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“Anesthetic Management Of Paraplegic Patient With Pregnancy For Spine Surgery”- (A Case Report) |
Dr. T. P. Doctor, Dr. S. D. Vakil |
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Summary Anaesthetic
management of a 23 years old paraplegic pregnant (7 months amenorrhoea) patient,
who was subjected for antero lateral
decompression at D4 level
under GA is discussed. It is emphasized that with a good team work by
obstetrician, anaesthesiologist and orthopaedician
in carrying out proper antenatal care, hospitalisation at proper time and
perioperative management, a successful out
come can be assured to such patients.
Introduction
As reported by
Friedman (1988), 50,000 pregnant women
undergo emergency surgery each year.1 Nonobstetric
surgery during pregnancy attribute to excessive
perinatal mortality and morbidity, because of the disease
itself rather than adverse effect of the surgery and
anaesthesia.2,3,4,5 Although there is
worldwide concern for tuberculosis,
still incidence of tuberculosis in women of
childbearing age has increased up to 40%,.6 General
anesthesia in pregnant women especially in third trimester
needs special attention, because of associated changes in
body physiology and chances of complications e.g.
premature labor etc. Usually surgery is delayed up to
36weeks until foetal lung maturity if possible, but semi
emergency or emergency surgery can be performed at
any time of pregnancy.2
Case report A 23 years old
female patient, weighing 60Kg, with
7months amenorrhoea, with Koch’s spine at level D4-D5 with paraplegia, was
posted for anterolateral decompression
as a semi emergency operation. Patient complained
of pain in back since 6 months; followed by weakness of both lower limbs and
inability to walk since 7
days. There was the past history of anorexia
and night sweats since 5-6 months. There was
no past history of cough, giddiness, trauma over back, convulsions, bowel
and bladder involvement. Patient was
on antituberculous treatment-isoniazid, ethambutol, pyrizinamide &
rifampicin since one week. On General
Examination - Patient was fully conscious,
moderately built and nourished. Pulse, blood
pressure, temperature, respiratory rate were normal.
Patient was pale, and there was no pedal edema. Local
examination of back and spine-tenderness in D4-D5
region;
no swelling / crepitus. On systemic examinationrespiratory
and cardiovascular systems were normal.
Central nervous system examination: - Hypotonia -below
D6 levels, with paraplegia
& normal power in both upper limbs.
Deep tendon reflexes- absent in both lower limbs
& present in both upper limbs. Per abdomen examination
showed: Uterofundal height - 28 weeks; foetal heart sounds (F.H.S) – 140 min-1,
regular; position-left occipitoanterior
(L.O.A.). Investigations
Haemoglobin -
9.5gms%, other hematological, renal &
liver function tests, serum electrolytes etc. were normal.
X-Ray Spine (A.P.View) - destruction of D4
vertebrae.
osteomylities of D4,
paravertebral abscess or myeloma? C.T.Scan
(Thorax) - suggestive of osteolytic lesion of
lower end of D3-D4?
Koch’s lesion. Ultra Sonographic Examination
(U.S.G.): - Uterus size-28weeks; F.H.S.- 136 min-1;
Placenta-right side grade-I with adequate amount of liquor. Pre-anesthetic
checkup was done. Patient was categorised
to ASA grade III and written consent for risk
of premature labor was obtained. tab. diazepam 10mg
orally given at previous night.
Aims of
anaesthetic management General anaesthesia was planned and the aims of anaesthetic management were as follows: 1. To avoid
hypotension and hypoxia intraoperatively. 2.
To maintain maternal and fetal oxygen delivery.
3. To avoid drugs
that crosses the placental barrier. 4.
To avoid premature labor. Premedication
of glycopyrrolate 0.004mgkg-1,
pentazocine 0.3mgkg-1,
phenargan 0.25mgkg-1 was
given intramuscularly
30minutes before surgery diazepam 0.06mgkg-1 was given intravenously
10minutes before the induction.
An intravenous line with 18G cannula was
established. During induction, patient was kept in supine
position with 150 left
lateral tilt with the help of a wedge.
Patient was preoxygenated with 100% oxygen for 3 min.
Induction was done with thiopentone sodium
5mgkg-1,
followed by suxamethonium 1.5mgkg-1,
administered intravenously to facilitate endotracheal
intubation with proper sized cuffed endotracheal tube
(ETT), applying Sellick’s manoeuvre; the tube was fixed
after confirming bilateral air entry. Maintenance of
anesthesia done with oxygen (50%), nitrous oxide (50%),
pancuronium bromide, halothane in trace concentrations
with controlled ventilation. On exploration through left thoracotony - paravertebral abscess was found at D4
level
and thoracic curettage was performed. At the end of
2hours and 55minutes of surgery, neuromuscular blockade
was reversed with neostigmine 0.04 mgkg-1
and atropine
0.01mgkg-1 intravenously.
Intraoperatively,
maternal pulse and blood pressure, continuous
E.C.G. monitoring, oxygen saturation, I/O
charts were monitored and all were normal. Blood loss
was replaced as required. Postoperatively,
patient was monitored for first 24
hours in the surgical intensive care unit. Oxygenation
was done with ventimask with flow of 2-3 liters. Foetal
heart rate monitoring was also done, analgesics, antibiotics
were given. No tocolytic agents were advised by the
obstetrician for prevention of premature labor.
Post operative
follow up Patient developed
mild pregnancy induced hypertension
in the later part of pregnancy and was treated.
On 62nd postoperative
day, a male baby with 2.2kg. BW with
APGAR score of 8, was delivered with the help of
outlet forceps under pudendal nerve block. On 3rd post
delivery day, anti-hypertensives were stopped and on 14th
post delivery day, patient
was discharged with C.N.S. status
- paraplegia & spasticity, both lower limbs with
decreased sensations below D6
without bladder & bowel
involvement with normal power, tone, sensations and
reflexes in the upper limbs. Discussion
The common
non-obstetric surgeries during pregnancy
are ovarian cyst, appendicectomy, Shirodker’s
operation etc. Regional anaesthesia is preferred as surgery
with general anaesthesia is associated with higher incidence of abortions,3
due to uterine relaxant effects
of volatile anaesthetic and
compromised uteroplacental blood flow.5
Commonly used anaesthetic agents are not teratogenic.4
Thiopentone sodium,
succinylcholine, nitrous oxide and halothane
have no teratogenic effects.1,7 Induction
of teratogenicity and induced abortions are more common in
first trimester and premature labor in third trimester.4,5
Lesions caused by trauma/ tumor do not prevent conception
and continuation of pregnancy.8
But pregnancy is likely
to be complicated by urinary tract infection, anemia,
pressure necrosis of skin and worsening of the disease
itself.9,10 Patients with lesions
above T10 may
have impaired cough reflex and in patients with higher-level lesions,
ventilatory support may be required in late pregnancy or
during labor.8
Care
of the paraplegic patient who has undergone
non-obstetric sugery in late pregnancy-role of anaesthesiologist
References 1.
Friedman J. M. : Teratogen Update-anesthetic agents
teratology. 1988; 37-69. 2. U. D. Samant and V. M.
Divekar : Anesthesia for non-obstetric
emergency in late pregnancy. Indian J Anaesth 1994; 42 (4):
284-286. 3. Valorie Major :
Anaesthetic management of the pregnant patient undergoing non-obstetric surgery, refresher’s
course lectures-38th annual Conference of
Indian Society of Anaesthetists
1989; (B:10) 1-3. 4. Cohen S. E. : Non
–obstetric surgery during pregnancy (In
chestnut D.H. edition); Obstetric anasethesia: st. Louis, Mosby
1994; 273. 5. Mazze R.I., Kallen B. :
Reproductive outcome after anesthesia
and operation during pregnancy (a registry study of 5405
cases). Obstetric and Gynecology 1989; 161: 1178.
6. Synder D. E., Layde P.
M., Johnson M.W., Lyle M. A. : Treatment
of tuberculosis during pregnancy. American Review
of Respiratory diseases 1980; 122: 65.
7. J. Moore, J. W. Dundee, R. S. J. Clarke : Pharmacology of
drugs in pregnancy. Willian Mccaughey: editor. Clinical
Anesthetic Pharmacology 1991; 519-532.
8. Hypertensive disorders in
pregnancy. Common complications of
pregnancy & autonomic hyperreflexia. In William’s obstetric
and gynecology -20th edition 1997; 1264 & 693-735. 9. Baker E.R., Cardenas
D. D., Benedetti T.J. : Risks associated
with pregnancy in spinal cord injured women. Obstetric and
Gynecology 1992; 80: 428. 10Hughes S.J., Short D.J., Usherwood M., C.D., Tebbutt H.
Management of the pregnant women with spinal cord injuries.
British journal of Obstetric and Gynecology 1991; 98: 513
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Source: DOCTOR, VAKIL : “ANAESTH. FOR PARAPLEGIC Indian J. Anaesth. 2003; 47 (3) : 227- |
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