[Anesthesia in pregnant women with HELLP syndrome: case report]

BACKGROUND AND OBJECTIVES

HELLP syndrome, characterized by hemolysis, high levels of liver enzyme, and low platelet count, is an advanced clinical stage of pre-eclampsia, progressing to high maternal (24%) and perinatal (up 40%) mortality, despite childbirth care in a timely manner. The goal is to describe the anesthetic management of a case with indication to emergency caesarean.

CASE REPORT

Female patient, 36 years old, gestational age of 24 weeks, with hypertensive crisis (BP 180/100 mmHg) and severe headache, was admitted to the operating room for a cesarean section after diagnosis of HELLP syndrome. Indicated for general anesthesia, we opted for total intravenous with intubation after rapid sequence induction with propofol and remifentanil in continuous target-controlled infusion, and rocuronium at a dose of 1.2 mg/kg. Maintenance was achieved with propofol and remifentanil. The surgical procedure was uneventful, the child was born with APGAR 1/5 and transferred to the NICU. At the end of surgery, the patient was extubated in the operating room and taken to the ICU. The postoperative period was uneventful with no changes worthy of note and the patient was discharged on the sixth postoperative day.

CONCLUSION

When general anesthesia is the choice in parturient with HELLP syndrome, tracheal intubation with rapid sequence induction due to possible difficult airway, as well as the use of drugs to control the hemodynamic response can minimize the complications associated with the procedure, as occurred in this case.

Anesthesia in pregnant women with HELLP syndrome: case report

BACKGROUND AND OBJECTIVES

HELLP syndrome, characterized by hemolysis, high levels of liver enzyme, and low platelet count, is an advanced clinical stage of pre-eclampsia, progressing to high maternal (24%) and perinatal (up 40%) mortality, despite childbirth care in a timely manner. The goal is to describe the anesthetic management of a case with indication to emergency cesarean.

CASE REPORT

Female patient, 36 years old, gestational age of 24 weeks, with hypertensive crisis (BP 180/100mmHg) and severe headache, was admitted to the operating room for a cesarean section after diagnosis of HELLP syndrome. Indicated for general anesthesia, we opted for total intravenous with intubation after rapid sequence induction with propofol and remifentanil in continuous target-controlled infusion, and rocuronium at a dose of 1.2mg/kg. Maintenance was achieved with propofol and remifentanil. The surgical procedure was uneventful, the child was born with APGAR 1/5 and transferred to the NICU. At the end of surgery, the patient was extubated in the operating room and taken to the ICU. The postoperative period was uneventful with no changes worthy of note and the patient was discharged on the sixth postoperative day.

CONCLUSION

When general anesthesia is the choice in parturient with HELLP syndrome, tracheal intubation with rapid sequence induction due to possible difficult airway, as well as the use of drugs to control the hemodynamic response can minimize the complications associated with the procedure, as occurred in this case.

Anesthetic management of a patient with multiple sclerosis - case report

BACKGROUND AND OBJECTIVES

Multiple sclerosis is a demyelinating disease of the brain and spinal cord, characterized by muscle weakness, cognitive dysfunction, memory loss, and personality disorders. Factors that promote disease exacerbation are stress, physical trauma, infection, surgery, and hyperthermia. The objective is to describe the anesthetic management of a case referred to urological surgery.

CASE REPORT

A female patient, 44 years of age, with multiple sclerosis, diagnosed with nephrolithiasis, referred for endoscopic ureterolythotripsy. Balanced general anesthesia was chosen, with midazolam, propofol and remifentanil target-controlled infusion; sevoflurane via laryngeal mask airway; and spontaneous ventilation. Because the patient had respiratory difficulty presenting with chest wall rigidity, it was decided to discontinue the infusion of remifentanil. There was no other complication or exacerbation of disease postoperatively.

CONCLUSION

The use of neuromuscular blockers (depolarizing and non-depolarizing) is a problem in these patients. As there was no need for muscle relaxation in this case, muscle relaxants were omitted. We conclude that the combination of propofol and sevoflurane was satisfactory, not resulting in hemodynamic instability or disease exacerbation.

[Anesthetic management of a patient with multiple sclerosis - case report]

BACKGROUND AND OBJECTIVES

Multiple sclerosis is a demyelinating disease of the brain and spinal cord, characterized by muscle weakness, cognitive dysfunction, memory loss, and personality disorders. Factors that promote disease exacerbation are stress, physical trauma, infection, surgery, hyperthermia. The objective is to describe the anesthetic management of a case referred to urological surgery.

CASE REPORT

A female patient, 44 years of age, with multiple sclerosis, diagnosed with nephrolithiasis, referred for endoscopic ureterolythotripsy. Balanced general anesthesia was chosen, with midazolam, propofol and remifentanil target-controlled infusion; sevoflurane via laryngeal mask airway; and spontaneous ventilation. Because the patient had respiratory difficulty presenting with chest wall rigidity, it was decided to discontinue the infusion of remifentanil. There was no other complication or exacerbation of disease postoperatively.

CONCLUSION

The use of neuromuscular blockers (depolarizing and non-depolarizing) is a problem in these patients. As there was no need for muscle relaxation in this case, muscle relaxants were omitted. We conclude that the combination of propofol and sevoflurane was satisfactory, not resulting in hemodynamic instability or disease exacerbation.

[Dexmedetomidine/propofol association for plastic surgery sedation during local anesthesia.]

BACKGROUND AND OBJECTIVES

Dexmedetomidine is a new alpha2-adrenergic receptor agonist with potentially useful characteristics for anesthesia. This comparative study aimed at evaluating the effects of dexmedetomidine on propofol requirements and cardiovascular/respiratory stability during plastic surgery sedation under local anesthesia.

METHODS

Participated in this study 40 female patients aged 16 to 60 years, physical status ASA I or II, scheduled for elective face, nose and breast plastic surgeries under local anesthesia. Patients were randomly allocated into two groups of twenty patients: C (control) and D (dexmedetomidine). Sedation was achieved in both groups with 1 mg.kg-1 bolus propofol followed by continuous infusion at an adjusted rate to provide conscious sedation. Group D patients received continuous intravenous dexmedetomidine at a rate of 0.01 microg.kg-1.min-1, concomitant with propofol infusion. The following were evaluated: effect of dexmedetomidine on propofol requirements; cardiovascular (SBP, DBP, MBP, HR) and respiratory (SpO2, P ET CO2) parameters; quality of perioperative bleeding control and postanesthetic recovery features.

RESULTS

Mean propofol infusion rate was lower in group D (35.2 +/- 5.3 microg.kg-1.min-1) as compared to group C (72.6 +/- 8.5 microg.kg-1.min-1). Mean SBP, DBP, MBP values have decreased as from 30 min in group D, remaining stable until procedure completion, while in Group C they have increased. HR remained stable in group D where as increased as from 30 min in group C. Mean time to open eyes under command was lower in group D (6.3 +/- 2.5 min) as compared to group C (8.9 +/- 2.7 min). Perioperative bleeding control was better in group D as compared to group C.

CONCLUSIONS

Dexmedetomidine/propofol association for sedation is safe and has the following advantages: decrease in propofol requirements, cardiovascular stability, good perioperative bleeding control, lack of significant effects on ventilation.

[Spinal anesthesia with 0.5% hyperbaric ropivacaine and 0.5% hyperbaric bupivacaine: a comparative study.]

BACKGROUND AND OBJECTIVES

Spinal anesthesia with ropivacaine has been proven safe both in experimental and clinical studies. On the other hand, ropivacaine is approximately half as potent as bupivacaine in spinal anesthesia when both drugs are used in hyperbaric solutions. This study aimed at comparing clinical spinal block features obtained with hyperbaric ropivacaine or bupivacaine in equipotent doses.

METHODS

Twenty ASA I or II patients, aged 20 to 60 years, scheduled for elective surgeries of lower limbs, perineum and inguinal hernioplasty, were randomly allocated into two groups . Group R (n = 10) were given 4 ml 0.5% hyperbaric ropivacaine and Group B (n = 10) were given 2 ml of 0.5% hyperbaric bupivacaine intratecally. Puncture was performed with a 25G needle in the sitting position. Monitoring consisted of SBP, DBP, MBP, HR, ECG and SpO2. Sensory and motor block onset and recovery times, hemodynamic and respiratory changes, and the incidence of adverse effects were recorded.

RESULTS

There were no differences between groups in demographics data, sensory block onset (174.4 +/- 75.9 vs. 191 +/- 51.7 s), motor block onset (373.6 +/- 214.6 vs. 240 +/- 60 s), upper level of sensory block T8 - T10 (90% of group R patients vs. 70% of group B), motor block grade 3 (50% of group R patients vs. 30% of group B), time to total sensory block recovery (178.5 +/- 65.2 vs. 181 +/- 26.9 minutes), time to total motor block recovery (192 +/- 50.7 vs. 162.5 +/- 37.8 minutes), and time for first spontaneous pain complaint (183.9 +/- 37.1 vs. 206.5 +/- 46.6 minutes).

CONCLUSIONS

No differences in spinal block clinical features were observed between hyperbaric 0.5% ropivacaine and 0.5% bupivacaine, when administered in equipotent doses. Data seem to confirm previous observations that in these conditions, ropivacaines potency is approximately half bupivacaines potency.

Thoracic epidural anesthesia with ropivacaine for plastic surgery

BACKGROUND AND OBJECTIVES

Thoracic epidural blockade is a method of hypotensive anesthesia able to reduce bleeding during surgery. This non-comparative study aimed at evaluating the results of thoracic epidural blockade with 0.5% ropivacaine associated to propofol continuous infusion sedation in plastic surgery.

METHODS

Participated in this study 60 female patients aged 18 to 62 years, physical status ASA I or II, scheduled for combined plastic surgeries of breast, abdomen, gluteus and liposuction. After epidural puncture in T9-T10 or T10-T11, patients received 40 ml of 0.5% ropivacaine and 15 microg sufentanil. Additional local anesthetic doses were administered through an epidural catheter, if necessary. Sedation was induced with 40 to 50 microg kg(-1) min(-1) propofol continuous infusion. Blockade installation and regression, hemodynamic and respiratory parameters and the incidence of adverse effects were investigated.

RESULTS

Upper sensory block level was T2 in 52 patients (86.6%), C4 in 4 (6.6%), and T3 in 4 (6.6%). Mean onset time was 9.1 +/- 8.2 min. Motor block grade 2 was obtained in 61.7% of patients, and grade 1 in 38.3%. Mean time for complete motor block regression was 377.9 +/- 68.5 min. Mean time for first spontaneous pain complaint was 965.1 +/- 371.3 min. SBP, DBP, MBP and HR mean values have significantly decreased as compared to control as from 15 min after local anesthetic injection, thus characterizing hypotensive anesthesia. Thirteen patients (21.7%) with SBP < 65 mmHg and/or MBP < 50 mmHg received a vasopressor (ethylphedrine) and 4 patients (6.7%) with HR < 50 bpm received atropine. No patient needed blood transfusion.

CONCLUSIONS

Thoracic epidural blockade with 0.5% ropivacaine and 15 microg sufentanil associated to propofol continuous infusion sedation is a satisfactory hypotensive anesthesia technique for combined plastic surgeries involving breast, abdomen, gluteus and liposuction. Continuous monitoring of hemodynamic and respiratory parameters as well as controlling blockade effects on those parameters are critical for the success and safety of the technique.

Intraocular pressure and ropivacaine in peribulbar block: a comparative study with bupivacaine

BACKGROUND

The aim of this study was to compare the effects on intraocular pressure (IOP) of ropivacaine and bupivacaine in peribulbar block.

METHODS

The study involved 40 patients with ASA physical status I, II or III undergoing cataract surgery under peribulbar block. Patients were allocated to two groups according to the local anesthetic used: Group R (n=20), 1.0% ropivacaine and Group B (n=20) 0.75% bupivacaine, both associated with 50 IU. ml-1 hyaluronidase, in peribulbar double injection technique. IOP was measured at four time points: 0=before block (control); 1=1 min after block; 2=5 min after block; 3=15 min after block.

RESULTS

Mean values of IOP (mm Hg) after block were significantly lower in Group R in comparison to Group B: time point 1=13.4+/-3.2 vs 20.8+/-4.7; time point 2=10.9+/-3.7 vs 14.4+/-3.8; time point 3=7.7+/-4.0 vs 10.5+/-3.1. The variation of IOP was different in each group. In Group R, the mean values obtained at the three time points after block were significantly lower than the control; in Group B, the mean value of IOP rose significantly 1 min after block and was lower than control only at time point 3.

CONCLUSIONS

Ropivacaine 1.0% associated with hyaluronidase in peribulbar block is better than 0.75% bupivacaine under the same standard conditions for lowering IOP in intraocular surgery. This effect is probably due to relaxation of the extraocular muscles after the block with both anesthetics, and possibly to a smaller intraocular blood volume due to vasoconstriction in the case of ropivacaine.

Ropivacaine in peribulbar block: a comparative study with bupivacaine

BACKGROUND

Ropivacaine is a new local anesthetic with alleged lower systemic toxicity and slightly lower potency as compared with bupivacaine. The present study aimed to evaluate the efficacy of ropivacaine in peribulbar block, as compared with that of bupivacaine.

METHODS

Eighty patients aged 45-92 years with physical status ASA I, II, or III were randomized to Group R (n=40) or Group B (n=40). Group R received 8.0 ml of 1.0% ropivacaine and Group B received 8.0 ml of 0.75% bupivacaine, both solutions with 50 IU/ml hyaluronidase, to induce peribulbar block according to the double-injection technique. Decreased ocular motility was the only criterion of successful block.

RESULTS

The percentage of patients with decreased ocular motility showing successful block was higher in Group R 1 and 5 min after injection. A score indicating successful peribulbar block was found in all patients 10 min after injection. While no patient complained of a burning sensation during ropivacaine injection, 22.5% of the patients given bupivacaine reported this symptom.

CONCLUSION

Both local anesthetics were effective in inducing peribulbar block for intraocular surgery. A tendency was noted to a faster onset of peribulbar block with ropivacaine; nevertheless, both drugs had a high degree of success for this block.