Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.52 no.3 Campinas May/June 2002
Continuous epidural anesthesia for cesarean section in a patient with Takayasus 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
do Hospital São Paulo e Casa de Saúde Santa Lúcia, Muriaé,
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
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 Takayasus arteritis
was successfully induced.
CASE REPORT: Primiparous patient, 25 years old, 63 kg, Takayasus 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 Takayasus arteritis, provided all precaution measures are taken with such patients.
Key words: ANESTHESIA, Obstetric; ANESTHETIC TECHNIQUES, Regional: epidural; DISEASE: Takayasus Arteritis
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.
Takayasus 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 Martorells 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 Takayasus 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 Takayasus arteritis patient.
Caucasian primiparous patient, Oriental ascendance, 25 years old, 63 kg, suffering from Takayasus 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 Ringers 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 1st and 5th 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 Ringers were perioperatively administered.
Patient was discharged in the 5th postoperative day without intercurrences.
Takayasus 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 Ringers 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. Takayasus 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 Takayasus arteritis patients, provided precaution measures are taken with such patients.
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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 ]
Dr. Aloísio Cerqueira Buettel
Address: Av. Cel. Francisco Gomes Campos, 83/301 São Francisco
ZIP: 36880-000 City: Muriaé, Brazil
Submitted for publication
October 9, 2001
Accepted for publication December 5, 2001
* Received from Hospital São Paulo, Muriaé, MG