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Anesthesia in severe preeclampsia Shusee Visalyaputra Siriraj Hospital Mahidol University Thailand.

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งานนำเสนอเรื่อง: "Anesthesia in severe preeclampsia Shusee Visalyaputra Siriraj Hospital Mahidol University Thailand."— ใบสำเนางานนำเสนอ:

1 Anesthesia in severe preeclampsia Shusee Visalyaputra Siriraj Hospital Mahidol University Thailand.

2 Outline 1.4 case examples 2.Definition & pathophysiology 3. Management - preoperative evaluation - anesthetic management in each case - anesthesia for vaginal delivery - anesthesia for cesarean section - choice of anesthesia epidural anesthesia spinal anesthesia general anesthesia 4.Q & A

3 Case example 1. ผู้ป่วย อายุ 30 ปี น้ำหนัก 75 กก. ตั้งครรภ์ 34 สัปดาห์ ความดัน เลือด 210/ 110 มม. ปรอท บวม โปรตีนในปัสสาวะ 4+ (severe preeclampsia) 2. ผู้ป่วย อายุ 30 ปี น้ำหนัก 134 กก. ตั้งครรภ์ 37 สัปดาห์ ความดันเลือด 200/ 110 มม. ปรอท บวม โปรตีนในปัสสาวะ (severe preeclampsia & obesity) 3. ผู้ป่วย. อายุ 32 ปี น้ำหนัก 70 กก. ตั้งครรภ์ 32 สัปดาห์ ความดันเลือด 160/ 100 มม. ปรอท บวม เจ็บใต้ชายโครงขวา โปรตีนในปัสสาวะ 4+ ผลตรวจทางห้องปฏิบัติการพบ เกล็ดเลือดต่ำ 63,000/ มม 3 หน้าที่ตับผิดปกติ (an aspartate aminotransferase (AST) > 70 U/L, lactatedehydrogenase (LDH) > 600 U/L), Bilirubin 1.mg/dL ( HELLP syndrome, which is one form of severe preeclampsia) 4. ผู้ป่วย อายุ 30 ปี น้ำหนัก 65 กก. ตั้งครรภ์ 35 สัปดาห์ มีอาการชัก 1 ครั้งก่อนมารพ ความดันเลือดสูง 200/ 120 มม. ปรอท บวม โปรตีนใน ปัสสาวะ 4+ (Eclampsia, which is one form of severe preeclampsia)

4 Severe Preeclampsia : definition Hypertension SBP >160, DBP > 110 mmHg Proteinuria >5 gm/24 h Either one of end organ damage - Oliguria (<400 ml/24 h) - Cerebral edema - blurred vision, headache, convulsion - Pulmonary edema - Hepatic dysfunction - epigastric pain, HELLP - Intrauterine growth retardation (IUGR)

5 Pathophysiology first trimester Invasion of trophoblast incomplete  maternal spiral arteries  placental ischaemia  released of inflammatory stimuli  second trimester endothelial cells damage, dysfunction  cytokines production  & vasoconstriction, platelet aggregation hypertension & proteinuria & end organ damage

6 Pathophysiology : End organ dysfunction or damage CNS - cerebral edema eclampsia Lung- pulmonary edema “no known about unequal involvement of each organs in each patient” Renal - proteinuria, oliguria Hepatic - elevated liver enzymes, - liver cells damage, HELLP Heart- cardiomyopathy

7 Preoperative Evaluation Airway edema Pulmonary edema Urine output Cerebral dysfunction Liver dysfunction t Fetal well being Severe hypertension, tachycardia Global Endothelial cells Dysfunction = Every organs involvement

8 Management in Severe Preeclampsia CVP- no correlated with PCWP at >8 mmHg - keep CVP 4-6 mmHg (by expert opinion) Fluid- lack of evidence support* - 80 ml/h (by expert opinion) * Duley L, et al. Cochrane database 2000 * Young PF 2000 Drugs - uncertainty in drug of choice to treat hypertension * * - use with local experience, on known side effects (by expert opinion) ** von Dadelszen P, et al 2007

9 Management in Severe Preeclampsia 1. ผู้ป่วย อายุ 30 ปี น้ำหนัก 75 กก. ตั้งครรภ์ 34 สัปดาห์ ความดันเลือด 210/ 110 มม.ปรอท บวม โปรตีนในปัสสาวะ 4 + (diagnosis = severe preeclampsia) normal coagulation profiles, Platelet count 150,000 mm 3, Anesthesia for vaginal delivery - Epidural anesthesia - better pain relief - attenuate BP response to pain - better control of maternal BP - improved utero placental blood flow - can be used for cesarean section

10 Management in Severe Preeclampsia Anesthesia for cesarean section - Choice of anesthesia - regional vs. general anesthesia regional is safer(difficult intubation) - Epidural vs. Spinal anesthesia - Epidural, - if has been used for vaginal delivery - can be used for cesarean section

11 Spinal anesthesia in severe preeclampsia 20 yrs -Avoid RA (hypotension might compromise NB) * Wallace, et al yrs yrs - small prospective study* - CSE, Epidural, GA - no sig. dif. in BP, NB ** Hood DD & Regina yrs yrs - large retrospective study** - spinal & epidural anesthesia - no. sig. dif in BP, NB

12 Spinal anesthesia in severe preeclampsia 1b, A b, A 2003 * spinal anesthesia severe preeclampsia vs healthy parturient frequent of hypotension 16% 53% * Aya et al, 2003 ** Dyer et al, b, A b, A 2003 ** - spinal vs GA - severe preeclampsia with nonreassuring fetal heart trace Hemodynamic changes – similar 1 min Apgar - lower in GA gr. 5 min Apgar - similar Umbilical pH vs. 7.23

13 Large RCT* - Spinal vs. epidural *Visalyaputra S, et al Spinal anesthesia in severe preeclampsia Hypotension= 51% vs. 33% Degree of hypotension =10 mmHg (95% CI 4-17 mmHg) Period of hypotension = median 1 vs 0 min Ephedrine requirement = median 6 vs 0 mg 1&5 min Apgar Scores =similar Umbilical blood gas =similar

14 General Anesthesia in Preeclampsia Airway edema is common - Mandatory to reexamine the airway soon before induction, then make decision to go on rapid sequence induction or awake intubation or spinal block (mother,s life Vs baby,s life) (giving a dead new born to the alive mother is better than giving a dead wife to the alive husband) Laryngoscopy and intubation may  severe  BP –Labetolol & NTG are commonly used acutely –Nifedipine 10 mg SL,hydralazine 20 mg titration –Fentanyl (2.5 mcg/kg), alfentanil (10 mcg/kg), lidocaine may be given to blunt response

15 General Anesthesia in Preeclampsia Steps of GA - Evaluate upper airway - Antacid prophylaxis,LUD - Non invasive monitoring -Decrease BP to around 140/90 mmHg by using - Labetolol & NTG are commonly used acutely - Nifedipine 10 mg SL,hydralazine 20 mg titration –Fentanyl (2.5 mcg/kg), alfentanil (10 mcg/kg), lidocaine may be given to blunt response –Thiopenthal,S Choline, cricoid pressure –S Choline, nitrous oxide, 1/4 Mac. volatile agents –Narcotics after delivery –Awake extubation –Postoperative closed observation (respiration. BP,urine output, consciousness)

16 Conclusion in patient no.1 (severe preeclampsia, with platelets > 100,000 mm 3 not obese) Conclusion in patient no.1 (severe preeclampsia, with platelets > 100,000 mm 3 not obese) Vaginal delivery: epidural anesthesia Cesarean section: Epidural or CSE is still the technique of choice, although nowadays, good evidences support the use of spinal anesthesia in preeclamptic patients (with platelets count > 100,000/mm 3 ). GA, if needed,airway should be evaluated first, decrease BP before intubation, postop close observation for residual relaxation, hypertension,pulmonary edema,eclampsia

17 patient no.2 (severe preeclampsia with obesity)

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27 Conclusion in patient no.2 (severe preeclampsia with obesity) Vaginal delivery: epidural anesthesia (sitting) Cesarean section: Epidural or CSE(sitting): the technique of choice but may be difficult, Spinal(sitting): may be easier & nowadays, good evidences support the use of spinal anesthesia in preeclamptic patients (with platelets count > 100,000/mm 3 ). GA, (severe preeclampsia + obesity + emergency = bad combination), airway should be evaluated before rapid sequence induction, if looks difficult, change to RA or awake intubation

28 3. Anesthesia in severe preeclampsia with platelets <100,000/mm 3 (HELLP) HELLP Syndrome ( H emolysis = abnormal peripheral smear,(bilirubin >1.2 mg%, LDH > 600 U/L) E levated L iver Enzymes = aspartate dehydrogenase (AST) > 70 U/L L ow P latelets = <100,000/mm 3 )

29 Dexamethasone can increase RA rate in HELLP Syndrome 4, C ** 37 patients with platelet <90,000/mm 3 steroidwithout steroid RA used 42% (11/26)0% (0/11) **Martin JN Jr, et al 2003 *O’ Brien JM, et al b, B * Dexamethasone 6 mg q 6 h x 4 doses steroid without steroid Platelets count 88, ,000 vs. 72, ,000/mm 3

30 Which level of platelet count that RA can be used? 4, C * Maximum Amplitude (MA) of 53 (normal) is correlated with platelet count 54,000/mm 3 (95% CI 40,000-75,000) *Orlikowski CE, et al 1996 Sharma SK, et al measure all phase of blood coagulation - 14% of severe preclampsia have platelet count <100,000/m 3 Tromboelastogram (TEG)

31 -Since severe preeclampsia has dynamic status of the disease, recent platelet levels should be determined before performing RA Vaginal delivery *: systemic narcotics * Dyer RA, et al 2007 cesarean section Risk vs benefit of RA & GA should be weighed Conclusion in patient no.3 HELLP syndrome, (platelets < 100,000 mm 3 ) Conclusion in patient no.3 HELLP syndrome, (platelets < 100,000 mm 3 ) - GA : if no difficult airway detected - Spinal anesthesia (small needle, good hands)

32 patient no.4 (Eclampsia) ** Moodley J, et al , C **- 66 stable eclamptic patients, - 37 epidural, 2 spinal RA in Eclampsia Pathophysiology* - hyperperfusion & loss of autoregulation (rather than focal ischaemia) - vasogenic edema in MRI * Belfort MA, et al , D * * * - use GA in patients with depressed level of consciousness, ventilation into postpartum. - use RA in patients with normal levels of consciousness *** Dyer DA, 2007

33 Final Conclusion:Severe Preeclampsia Vaginal delivery: epidural or systemic analgesics In HELLP, patients with platelet count <100,000/mm 3 GA or spinal ( if platelet >75,000/mm. 3 ) In Eclampsia RA is suggested in stable eclamptic patient with good consciousness Cesarean section elective - epidural, spinal,CSE urgency, non reassuring fetal heart trace - spinal emergency, severe fetal bradycardia (prolapsed cord) - GA (evaluate upper airway, then rapid sequence, awake or change to RA)

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ดาวน์โหลด ppt Anesthesia in severe preeclampsia Shusee Visalyaputra Siriraj Hospital Mahidol University Thailand.

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