CLINICAL REPORT

Continuous epidural anesthesia for cesarean section in a patient with Takayasu’s arteritis. Case report ^*

Anestesia peridural continua para cesárea en paciente con arteritis de Takayasu. Relato de caso

Aloísio Cerqueira Buettel, M.D.^I; Roberto Monteiro de Castro, M.D.^I; Itagyba Martins Miranda Chaves, TSA, M.D.^II; Luiz Henrique Gonçalves, M.D.^III

^IAnestesiologista do Hospital São Paulo e Casa de Saúde Santa Lúcia, Muriaé, MG
^IIResponsável pelo CET/SBA do Hospital Universitário de Juiz de Fora (HUJF); Professor Adjunto IV da Disciplina de Anestesiologia da FM da UFJF
^IIIAngiologista e Cirurgião Vascular do Hospital São Paulo, Muriaé, MG

Correspondence

SUMMARY

BACKGROUND AND OBJECTIVES: Continuous epidural anesthesia with titrated doses of local anesthetics is safe and effective for patients not tolerating blood pressure fluctuations. This report aimed at presenting a case in which continuous epidural anesthesia for Cesarean section in a patient with Takayasu’s arteritis was successfully induced.
CASE REPORT: Primiparous patient, 25 years old, 63 kg, Takayasu’s arteritis, 34 to 35 weeks of gestation, acute fetal distress, blood pressure = 155/85, HR = 92, no carotid, upper and right lower limb pulse. Patient had only left palpable popliteal pulse. Epidural continuous anesthesia was induced with 25 mg titrated doses of 0.5% bupivacaine with epinephrine (1:200.000), in 5-minute intervals, up to a total dose of 100 mg with 2 mg morphine and 100 µg fentanyl.
CONCLUSIONS: Continuous epidural anesthesia with titrated doses of 0.5% bupivacaine may be used in patients with Takayasu’s arteritis, provided all precaution measures are taken with such patients.

Key words: ANESTHESIA, Obstetric; ANESTHETIC TECHNIQUES, Regional: epidural; DISEASE: Takayasu’s Arteritis

RESUMEN

JUSTIFICATIVA Y OBJETIVOS: Anestesia peridural continua con titulación de las dosis de anestésico local proporciona eficacia y seguridad en pacientes que no toleran flutuaciones de la presión arterial. El objetivo de este relato es presentar un caso en que fue utilizado con suceso anestesia peridural continua para cesárea en paciente con arteritis de Takayasu.
RELATO DEL CASO: Paciente primigesta, 25 años, 63 kg, portadora de Arteritis de Takayasu, con 34-35 semanas de gestación, presentando sufrimiento fetal agudo, PA de 155/85 mmHg, FC de 92 bpm, con ausencia de pulsos carotídeos, así como en los miembros superiores y del miembro inferior derecho. Presentaba apenas pulso poplíteo izquierdo palpable. Fue realizado bloqueo peridural continuo con dosis fraccionadas de 25 mg de bupivacaína a 0,5% con epinefrina (1:200.000), a intervalos de 5 en 5 minutos hasta un total de 100 mg, asociándose 2 mg de morfina y 100 µg de fentanil.
CONCLUSIONES: La anestesia peridural contínua con dosis tituladas de bupivacaína a 0,5% con epinefrina puede ser utilizada en pacientes con Arteritis de Takayasu, tomándose las medidas de precaución con portadoras de esa enfermedad.

INTRODUCTION

Takayasu’s arteritis is a disease affecting aorta and its branches, as well as the pulmonary artery. It is also called aortic arch syndrome, pulseless disease, occlusive thromboarteriopathy or Martorell’s syndrome. It has inflammatory characteristics with changes in vessels size, allowing for the development of stenosis, obstructions and aneurysms, with severe hemodynamic effects ¹.

Female patients (9:1), mean age of 23 years and of Asian or Oriental ascendance are predominantly affected ¹.

Major signs and symptoms are brain ischemia, pulseless in upper extremities, arterial hypertension, visual disorders, neck, back or hip pain ^1,2.

Blood pressure maintenance during anesthesia is paramount because Takayasu’s arteritis is often fatal, resulting in death by brain ischemia or heart failure ³.

This report aimed at describing a case where continuous epidural anesthesia was successfully used for C-section in a Takayasu’s arteritis patient.

CASE REPORT

Caucasian primiparous patient, Oriental ascendance, 25 years old, 63 kg, suffering from Takayasu’s arteritis, with 34-35 weeks of gestation and receiving 5 mg prednisone (maintenance dose) and 10 mg enalapril. After falling from her height and suffering abdominal trauma, fetal cardiotocography revealed non-reactive fetus and urgent C-section was indicated due to acute fetal distress. At physical evaluation she presented: heart rate = 92 bpm, lack of carotid, upper limbs and right lower limb pulses. Only left popliteal pulse was palpable and pulmonary auscultation was normal. Venous puncture was performed in the right forearm with an 18G catheter and previous hydration was started with 1000 ml lactated Ringer’s solution. Monitoring consisted of continuous ECG, pulse oximetry, vesical catheterization and non-invasive mean blood pressure on the left leg at 3-minute intervals, with initial results of SBP = 155 mmHg, DBP = 85 mmHg and MBP = 107 mmHg.

Epidural puncture was performed with the patient in the left lateral position at L₂-L₃ interspace, using a 16G Tuohy needle and the loss of resistance to air technique. As a test dose, 25 mg of 0.5% bupivacaine with epinephrine (1:200.000) were injected associated to 2 mg morphine and 100 µg fentanyl. Next, the catheter was introduced approximately 3 cm in the cephalad direction. Patient was then placed in the supine position with uterine displacement to the left and received 3 L.min^-1 oxygen through a nasal catheter. Additional 25 mg of 0.5% bupivacaine with epinephrine 1:200.000 were injected at 5-minute intervals in a total dose of 100 mg bupivacaine. After reaching blockade level T₄, surgical procedure was started and lasted 50 minutes. After 5 minutes of surgery there has been a MBP decrease to 65 mmHg which was promptly corrected with 5 mg intravenous ephedrine. After fetal extraction, who obtained Apgar scores of 8 and 10 in the 1^st and 5^th minute, respectively, blood pressure stabilized with no need for additional vasopressant doses. Patient was not sedated and remained awaken and cooperative without consciousness changes. Heart rate varied from 80 to 115 bpm with normal ECG. Additional 1000 ml lactated Ringer’s were perioperatively administered.

Patient was discharged in the 5^th postoperative day without intercurrences.

DISCUSSION

Takayasu’s arteritis is a disease with inflammatory characteristics predominantly affecting Oriental females ¹.

It is a primary aortic disease affecting its major branches and leading to pulseless upper limbs, retinopathy, aortic arch syndrome, thromboarteriopathy and non-specific aorto-arteritis ^1,2,4.

Major signs and symptoms are headache, discomfort, difficult to control hypertension, pulseless extremities, visual disorders, neck, back or hip pain. Lab tests abnormalities reinforcing the diagnosis include anemia, increased VHS, immunoglobulins, C3 and C4, anti-aortic antibodies and positive C-reactive protein ^1,2.

Continuous epidural anesthesia was the technique of choice because there was the need to titrate local anesthetics dose, to reach the correct blockade level for the procedure and to maintain patient awaken for a better neurological evaluation and possibility of correcting blood pressure changes. In spite of the care taken in displacing the uterus to the left, in administering titrated anesthetic doses and in pre-hydrating with 1000 ml lactated Ringer’s ⁵, in addition to a test dose to prevent inadvertent intravascular injection, there has been one hypotension episode which promptly responded to 5 mg intravenous ephedrine. Takayasu’s arteritis patients do not tolerate preload decreases since diffuse arteritis imply in stenotic and non-compliant vessels, which interferes with the compensation mechanism. This explains the difficult to control hypertension ^6,7. Since stenotic vessels are unable to decrease preload, there is an increase in BP secondary to the increased volume that comes with gestation ^8,9.

Local anesthetics was 0.5% bupivacaine which, when associated to fentanyl, has a shorter onset time as compared to 2% lidocaine also associated to fentanyl and causes less systolic pressure decrease as compared to 0.75% ropivacaine ^10,11. Morphine was associated to prevent postoperative pain-induced blood pressure increases ⁹.

There was no need for postoperative analgesics. Patient referred just mild pruritus.

The conclusion was that continuous epidural anesthesia with titrated 0.5% bupivacaine doses and epinephrine can be used in Takayasu’s arteritis patients, provided precaution measures are taken with such patients.

REFERENCES

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10. Johson C, Ransil BJ, Oriol N - Comparison of onset time between 0.5% bupivacaine and 3% 2-chloroprocaine with and without 75 µg fentanyl. Reg Anesth, 1991;16:228-231.        [ Links ]

11. Björnestad E, Smedvig JP, Bjerkreim T et al - Epidural ropivacaine 7.5 mg/ml for elective caesarean section: a double-blind comparison of efficacy and tolerability with bupivacaine 5 mg/ml. Acta Anaesthesiol Scand, 1999;43: 603-608.        [ Links ]

Correspondence to
Dr. Aloísio Cerqueira Buettel
Address: Av. Cel. Francisco Gomes Campos, 83/301 São Francisco
ZIP: 36880-000 City: Muriaé, Brazil
E-mail: alobuettel@bol.com.br

Submitted for publication October 9, 2001
Accepted for publication December 5, 2001

* Received from Hospital São Paulo, Muriaé, MG