet Anesth; 2007, 16:82-5.
5. Isla A, Alvarez F, Gonzalez A, García-Grande A, Perez-Alvarez
M, García-Blazquez M: Brain tumor and pregnancy. Obstet
Gynecol; 1997, 89:19-23.
6. Tewari KS, Cappuccini F, Asrat T, Flamm BL, Carpenter SE, DiSaia
PJ, Quilligan EJ: Obstetric emergencies precipitated by malignant
brain tumors. Am J Obstet Gynecol; 2000, 182:1215-21.
7. Cirak B, Kiymaz N, Kerman M, Tahta K: Neurosurgical procedures
in pregnancy. Acta Cir Bras; 2003, 18:5-9.
8. Balki M, Manninen PH: Craniotomy for suprasellar meningioma in
a 28-week pregnant woman without fetal heart rate monitoring. Can
J Anaesth; 2004, 51:573-6.
9. Kuczkowski KM: Nonobstetric surgery during pregnancy: What are
the risks of anaesthesia? Obstet Gynecol Surv; 2004, 59:52-6.
10.Giannini A, Bricchi M: Posterior fossa surgery in the sitting position
in a pregnant patient with cerebellopontine angle meningioma. Br J
Anaesth; 1999, 82:941-4.
11.Horrigan TJ, Villarreal R, Weinstein L: Are obstetrical personnel
required for intraoperative fetal monitoring during nonobstetric
surgery? J Perinatol; 1999, 19:124-6.
12.Macarthur A: Craniotomy for suprasellar meningioma during
pregnancy: role of fetal monitoring. Can J Anaesth; 2004,
51:535-8.
13.Rosen MA: Management of anesthesia for the pregnant surgical
patient. Anesthesiology; 1999, 91:1159-63.
14.Tuncali B, Aksun M, Katircioglu K, Akkol I, Savaci S: Intraoperative
fetal heart rate monitoring during emergency neurosurgery in a
parturient. J Anesth; 2006, 20:40-3.
15.Garite TJ: Intrapartum fetal evaluation. In: Gabbe SG, Niebyl JR,
Simpson JL, eds. Obstetrics: Normal and problem pregnancies.
Philadelphia: Churchill livinstone Elsevier Inc, 2007, 364-395.
16.Immer-Bansi A, Immer FF, Henle S, Spörri S, Petersen-Felix S:
Unnecessary emergency caesarean section due to silent CTG during
anaesthesia? Br J Anaesth; 2001, 87:791-3.
17.Liu PL, Warren TM, Ostheimer GW, Weiss JB, Liu LM: Foetal
monitoring in parturients undergoing surgery unrelated to pregnancy.
Can Anaesth Soc J; 1985, 32:525-32.
18.Ong BY, Baron K, Stearns EL, Baron C, Paetkau D, Segstro R:
Severe fetal bradycardia in a pregnant surgical patient despite normal
oxygenation and blood pressure. Can J Anaesth; 2003, 50:922-5.
19.Littleford J: Effects on the fetus and newborn of maternal analgesia
and anesthesia: a review. Can J Anaesth; 2004, 51:586-609.
UNEXPECTED POSTOPERATIVE SEIZURE
AFTER MASTOID SURGERY
- A Case Report -
Erkalp Kerem*, Basaranoglu Gokcen*,
Kokten Numan**, Ilhan Emre**, Egeli Unal***,
Ozdemir Haluk* and Saidoglu Leyla*
Postoperative seizures (expected after neurosurgery) are rare events. When they do occur,
they are usually attributable to an identifiable drug reaction, a metabolic or neurological event1. We
report a case of postoperative seizure in postanesthesia care unit.
A 19-yr-old female, 48 kg, was admitted to a hospital for left middle-ear surgery. Her medical
history, physical examination and laboratory evaluation were normal. Anesthesia was induced
with fentanyl 1 µg/kg, thiopental 5 mg/kg and rocuronium 0.5 mg/kg to produce neuromuscular
blockade. Anesthesia was initially maintained with oxygen, nitrous oxide and sevoflurane. Mastoid
surgery was completed in 195 minutes after induction.
The patient was extubated, but approximately 10 minutes after arrival in recovery she started
to generalized tonic clonic convulsion. Oxygen was administered by face mask and thiopental 100
mg was administered intravenously. Blood sugar, electrolytes and body temperature were normal.
After ten minutes convulsion episode was repeated. Because of the continuing seizure activity in a
patient at risk of pulmonary aspiration and security of air way, her trachea was intubated by using
thiopental and succinylcholine and ventilation controlled artificially. The seizures were controlled
with midazolam and phenytoin.
Computerized tomography (CT) showed left temporal cortical suspected hipodensity (Fig. 1)
and the patient was transferred to ICU.
From Vakif Gureba Hospital, Istanbul, Turkey.
*
Department of Anesthesiology.
** Department of Ear, Nose and Throat.
*** Department of Radiology.
Corresponding author: Kerem Erkalp. Kartaltepe Mah., Bilgehan Cad., no. 64/6, 34040, Bayrampasa/Istanbul, Turkiye.
Tel: 0090 532 7879500, Fax: 0090 212 621 75 80. E-mail address: [email protected]
597
M.E.J. ANESTH 20 (4), 2010
598
Fig. 1
Computerized tomography (CT) showed left temporal cortical
suspected hipodensity (Early postoperative period)
Neurological consultation was conducted and it
was thought to be a new epileptogenic focus in left
temporal lobe with iatrogenic brain injury. After 3
days, the patient was discharged without neurologic
deficit in anticonvulsant therapy with phenytoin 300
mg orally. The magnetic resonance imaging (MRI)
scan showed hyperintense signals area in left temporal
cortex (Fig. 2). She was sent to the ward after normal
physical examination findings.
There are numerous anesthetic and nonanesthetic
causes of postoperative seizures; local anesthetics,
inhalation anesthestics, opioids, drug reaction,
hypoxia, hypocarbia, hypoglycemia, hyponatremia,
hypocalcaemia, acidosis, pyrexia, psychogenic
seizures (pseudoseizures). Postoperative seizures may
result from global or focal cerebral ischemia due to
hypoperfusion, particulate or air emboli, or metabolic
E. Kerem et. al
Fig. 2
Magnetic resonance imaging (MRI) scan showed hyperintense
signals area in left temporal cortex (3 days after surgery)
causes2.
Iatrogenic complications can and do occur in
ear surgery. Damage occur if a cutting burr is used
with excessive pressure directed onto an edge of the
bone. The BURR can jump of the bone through the
exposed dura into the middle fossa with damage to the
arachnoids and surface of temporal lobe itself3. The
operating microscope has dramatically reduced the risks
of injury, but surgeons still maintained a heightened
awareness of these complications, as many injuries are
not visually detected at the time of surgery4.
We believe that, in our case the seizure may have
occurred secondary to damage to the temporal cortex
due to iatrogenic brain injury. To our knowledge
seizures associated with iatrogenic brain injury is not
well documented as a cause of postoperative seizures.
References
1. Ng L, Chambers N: Postoperative pseudoepileptic seizures in a
known epileptic: complications in recovery. Br J Anaesth; 2003,
91:598-600.
2. Bronster DJ: Neurologic complications of cardiac surgery: current
concepts and recent advances. Curr Cardiol Rep; 2006, 8:9-16.
3. Tos M: Manual of middle ear surgery. 1995. volume II. 66.
4. Abbas GM, Jones RO: Measurements of drill-induced temperature
change in the facial nerve during mastoid surgery: a cadaveric
model using diamond burs. Ann Otol Rhinol Laryngol; 2001 Sep,
110(9):867-70.
PSYCHO-MIMETIC MANIFESTATIONS
FOLLOWING PROPOFOL
IN DAY CARE SURGERY
- Case Reports -
Pradipta Bhakta,* Pragnyadipta Mishra,**
and Q utaiba A mir Tawfic ***
Abstract
Objectives: Propofol has virtually replaced other agents for induction of anesthesia in the
ambulatory setting because of its favorable recovery profile. Psycho-mimetic effects, common
after use of ketamine, are not so well known for propofol. We present two case reports where
patients had two spectrum of abnormal psychological outbreaks after propofol anesthesia.
Case Reports: Two healthy young patients were scheduled for short day care procedures under
general anesthesia. In both cases anesthesia was induced with propofol plus fentanyl and maintained
with inhalational anesthetic agents. After uneventful completion of surgery, both patients were
transferred to recovery room where they manifested unusual psycho-mimetic reactions. The first
patient had emotional outburst in the form of crying and the other had violent reaction requiring
haloperidol for control.
Conclusion: Psycho-mimetic reactions can occur after anesthesia using propofol in the short
duration day care procedures, in patients with or without preexisting psychiatric problems, needing
antipsychotic medications for control.
Key Words: Case report, Emotional outbreak, Propofol anaesthesia, Day Care surgery.
*
**
***
Dept. of Anesthesia and Intensive Care, Sultan Qaboos University Hospital, Muscat, Oman.
Dept. of Pediatric Anesthesiology Cincinnati Children’s Hospital & Medical Centre, Cincinnati, Ohio, USA.
Dept. of Anesthesia and Intensive care, Sultan Qaboos University Hospital, Muscat, Oman.
Corresponding author: Dr. Pragnyadipta Mishra (MD, DNB), Clinical Fellow, Dept. of Pediatric Anesthesiology,
Cincinnati Children’s Hospital & Medical Centre, Cincinnati, Ohio-45229, USA, Tel: +1-513-257-1361.
E-mail: [email protected]
Financial support: There was no financial support of any kind involved with this study.
599
M.E.J. ANESTH 20 (4), 2010
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P. Mishra et. al
Introduction
Propofol has replaced other agents for
induction of anesthesia in the ambulatory setting
because of smooth, fast and clear headed recovery.
Contrastingly, subhypnotic concentration of propofol
has been reported to result central nervous system
(CNS) adverse effects including perioperative
mood alterations. We describe two such incidences
where patients developed unusual psycho-mimetic
manifestations during recovery from short general
anesthesia using propofol as induction agent.
Case 1
A 23 year old lady, ASA I, weighing 46 Kg, was
scheduled for day care anal sphincterotomy. Sedative
pre-medication was withheld. Anesthesia was induced
with intravenously fentanyl 100 microgram and
propofol 100 mg and maintained with 60% N2O in O2
and isoflurane along with incremental doses of propofol
and fentanyl. She was kept on spontaneous ventilation
with mask and oropharyngeal airway. Duration of
operation was approximately 20 minutes and it was
uneventful. Total amount of propofol and fentanyl
used were 150mg and 150microgram respectively.
She behaved abnormally recovery from
anesthesia. There was no response to verbal command
even though she was opening her eyes. Shortly after
that she started weeping and later cried loudly. She was
asked repeatedly whether she was feeling pain, but the
answer was always negative. Her emotional outburst
was settled after reassurance from us. Later she was
shifted to PACU for further monitoring.
In PACU, a detail history was taken by a female
doctor. It was found that she was under constant stress
starting from her marriage. She became pregnant
immediately after her marriage and was being abused
constantly by her in-laws.
Case 2
A 29 years old female patient, ASA I, 50 Kg,
diagnosed case of incomplete abortion and was
scheduled for emergency suction and evacuation.
Premedication was withheld.
General anesthesia was induced with intravenous
fentanyl 100microgram and propofol 120mg. Size
three proseal LMA was inserted and anesthesia was
maintained with 60% N2O in O2 and incremental doses
of propofol and fentanyl when necessary. Inhalational
agent was avoided. Spontaneous ventilation was used.
Surgery was completed uneventfully in fifteen minutes.
Total dose of propofol used was 180mg. She was
shifted to PACU after she became awake and stable.
In the PACU she behaved abnormally, struggling
and trying to jump out from bed. Initially it was thought
because of pain. So, incremental doses of fentanyl
were given. But even after additional 100microgram
of fentanyl there was no change in behavior. Attempt
to resist the patient made her more violent. She started
using offensive filthy words and thrashing the nursing
staff. At this time haloperidol 2.5mg was given
intravenously. After that she gradually became quite.
Rest of her stay in the recovery as well as general ward
was uneventful.
Next morning she became fully awake and
co-operative. But she was not able to recollect the
previous event. Later, a detail history was taken from
the patient as well as relative by the psychiatrist and it
revealed that she had a history of claustrophobia and
bed wetting till the age of nine years.
Discussion
Psycho-mimetic and emotional reactions are
known side effects of ketamine, but they are not so well
known with propofol.1,2 Sub-hypnotic concentrations
of propofol can produce CNS adverse effects like
postoperative alteration in mood. Patients emerging
from propofol anesthesia were more likely to exhibit
sensation-seeking tendencies (e.g. adventurous, daring,
energetic) and to feel elated and even euphoric.3,4 It may
result in dream and hallucination in day care setting.5
Even sexual hallucination and opisthotonos have been
reported.6,7
To date, no incidence of emotional or
psychological outburst has been reported in literature.
Both of our patients behaved normally during
pre-anesthetic assessment and did not show any
signs or symptoms of psychiatric disorders. The
anesthesia technique used was well established for
short duration day care procedures and none of the
PSYCHO-MIMETIC MANIFESTATIONS FOLLOWING USE OF PROPOFOL IN DAY CARE SURGERY
agents used for anesthesia other than propofol could
have promoted these psycho-mimetic effects. Thus a
probable deduction is that propofol may have caused
suppression of inhibitory areas of brain that resulted in
outburst of long term emotional stress, which was not
revealed earlier (as in 1st case) and expression of some
hidden psychological behavior (as in 2nd case). Also the
inherent psychogenic effects of propofol (mentioned
earlier) may have played a role here. Probable
explanation of its occurrence in day care cases is that
lack of proper preanesthetic counseling and avoidance
601
of premedication may have resulted in expression of
psychological phenomenon in the setting of propofol
induced inhibition of higher centers of CNS and its
inherent psycho-mimetic effect.
Conclusion
Emotional and psycho-mimetic reactions may
occur after propofol anesthesia especially in day care
patients with background history of chronic stress and
psychological disorders.
References
1. Garfield JM, Garfield FB, Stone JG, et al: A comparison of
psychological responses to ketamine and thiopentone-nitrous oxidehalothane anesthesia. Anesthesiology; 1972, 36:329-38.
2. Crossen G, Reves J, Stanley T: Dissociative anesthesia. In Crossen
G, Reves J, Stanley T (Eds): Intravenous Anesthesia and Analgesia.
Philadelphia, Lea & Fabiger, 1988, p. 99.
3. White PF, Freire AR: Ambulatory (Outpatient) Anesthesia. In
Miller RD, ed. Miller’s Anesthesia, 6th ed. Philadelphia, pensylvania:
Elsevier Churchill Livingstone, 2005, pp. 2603-4.
4. McDonald NJ, Mannion D, Lee P, et al: Mood elevation and
outpatient anaesthesia. A comparison between propofol and
thiopentone. Anaesthesia; 1988, 43 (suppl.):68-9.
5. Hocking G: Propofol-an interesting new side effect? Anaesthesia;
1996, 51:101.
6. Nelson V: Hallucination after propofol. Anaesthesia; 1988,
43:170-1.
7. Cameron AE: Opisthotonos again. Anaesthesia; 1987, 42:1124.
M.E.J. ANESTH 20 (4), 2010
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P. Mishra et. al
USE OF DEXMEDETOMIDINE AS THE MAIN
ANESTHETIC AGENT in PATIENTS WITH
LARYNGO-TRACHEOMALACIA
- A Case Report-
Khaled Al Zaben, Ibraheem Qudaisat,
Bassam Al Barazangi and Izdiad Badran
Abstract
The successful use of Dexmedetomidine as the main anesthetic agent for three pediatric
patients with tracheomalacia presenting for different kinds of urgent operations is described.
Patients were kept spontaneously breathing without intubation during their whole procedures.
Surgical conditions were adequate, and hemodynamic and respiratory profiles were within
baseline limits.
Introduction
Providing general anesthesia to patients with tracheomalacia can be a big challenge to the
anesthetist in terms of the type of anesthetic agents used and airway and ventilatory management1.
Easy collapsibility of the trachea during coughing and recovery from anesthesia may make
extubation of the trachea extremely difficult, leading to prolonged intubation and ventilation in these
patients1,2. The avoidance of endotracheal intubation, where practical, may decrease postoperative
coughing and the risk of airway collapse on emergence3.
Dexmedetomidine is a potent alpha-2-adrenergic agonist, which has analgesic and sedative
effects with little effect on ventilation4,5. In the present case report, we describe the use of
dexmedetomidine as the primary anesthetic in three pediatric patients who underwent different
emergency operations without airway intervention. The same surgeon with whom the anesthesia
plan was pre-discussed carried out the three operations.
From Department of Anesthesia, Faculty of Medicine, Jordan University, Amman, Jordan.
Corresponding author: Dr. Khaled AL ZABEN, Department of Anesthesia, Jordan University Hospital,
Amman 11942, Jordan. E-mail: [email protected]
603
M.E.J. ANESTH 20 (4), 2010
604
Case 1
A 5-month-old male infant, (4 kg), known to
have seizure disorder, developmental delay, failure to
thrive and laryngomalacia was scheduled for repair
of irreducible inguinal hernia and insertion of a
gastrostomy feeding tube. On preoperative evaluation,
the patient had inspiratory stridor, tachypnea, and
tachycardia. His SpO2 was 88% on 5 L/min. O2. He
had left subclavian central venous line inserted due to
difficult peripheral venous access.
Upon arrival to the OR, standard monitors were
applied. A loading dose of Dexmedetomidine (1 µg/
kg) was then given over 10 minutes followed by a 2
µg/kg/hr infusion. A slow infusion of propofol (50 µg/
kg/min) was also started. After the loading dose of
Dexmedetomidine, the surgeon was asked to pinch the
skin with forceps to assess the adequacy of sedation
before infiltration of local anesthetic solution. A total
of 3ml Bupivacaine 0.25% was infiltrated by the
surgeon. The patient was kept spontaneously breathing
with 3 L/minute O2 flow applied through a simple
facemask. During the procedure, the patient’s SpO2
remained around its baseline with an end-tidal CO2 of
45-50mmHg measured through a catheter under the
face mask. Heart rate and mean blood pressure were
decreased by less than 20% from their baseline and
there was no significant drop in the respiratory rate.
Surgical conditions were excellent throughout.
By the end of the surgery, drug infusions were stopped
and patient sent back to pediatric intensive care unit
(PICU) where he remained sedated for around one and
half hours without the need for additional analgesic
medications.
Case 2
A 3-year-old female patient (10 kg) known to
have bilateral hydronephrosis and laryngomalacia was
scheduled for diagnostic cystoscopy. On pre-operative
assessment she was tachycardic (115 b/m), BP 100/70
mmHg. She had expiratory stridor with SpO2 of 90% on
3L/min. facemask oxygen. Her attending pediatrician
indicated that this was her best condition and nothing
else could be done to improve her condition.
In the operating theatre, standard ASA monitoring
was applied and a new peripheral intravenous line was
K. Al Zaben et. al
secured, A loading dose of Dexmeditomidine 1 µg/kg
was infused over 10 minutes then continued as infusion
at 2 µg/kg/hr. Propofol 1% infusion was also started
at 50 µg/kg/min. Lignocaine gel was applied in the
patient’s urethra by the surgeon for topical anesthesia
prior to insertion of the cystoscope. The patient was
kept spontaneously breathing through a simple face
mask with oxygen flow of 4 liters/min. The procedure
was done uneventfully in 15 minutes and the patient had
no significant changes in her blood pressure, heart rate,
respiratory rate and end tidal CO2. She was transferred
to the PACU, where she remained sedated for about 80
minutes and discharged to the ward afterwards.
Case 3
A 3-year-old female patient (12 kg) with a
history of congenital tracheo-esophageal fistula
repaired when she was one day old, presented with
a history suggestive of foreign body aspiration. She
was known to have recurrent chest infections but her
current presentation was associated with more than
usual difficulty in breathing and transient attacks of
cyanosis. She was brought to theatre as an emergency
case for rigid bronchoscopy. Preoperative evaluation
revealed that the patient is having severe inspiratory
stridor and expiratory wheezes. SpO2 was 85% on
4 L/min oxygen via simple facemask.
On arrival to the OR, oxygen treatment was
maintained at 4 Lit/min. via simple face mask, standard
ASA monitors applied, and her in situ venous access
checked. Dexmedetomidine 2 µg/kg was given as a
loading dose over 10 minutes and continued as infusion
6 µg /kg/hr, Propofol intravenous infusion was also
started at 100 µg/kg/min. Topical anesthesia lignocaine
spray up to a total dose 4mg/kg was applied two
minutes prior to insertion of the rigid bronchoscope.
The procedure, which revealed the presence of
laryngo-tracheomalacia, was done smoothly in about
15 minutes, and ended with the recovery of a fragment
of a melon seed shell from the patient’s right main
bronchus. During the procedure, the patient maintained
spontaneous ventilation with SpO2 85-90%, End-tidal
CO2 45-50 mmHg. There were no significant changes
in her baseline heart rate and blood pressure. By the end
of the procedure, the infusions were discontinued and
the patient was sent to the PACU where she remained
USE OF DEXMEDETOMIDINE AS THE MAIN ANESTHETIC AGENT in PATIENTS WITH LARYNGOTRACHEOMALACIA
sedated for about two hours and discharged to the ward
afterwards.
Discussion
The choice of anesthetic option for patients with
airway malacia who present for different types of
surgeries can be difficult and tricky1. This is especially
true for those patients presenting for emergency
operations where preparation of patients can be limited.
The option of general anesthesia technique
for these patients usually requires the use of airway
and ventilation support maneuvers such as CPAP
or PEEP to prevent intraoperative airway collapse.
As postoperative coughing with the risk of airway
collapse on emergence will increase with the use of
endotracheal intubation6-8, the avoidance of a tracheal
tube, provides smoother anesthesia course. Also,
reports of Laryngeal mask airway (LMA) use in these
patients ranged between success3,9,10 and failure6.
Although the use of inhalational technique while
maintaining spontaneous respiration is a logical way
of general anesthesia in these patients, there had been
some case reports of Isoflurane and Enflurane induced
tracheomalacia11,12. Precipitation of airway obstruction
during sevoflurane general anesthesia in a child with
congenital tracheomalacia had also been reported6.
The use of Intravenous anesthesia maintenance
techniques is yet another option especially in older
children1. However, the use of Propofol which is the
most commonly used intravenous anesthetic agent for
total intravenous anesthesia, was found to be associated
with dose-related depression of central respiratory
output to upper airway dilator muscles and of upper
airway reflexes13.
In view of those limitations, we opted to use
a Dexmedetomidine-based sedation technique,
supplemented with minimal dose Propofol and combined
with local anesthetic infiltration/topicalization of the
surgical site as necessary.
Dexmedetomidine is an α 2-adrenergic agonist
which is currently FDA-approved for the short-term
(less than 24 hours) sedation of adult ICU patients.
It has analgesic and sedative effects with little effect
on ventilation4. Literature about its clinical use in
pediatric patients is based on case reports and includes
605
sedation during mechanical ventilation, prevention of
emergence agitation following general anesthesia with
sevoflurane or desflurane, provision of proceduralsedation, and to prevent withdrawal following the
prolonged use of opioids and benzodiazepines14.
Our aim was to avoid airway maneuvering
during anesthesia, meanwhile maintaining adequate
spontaneous breathing. In all of the three cases herein
presented, this was achieved successfully with adequate
intra-and postoperative outcome.
Use of dexmedetomidine as the sole anesthetic
will require higher doses, (5-10 µg /kg/hr), which
might affect the respiratory and hemodynamic
profile. This is especially true for upper airway
surgery as described by Ramsay and Luterman15.
Shukry et al16 in their use of dexmedetomidine
as the sole anesthetic in four infants requiring
bronchoscopy in a dose of 2-5 µg/kg/hr found out that
a bolus dose of propofol was needed for one of the
patients. They suggested that infusing a small dose
of propofol would decrease the Dexmeditomidine
needed to achieve adequate surgical conditions
without respiratory and cardiac complications, a
combination technique opted in our patients.
Although brief in duration, rigid bronchoscopy is
an intensely stimulating procedure that requires better
control of airway reflexes. Seybold et al19 successfully
used Dexmedetomidine (2.5 µg/kg/hr with boluses
of 0.25-1 µg /kg) combined with propofol 200-250
µg/kg/min for rigid bronchoscopy in two pediatric
patients. In our bronchoscopy case we did not use
Dexmedetomidine increments but instead we used a
higher loading dose and infusion rate (2 µg /kg and
6 µg/kg/hr respectively), and smaller Propofol dose
(100 µg/kg/min). Our plan was based on the fact that
respiration is more likely to still be preserved when
Dexmedetomidine is used as the primary anesthetic
agent than Propofol.
In conclusion, we report on three cases of
successful use of Dexmedetomidine-based anesthesia
in patients with airway malacia who presented for
different emergency surgeries. Airway interventions
were successfully avoided and surgical conditions
were adequate. Further controlled studies are needed to
establish the safety and efficacy of Dexmedetomidinebased anesthesia in such patients.
M.E.J. ANESTH 20 (4), 2010
606
K. Al Zaben et. al
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1. Austin J, Ali T: Tracheomalacia and bronchomalacia in children,
pathophysiology, treatment, assessment and anaesthetic management.
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2. Suto Y, Tanabe Y: Evaluation of Tracheal collapsibility in Patients
with Tracheomalacia Using Dynamic MR Imaging during Coughing.
AJR Am J Roentgenol; 1998, 171:393-394.
3. Yamaguchi S, Takanishi T, Matsumoto T, et al: Use of a laryngeal
mask in a patient with bronchomalacia. Masui; 1996, 45:348-351.
4. Chad M: Brummett, Dexmedetomidine: A Clinical Review,
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25:41-42.
5. Takrouri MS, Seraj M A, Channa AB, el-Dawlatly AA, Thallage
A, Riad W, Khalaf M: Dexmeditomidine in intensive care unit:
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6. Okuda Y, Sato H, Kitajima T, Asai T: Airway obstruction during
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7. Asai T, Shingu K: Airway obstruction in a child with asymptomatic
tracheobronchomalacia. Can J Anaesth; 2001, 48:7, 684-687.
8. Celiker V, Basgul E, Karagoz AH: Anesthesia in BeckwithWiedemann syndrome, Pediatric Anaesthesia; 2004, 14:778-780.
9. Ghelber O, Szmuk P, Alfery DD, Ezri T, Agro F: Use of
CobraPLUSTM in a child with tracheomalacia. Acta Anaesthesiol
Scand; 2007 Jul, 51(6):782-3.
10.Patrick N, Joseph N, Kim R: Use of the Proseal Laryngeal Mask
Airway In An Infant With Repaired H-Type Tracheoesophageal
Fistula and Tracheomalacia. Pediatric Anesthesia; 2008, 18:74-76.
11.Katoh H, Saitoh S, Takiguchi M, et al. A case of tracheomalacia
during Isoflurane Anesthesia. Anesthesia Analgesia; 1995,
80:1051-3.
12.Yamaya K, Ujike Y, Namiki A: Tracheobronchomalacia occurring
under general anesthesia: a case report. Rinsho Masui; 1986, 10:33740.
13.Peter R: Eastwood, Peter R. Platt, Kelly Shepherd, Kathy Maddison,
David R. Hillman, Collapsibility of the Upper Airway at Different
Concentrations of Propofol Anesthesia. Anesthesiology; 2005,
103:470-7.
14.Joseph D: Tobias, Clinical uses of dexmedetomidine in pediatric
anesthesiology and critical care, Seminars in Anesthesia,
Perioperative Medicine and Pain; 2006, 25:57-64.
15.Ramsay MA, Luterman DL: Dexmedetomidine as a total intravenous
agent. Anesthesiology; 2004, 101:787-790.
16.Shukry M, Kennedy K: Dexmedetomidine as a total intravenous
anesthetic in infants. Pediatric Anesthesia; 2007, 17:581-583.
17.Seybold JL, Ramamurthy RJ, Hammer GB: The use of
Dexmeditomidine during laryngoscopy, bronchoscopy, and tracheal
extubation following tracheal reconstruction. Paediatric Anaesth;
2007 Dec, 17(12):1212-1214.
PRIMARY MALIGNANT MELANOMA
OF THE TRACHEA
Mohamad Nattout, Nabil Fuleihan,
Omar Sabra, Ibrahim Aburizk,
Abdul-latif Hamdan
Abstract
Tracheal melanomas represent the rarest type of extracutaneous melanomas. The clinical
manifestation is similar to other tracheal tumors and ranges from symptoms of airway obstruction
such as dyspnea and stridor to other nonspecific symptoms such as hoarseness, cough and
hemoptysis. Bronchoscopy is required to draw the origin of the lesion biopsy is needed to establish
histologic diagnosis. Treatment consists of either palliative surgery aiming at restoring the airway
or tracheal resection and end to end anastmosis. We would like to present here below a rare case of
tracheal melanoma and discuss the various diagnostic and therapeutic means.
Key Words: melanoma; airway obstruction; trachea.
Introduction
Primary tumors arising from the trachea are uncommon. The clinical incidence does not
exceed 0.2 per 100,000 people per year and the post-mortem prevalence is about 1 per 15,000
autopsies1. When present it is important to recognize the association of primary tracheal tumors
with other head and neck tumors, with the increased risk being estimated as 11 fold2. More than fifty
percent of these tumors are malignant and the most frequent histopathologic types are squamous
cell carcinoma followed by adenocarcinoma There are only few reports in the literature on primary
tracheal melanomas and these represent the rarest type of extracutaneous melanomas3-6. This case
report describes the relevant radiologic and clinical features of this uncommon malignancy.
*
Lecturer.
** Professor.
*** Resident.
****Associate Professor, Department of Otolaryngology, American University of Beirut Medical Center.
Corresponding author: Abdul-Latif Hamdan, MD, FACS, American University of Beirut, Department of Otolaryngology,
P.O. Box: 110236, Tel/Fax: 961-1-746660. E-mail: [email protected]
607
M.E.J. ANESTH 20 (4), 2010
608
Case Presentation
A 28 year old male, previously healthy, presented
to the American University of Beirut with history of
severe upper airway obstruction. He reported history
of progressive dyspnea, shortness of breath and
hemoptysis of two month duration. Medical history
was negative for asthma or chest pain or other systemic
illnesses. His physical exam revealed “stridor”
and suprasternal retractions. Fiberoptic laryngeal
endoscopy did not show any laryngeal abnormalities
with normal mobility of the vocal folds. Computerized
tomography of the neck and chest revealed a tracheal
mass obstructing almost ninety percent of the tracheal
lumen (Fig. 1). Magnetic Resonance imaging did not
show extension into the mediastinum. PET scan did
not show any metastatic lesion or other primary except
the tracheal lesion. Patient underwent tracheostomy
under local anesthesia followed by bronchoscopy.
Bronchoscopy revealed a tracheal mass with a nodular
surface arising from the right posterolateral wall at
the level of the fifth tracheal ring and extending to
the seventh tracheal ring. The lesion was occupying
most of the tracheal lumen. Biopsy was taken and
sent for histopathological examination. The following
immunohistochemical stains were performed:
HMB45, S-100, Vimentin and Cytokeratin AE1/AE3.
All the results were positive except for cytokeratin
AE1/AE3 which was negative. The diagnosis was
consistent with a primary malignant melanoma of the
trachea (Fig. 2).
Fig. 1
Computerized Tomography of the neck showing
a tracheal tumor arising from the right posterolateral
wall of the trachea and occluding almost
all the tracheal lumen
M. Nattout et. al
Fig. 2
A: H & E stain: Tumor composed of interlacing bundles of
spindle cells, with vesicular nuclei containing prominent
nucleoli, occasional cytoplasmic melanin is noted. The tumor
fills and expands the subepithelial stroma. B: HMB-45 positive
cells are seen
Discussion
Primary tracheal melanoma is extremely
uncommon despite the increase in the incidence of
malignant melanoma of the skin and the few reports
of intratracheal metastasis3. In a retrospective review
of 360 primary tracheal tumors, only one patient
had tracheal melanoma7. The clinical manifestation
of primary tracheal melanomas is similar to other
tracheal tumors and ranges from symptoms of airway
obstruction such as dyspnea, stridor wheezes and
cyanosis, to other nonspecific symptoms such as
hoarseness, cough, hemoptysis, weight loss and chest
pain. Invasion into adjacent structures may present
as a neck mass with the presence of dysphagia and
odynophagia.2,5. Tracheal tumors are rarely discovered
by chest or neck radiographs especially in the early
stages. Not more than 50% are identified based on
PRIMARY MALIGNANT MELANOMA OF THE TRACHEA
these means as reported by a radiologic and clinical
study conducted by Li et al. Barium esophagogram
is helpful in detecting esophageal invasion when
the mass is arising from the posterior tracheal wall.
Computerized tomography is the most important
imaging modality with an accuracy that exceeds
tomography. It provides a good cross sectional image of
the trachea and the endoluminal tumor extent, however
it may underestimate the vertical length of the tumor
in view of the volume averaging5,6. Bronchoscopy is
required to draw the origin of the lesion and to map
the extent of the tumor in relation to the vocal folds.
Biopsy remains the hallmark to establish histologic
diagnosis. There are strict criteria for the microscopic
diagnosis of primarily melanoma of the trachea and
these include the presence of a solitary tracheal tumor
containing melanin histologically in the absence of
tumor outside the trachea, junctional changes in the
mucosa between melanoma cells and normal lining
and invasion beyond the epithelium and submucosa8,9.
Immunostains for HMB-45 and S-100 are usually
positive in these tumors. These were the findings in
our reported case.
There were several attempts to explain the
609
oncogenesis of mucosal melanomas in general and to
postulate the histogenesis of lower respiratory tract
melanomas in specific. Shivas and MacLennan have
suggested the term “melanogenic metaplasia”, where
mucus-secreting cells are histologically altered into
melanin- producing cells. Reid and Metha and Walsh
reported that squamous metaplasia is the origin of
mucosal melanomas. Others have speculated that
melanocytes migrate during embryogenesis to the
developing lower respiratory tract or arise from a
neuroendocrine cell precursor (Kul-chitsky cell)5-9.
Treatment consists of either palliative surgery
aiming at restoring the airway by means of laser usage
or therapeutic with tracheal resection and end to end
anastmosis10. For laser usage, various therapeutic
options are available and these include the carbon
dioxide CO2 laser, the argon, the neodymium:yttriumaluminum-garnet ( Nd: YAG) and the new argon
plasma coagulation (APC) technique under flexible
bronchoscopy. Radiation therapy or endobronchial
brachytherapy may be added especially in cases of
incomplete resection. Chemotherapy is recommended
however the prognosis remains poor irrespective of the
modality of treatment.
References
1. Heffner DK: Diseases of the trachea. In: Barnes L, ed. Surgical
Pathology of the Head and Neck, vol. 1. New York: Marcel Dekker
Inc, 1985, pp. 487-531.
2. Lefor AT, Bredenberg CE, Kellman RM, Aust JC: Multiple
malignancies of the lung and head and neck. Arch Surg; 1986,
121:265-70.
3. Koh HK: Cutaneous melanoma. N Engl J Med; 1991, 3:171-182.
4. Allen AC, Spitz S: Malignant melanoma, a criteria for diagnosis
and prognosis. Cancer; 1953, 6:1.
5. Mori K, Cho H, Som M: Primary “flat” melanoma of the trachea. J
Pathol; 1977, 121:101-4.
6. Duarte IG, Gal AA, Mansour KA: Primary malignant melanoma of
the trachea. Ann Thorac Surg; 1998, 65:559-60.
7. Gaissert HA, Grillo HC, Shadmehr MB, Wright CD, Gokhale M,
Wain JC, Mathisen DJ: Uncommon primary tracheal tumors. Ann
Thorac Surg; 2006, 82(1):268-723.
8. Colby TV, Koss MN, Travis WD: Tumors of the lower respiratory
tract. In: Armed Forces Institute of Pathology. Atlas of tumor
pathology, third series, fascicle 13. Armed Forces Institute of
Pathology; 1995, pp. 483-7.
9. Jennings TA, Axiotis CA, Kress Y, Carter D: Primary malignant
melanoma of the lower respiratory tract. Am J CLin Pathol; 1990,
94:649-55.
10.Capaccio P, Peri A, Fociani P, Ferri A, Ottaviani F: Flexible argon
plasma coagulation treatment of obstructive tracheal metastatic
melanoma. Am J Otolaryngol; 2002, 23(4):253-255.
M.E.J. ANESTH 20 (4), 2010
610
Tracheal Schwannoma:
A Misleading Entity
Abdul Latif Hamdan*, Roger V. Moukarbel*,
Ayman Tawil**, Mohamad El-Khatib***,
Ussama Hadi*
ABSTRACT
Primary tracheal tumors are rare with the majority being malignant. Benign lesions are less
frequent with primary tracheal schwannomas accounting for less than 0.5% of tracheal tumors.
They are more common in females and their clinical presentation is non-specific. Chronic cough,
progressive respiratory distress and even asthma-like conditions prevail as presenting symptoms
and signs. Laryngotracheal endoscopy reveals a solitary, well encapsulated mass arising most often
from the posterior tracheal wall. The diagnosis of tracheal schwannomas is primarily pathological.
Endoscopic excision, sleeve excision or tracheal resection, are all commonly accepted treatment
modalities. Proper awarness of these lesions is crucial in the pre-operative work-up of patients
presenting with stridor.
Key words: Trachea, shwannoma, resection.
Introduction
Primary tracheal tumors are rare with the majority being malignant. Benign lesions are less
frequently encountered and embrace a wide heterogeneous group comprising adenomas, papillomas,
fibromas, lipomas, hemangiomas and neurogenic tumors1. Though benign as indolent lesions,
their clinical presentation might be malignant. The lack of localizing symptoms often misleads
the primary physician and results in a delayed diagnosis. Pre-operative work-up and proper mode
of anesthesia delivery is important and may avoid a tracheostomy on these patients unless severe
obstruction is present. A case report of a rare, primary tracheal schwannoma is described with
emphasis on the pathologic findings and modalities of treatment.
Case Report
A 68 year old lady diabetic, hypertensive and cardiac presented six weeks status open heart
surgery with history of respiratory failure following multiple attempts of extubation. Her history
dates back to the time of surgery when difficult intubation was encountered upon induction of
anesthesia. Direct laryngoscopy and bronchoscopy done by an outside physician revealed a
tracheal mass at the level of the second tracheal ring obstructing the airway. A tracheotomy was
done and the patient was sent to us for further evaluation and treatment. Further questioning
*Department of Otolaryngology- Head & neck Surgery, American University of Beirut Medical Center.
**Department of Pathology & Laboratory Medicine, American University of Beirut Medical Center.
***Department of Aneasthesiology, American University of Beirut Medical Center.
Corresponding Author: Abdul-latif Hamdan, MD, FACS, Department of Otolaryngology-Head & Neck Surgery,
American University of Beirut Medical Center, P.O. Box: 11-0236, Beirut-Lebanon, Tel: 961 1 350000, ext. 7695,
Fax: 961 1 746660. E-mail: [email protected]
611
M.E.J. ANESTH 20 (4), 2010
612
of the family members revealed history of asthma
with noisy breathing, exertional dyspnea and
decrease in exercise tolerance for which the patient
was treated to no avail. A fiberoptic nasopharyngeal
laryngoscopy revealed normal vocal cord mobility
with the evidence of a high tracheal mass. Magnetic
resonance imaging of the neck revealed a 1-2 cm
tracheal lesion arising from the posterior tracheal
wall with a high signal intensity on a T2 weighted
images (Fig. 1). There was no evidence of cartilage
invasion or extratracheal spread. Bronchoscopy
was done under general anesthesia and showed
a soft smooth well rounded 2x2 cm mass located
around 3cm below the true vocal cords. Incisional
biopsy showed an expanding, well circumscribed
submucosal mesenchymal neoplasm arising from
the respiratory mucosa and compressing submucosal
glands. High power view of the tumor showed neural
spindled cells with bland nuclei that focally showed
a palisaded arragement forming verocay bodies.
Immunohistochemical staining for S-100 protein and
vimentin were positive (Fig. 2). The diagnosis was
consistent with tracheal shwannoma.
Fig. 1
T2 weighted images, coronal cuts taken at level of tracheal
narrowing, showing obliteration
of the lumen by this high signal mass.
Fig. 2
Well circumscribed submucosal mesenchymal neoplasm
A. L. Hamdan et. al
arising from the respiratory mucosa
and compressing submucosal glands. High power view
of the tumor showed neural spindled cells with bland nuclei
that focally showed a palisaded arragement
forming verocay bodies.
Patient underwent surgical excision of the tumor
with resection of two tracheal rings and primary end to
end anastomosis. Patient was extubated directly postoperatively with no complications. Routine fiberoptic
endoscopy at 6 months interval for the first year
showed no recurrences.
Discussion
Primary tracheal schwannomas are rare lesions of
the trachea, accounting for less than 0.5% of tracheal
tumors1. They are more common in females with no
age predilection2. Their clinical presentation varies and
is usually non-specific. Chronic cough, progressive
respiratory distress and even asthma-like conditions
prevail as presenting symptoms and signs1,2,3. Poor
response to conventional medical treatment prompts the
physician to seek further investigation. Unfortunately,
an average delay of 10-15 months between onset of
symptoms and diagnosis is reported3.
Radiological studies can be non specific.
Computerized Tomography scan usually shows
a well circumscribed enhancing mass within the
tracheal lumen1,4 with no specific features. Magnetic
Resonnance Imaging of a tracheal shwannoma,
similar to other peripheral schwannomas, displays
isointensity or hyperintensity on T1-weighted images
and hyperintensity on T2-weighted images with
heterogeneous enhancement as seen in our case5.
Laryngotracheal endoscopy reveals a solitary, well
encapsulated mass arising most often from the posterior
Tracheal Schwannoma: A Misleading Entity
tracheal wall; the lower third of the trachea is the most
common site followed by the upper and then the middle
thirds1,3. Proper awarness of these lesions is crucial in
the pre-operative work-up of patients presenting with
stridor. The anesthiology team should be ready to
secure the airway by means other than the conventional
ones such as endotracheal intubation. Laryngeal mask
anesthesia or jet ventilation, delivering oxygenation
proximal to the site of the lesion and avoiding direct
manipulation of the tracheal lumen are important
issues to keep in mind.
The diagnosis of tracheal schwannomas is
primarily pathological. Grossly, they are well
circumscribed and encapsulated; microscopically,
neural spindle cells in compact fashion (Antoni A
areas) as well as in loose myxoid fashion (Antoni B
areas) are demonstrated. Verocay bodies, which are
areas of palisading nuclei, are present in Antoni A
areas3. No capsular invasion, nuclear pleomorphism
or mitoses is present. Immunohistochemical stains for
S-100 protein and vimentin are positive4. These were
the findings in our case. The differential diagnosis of
spindle cell lesions of the larynx and trachea includes
spindle cell carcinoma, as well as a variety of benign
and malignant mesenchymal lesions. Spindle cell
carcinoma can be easily identified by demonstrating
613
a direct relationship of the tumor with the adjacent
epithelium and by immunohistochemical staining for
cytokeratin. Among the benign mesenchymal lesions
is nodular fasciitis which may display mitotic figures,
but the latter are not atypical. Malignant lesions
include a number of spindle cell sarcomas such as
fibrosarcoma, synovial sarcoma, and leiomyosarcoma;
however, these are extremely rare in this location and
do not arise from the surface epithelium.
The rarity of these lesions has led surgeons to
practice different surgical techniques but the primary
treatment is surgical excision. No standard procedure
has been adopted. Endoscopic excision, sleeve
excision or tracheal resection, are all commonly
accepted treatment modalities. Endoscopic excision
using either the cold steel instruments or laser is better
suited for pedunculated lesions with no extra-tracheal
component1. Tracheal resection with reconstruction
has been more advocated for sessile lesions with or
without an extra-tracheal component1,2, which was the
procedure of choice in our case.
The duration of follow up after surgical
intervention has not been consistent throughout the
literature, mainly because of the rarity of the lesion.
References
1. Rusch VW, Schmidt RA: Tracheal schwannoma: management by
endoscopic laser resection. Thorax; 1994, 49:85-86.
2. Horovitz AG, Khalil KG, Verani RR, et al: Primary intratracheal
neurilemoma. J Thorac Cardiovasc Surg; 1983, 85:313-320.
3. Pang LC: Primary neurilemoma of the trachea. South Med J; 1989,
82:785-787.
4. Dorfman J, Jamison BM, Morin JE: Primary tracheal schwannoma.
Ann Thorac Surg; 2000, 69:280-281.
5. Baba Y, Ohkubo K, Seino N, Churei H, Shirahama H, Nakajo
M: MR imaging appearances of schwannoma: correlation with
pathological findings. Nippon-Igaku-Hoshasen-Gakkai-Zasshi;
1997 Jul, 57(8):499-504.
M.E.J. ANESTH 20 (4), 2010
GUIDELINES FOR AUTHORS
The Middle East of Anesthesiology publishes original
work in the fields of anesthesiology, intensive care, pain, and
emergency medicine. This includes clinical or laboratory
investigations, review articles, case reports and letters to the
Editor.
Submission of manuscripts:
The Middle East Journal of Anesthesiology accepts
electronic submission of manuscripts as an e-mail attachment
only.
Manuscripts must
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Beirut, Lebanon
E-mail: [email protected]
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M.E.J. ANESTH 20 (4), 2010
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