The anesthetic management for cesarean delivery in a patient with Shone's syndrome

Shone's syndrome is a rare congenital cardiac condition that consists of up to four obstructive left-sided cardiac lesions. We report a 17-yr-old nullipara with Shone's syndrome who presented for cesarean delivery. She had mild mitral stenosis and mild left ventricular outflow tract obstruction. Epidural anesthesia was attempted, but the patient developed severe hypotension associated with fetal bradycardia necessitating immediate cesarean delivery under general anesthesia. The peripartum anesthetic and management considerations for these patients are discussed.     

Parturients with hypertrophic cardiomyopathy: case series and review of pregnancy outcomes and anesthetic management of labor and delivery

BackgroundAdvances in understanding the pathogenesis, diagnosis and management of hypertrophic cardiomyopathy have resulted in increased longevity and a better quality of life of affected patients considering pregnancy. Several case series which focused predominantly on obstetric details have reported generally good outcomes. However, there remains a paucity of data on the specifics of obstetric anesthesia in women with hypertrophic cardiomyopathy.MethodsAfter Institutional Review Board approval, we reviewed antepartum transthoracic echocardiograms, cardiology, obstetric, anesthetic, and nursing labor records with a focus on anesthesia for labor and delivery and early postpartum complications in patients with hypertrophic cardiomyopathy who delivered between January 1993 and December 2013.ResultsThere were 23 completed pregnancies in 14 patients: 12 parturients (52%) delivered vaginally, of whom seven (30%) required assistance (forceps, vacuum), and 11 (48%) had a cesarean delivery. In 17 cases (74%) delivery was uneventful, but six patients (26%) had complications including congestive heart failure (n=3) and postpartum hemorrhage (n=3). All patients had neuraxial labor anesthesia/analgesia, and none received general anesthesia. No hemodynamic instability or fetal distress directly related to anesthesia was documented.ConclusionThe database search of approximately 160 000 deliveries over 20 years revealed only a small number of hypertrophic cardiomyopathy patients with completed pregnancies. No maternal or neonatal deaths were documented. Overall morbidity rate was 26% with a 13% incidence of peripartum congestive heart failure. In patients with mild to moderate disease, neuraxial anesthesia was safe, effective and well tolerated with no hemodynamic instability related to administration of local anesthetics.     

Anesthetic management of super-morbidly obese parturients for cesarean delivery with a double neuraxial catheter technique: a case series

Parturients with super-morbid obesity, defined as body mass index greater than 50 kg/m², represent a growing segment of patients who require anesthetic care for labor and delivery. Severe obesity and its comorbid conditions place the parturient and fetus at greater risk for pregnancy complications and cesarean delivery, as well as surgical and anesthetic complications. The surgical approach for cesarean delivery in these patients may require a supra-umbilical vertical midline incision due to a large pannus. The dense T4-level of spinal anesthesia can cause difficulties with ventilation for the obese patient during the procedure, which can be prolonged. Patients also may have respiratory complications in the postoperative period due to pain from the incision. We describe the anesthetic management of three parturients with body mass index ranging from 73 to 95 kg/m² who had a cesarean delivery via a supra-umbilical vertical midline incision. Continuous lumbar spinal and low thoracic epidural catheters were placed in each patient for intraoperative anesthesia and postoperative analgesia, respectively. Continuous spinal catheters were dosed with incremental bupivacaine boluses to achieve surgical anesthesia. In one case, the patient required respiratory support with non-invasive positive pressure ventilation. Two cases were complicated by intraoperative hemorrhage. All patients had satisfactory postoperative analgesia with a thoracic epidural infusion. None suffered postoperative respiratory complications or postdural puncture headache. The use of a continuous lumbar spinal catheter and a low thoracic epidural provides several advantages in the anesthetic management of super-morbidly obese parturients for cesarean delivery.     

Impact of intra-operative dexamethasone after scheduled cesarean delivery: a retrospective study

BackgroundDexamethasone is an effective analgesic and anti-emetic in patients undergoing many surgical procedures but its effects on pain after cesarean delivery are poorly studied. The aim of this study was to evaluate if routine intra-operative administration of dexamethasone improved analgesia and decreased postoperative nausea and vomiting after scheduled cesarean delivery.MethodsElectronic medical record data for scheduled cesarean deliveries performed under neuraxial anesthesia, before and after a practice change that introduced the routine use of intravenous dexamethasone 4 mg, were obtained. Patients were analyzed based on whether they received routine care (n=182) or also received dexamethasone (n=187). The primary outcome was time to first opioid use. Secondary outcomes included postoperative opioid consumption, pain scores, incidence and treatment of postoperative nausea and vomiting, satisfaction and length of stay.ResultsThere was no significant difference between groups in median time to first postoperative opioid administration (15.8 [3.4–48.0] h routine care vs 14.7 [3.2–38.8] h routine care plus dexamethasone, P=0.08). There were no significant differences in any secondary outcomes.ConclusionsThis impact study involving more than 360 patients suggests that routine administration of intra-operative intravenous dexamethasone 4 mg does not provide additional analgesic benefit after scheduled cesarean delivery, in the context of a multimodal postoperative analgesic regimen. Studies are required to determine if a larger dose or repeated administration influence postoperative analgesia or side effects, or whether certain subsets of patients may benefit.     

Neck pain and disability outcomes following chiropractic upper cervical care: a retrospective case series

Objective

To investigate the use of an upper cervical low-force (UCLF) chiropractic procedure, based on a vertebral alignment model, in the management of neck pain and disability by assessing the impact on valid patient outcome measures.

Design

A retrospective case series.

Methods

Consecutive patient files at a private chiropractic practice over a 1-year period were reviewed for inclusion. Data for the first visit, pre- and post-adjustment atlas alignment radiographic measurements, baseline and 2-weeks NDI (100 point) and verbal NRS (11 point) were recorded. The data were analyzed in their entirety and by groups comparing <30% vs. >30% post adjustment atlas alignment changes.

Results

Statistically significant clinically meaningful improvements in neck pain NRS (P < 0.01) and disability NDI (P < 0.01) after an average of 13.6 days of specific chiropractic care including 5.7 office visits and 2.7 upper cervical adjustments were demonstrated. There were no serious adverse events. Cases with the post-adjustment skull/atlas alignment measurement (atlas laterality) that were changed more than 30% on the first visit toward the orthogonal alignment predicted a statistically and clinically significant better outcome for NDI in 2 weeks.

Conclusions

UCLF chiropractic instrument adjustments utilizing a vertebral alignment model are promising for the management of patients with neck pain based on assessment using valid outcome measures.     

Peripartum anesthetic management of patients with Takayasu's arteritis: case series and review

Takayasu or pulseless disease is a rare, chronic progressive inflammatory disease that causes thrombosis and occlusion of systemic and pulmonary arteries. Almost 80% of patients are women in their childbearing years. We present three patients with Takayasu’s disease who between them had six pregnancies and discuss them in the context of a review of previously published cases. Assessment of the parturient with Takayasu’s disease should include an evaluation of the extent of disease, including organ ischemia such as cardiac, renal, cerebral and limb. A multidisciplinary approach should be taken to optimize the parturient’s status and formulate a plan for delivery. Peripartum anesthetic management should include optimization of intravascular volume and appropriate monitoring, which may be difficult in the pulseless patient. A regional anesthetic technique may be preferred over general anesthesia to allow monitoring of the cerebral circulation. A slowly titrated regional technique may prevent hemodynamic instability. Patients should be closely monitored postpartum with attention to hypertensive or end organ complications.     

The anesthetic management of a case of tracheogastric fistula

IMPLICATIONS: A 68-yr-old man developed a tracheogastric fistula after esophageal resection with gastric interposition. We report the anesthetic management of this patient undergoing tracheal repair and fistula closure.     

Anesthetic management of peroral endoscopic myotomy for esophageal achalasia: a retrospective case series

Peroral endoscopic myotomy (POEM) is a newly developed, less invasive treatment for esophageal achalasia that requires general anesthesia under positive pressure ventilation. In this retrospective case series, we describe the anesthetic management of 28 consecutive patients who underwent POEM for esophageal achalasia. Anesthesia was maintained with sevoflurane and remifentanil under positive pressure ventilation through a tracheal tube. Retained contents in the esophagus were evacuated just before anesthesia induction to prevent regurgitation into the trachea. The POEM procedure was performed using an orally inserted flexible fiberscope. Elevation of end-tidal carbon dioxide after initiating esophageal carbon dioxide insufflation was observed in all patients and was treated by minute adjustments to the ventilation volume. Scopolamine butylbromide-induced tachycardia in one patient was treated with landiolol hydrochloride, which is a short-acting beta 1-selective blocker. Minor subcutaneous emphysema around the neck was observed in one patient. POEM was successfully completed, and tracheas were extubated immediately after the procedure in all patients. Our findings suggest that prevention of aspiration pneumonia during anesthesia induction, preparation for carbon dioxide insufflation-related complications, and treatment of scopolamine butylbromide-induced tachycardia play important roles in safe anesthesia management of POEM for esophageal achalasia.     

The anesthetic management of a case of tracheal necrosis

A 63-yr-old female patient developed a tracheal necrosis after esophageal resection with gastric interposition. We report the anesthetic management of this patient undergoing tracheal repair focusing on an original airway management and ventilation strategy.     

Influence of anesthetic management on quality of magnetoencephalography scan data in pediatric patients: a case series

Background:  Magnetoencephalography (MEG) is increasingly used in the presurgical evaluation of pediatric seizure patients. Many pediatric patients require sedation or anesthesia to tolerate these exams. However, the available literature on anesthetic management in this population is very limited.
Methods:  We retrospectively reviewed the records of all patients who underwent MEG scanning at our institution with regard to the interaction of anesthetic management and quality of scan data.
Results:  High-dose propofol infusions (≥200 μg·kg⁻¹·min⁻¹) were associated with high frequency artifacts that interfered with the identification of epileptiform discharges. Lower-dose propofol infusions (≤100 μg·kg⁻¹·min⁻¹) did not produce artifacts but required co-administration of fentanyl to prevent patient motion. Dexmedetomidine infusions were not associated with signal artifacts and prevented patient motion very well in our initial patients and became our standard technique.
Conclusion:  In our experience, dexmedetomidine infusions are preferable to propofol-based techniques for pediatric MEG scans due to the absence of adverse effect on interictal activity.     

瘢痕子宫剖宫产的风险与麻醉处理

目的 探讨瘢痕子宫剖宫产手术产妇和围产儿的风险与麻醉处理.方法 瘢痕子宫剖宫产术100例,年龄24～43岁.硬膜外麻醉90例(A组),全身麻醉10例(B组).术中连续监测ECG、BP、HR、SpO_2;危重产妇监测CVP.记录切皮至胎儿娩出(I-D)时间、切开子宫至胎儿娩出(U-D)时间和新生儿Apgar评分.结果 A组硬膜外阻滞不全20例(22％).B组I-D时间短于A组L(7.5±2.0)min vs.(12.3±2.6)min](P<0.01).全组术中低血压32例(32％);新生儿窒息21例(21％);Apgar评分低于3分11例(死亡5例),4～7分10例,8～10分79例.产妇子宫次全切除2例、膀胱损伤修补1例、术中大量出血15例.结论 瘢痕子宫剖宫产手术产妇和新产儿的风险明显增加,硬膜外阻滞不全发生率较高,有效预防和正确处理高危因素是降低瘢痕子宫剖宫产产妇及新生儿并发症和死亡率的关键. gar评分.结果 A组硬膜外阻滞不全20例(22％).B组I-D时间短于A组L(7.5±2.0)min vs.(12.3±2.6)min](P<0.01).全组术中低血压32例(32％);新生儿窒息21例(21％ ;Apgar评分低于3分11例(死亡5例),4～7分10例,8～10分79例.产妇子宫次全切除2例、膀胱损伤修补1例、术中大量出血15例.结论 瘢痕子宫剖宫产手术产妇和新产儿的风险明显增加,硬膜外阻滞不全发生率较高,有效预防和正确处理高危因素是降低瘢痕子宫剖宫产产妇及新生儿并发症和     

Alagille syndrome and pregnancy: anesthetic management for cesarean section

A 34-year-old multiparous woman with a breech presentation, intrauterine growth restriction and premature rupture of membranes was transferred to our referral unit at 33 weeks of gestation. She was diagnosed with Alagille syndrome soon after birth because of cholestasis and pruritus. Her condition was later complicated by esophageal varices, treated with propranolol, thrombocytopenia, and insulin-dependent diabetes. She had characteristic facies, posterior embryotoxon, “butterfly” vertebrae but had no cardiac or renal abnormalities. Due to the early onset of spontaneous labor, emergency cesarean section under general anesthesia was performed 48 h after admission. This is the first case describing anesthetic care during delivery in a patient with Alagille syndrome. We discuss the anesthetic implications of the syndrome, emphasizing problems associated with portal hypertension and cholestasis, thrombocytopenia and cardiac abnormalities such as pulmonary artery stenosis.     

Report of a case: the anesthetic management for fetal tracheal intubation with intact uteroplacental circulation during cesarean section

We experienced a case of cesarean section in a patient with a fetus having a prenatally diagnosed huge cervical mass, which could cause airway obstruction immediately after delivery. The fetal cervical mass was confirmed at 19 gestational weeks, and amniocentesis was performed at 33 weeks. At 35 weeks, MRI showed the large mass that could disturb the airway patency after birth, and elective cesarean section was scheduled at 37 weeks. In the anesthetic management, anesthesia was maintained with isoflurane in oxygen, and ritodorine and nitroglycerin were used for obtaining uterine relaxation and keeping uteroplacental circulation. Fetal head was exposed from the uterine incision site and tracheal intubation was successfully performed. After confirming the neonatal oxygenation under manual ventilation, the baby was delivered. After delivery, the mass was diagnosed as cystic hygroma and he was maintained under mechanical ventilation in NICU. Five months later subtotal excision of the cervical cystic hygroma and tracheostomy were performed.