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Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.54 no.5 Campinas Sept./Oct. 2004
Total intravenous anesthesia in Osteogenesis imperfecta patient. Case report*
Anestesia venosa total en paciente portador de Osteogénesis imperfecta. Relato de caso
José Francisco Nunes Pereira das Neves, TSA, M.D.I; Roberto Silva Sant'Anna, M.D.II; João Rosa de Almeida, M.D.II; Rodrigo Machado Saldanha, TSA, M.D.II; Marcos Gonçalves Magalhães, M.D.III
ICo-Responsável pelo CET/SBA
da Universidade Federal de Juiz de Fora; Anestesiologista do Hospital Monte
IIAnestesiologista do Hospital Monte Sinai
IIIME1 do CET/SBA da Universidade Federal de Juiz de Fora
BACKGROUND AND OBJECTIVES: Osteogenesis
Imperfecta is an uncommon genetic connective tissue disease with prevalence
of 1/10000, primarily involving endochondral ossification, resulting in brittle
bones, multiple fractures and skeletal deformities. This article aimed at reporting
a case of Osteogenesis Imperfecta patient submitted to total intravenous anesthesia
for fractured femur surgical repair.
CASE REPORT: Male patient, 15 years old, 41 kg, 140 cm, with history of Osteogenesis Imperfecta and cardiopathy, scheduled for fractured femur surgical repair. In the operating room patient was monitored with ECG, HR, NIBP and SpO2 and was submitted to total intravenous anesthesia with propofol, alfentanil and cisatracurium. Monitoring of PETCO2 and esophageal temperature was introduced after TI. There have been no complications both in the intraoperative period and in the post-anesthetic care unit. Patient was discharged 5 days later.
CONCLUSIONS: This report has shown satisfactory intra and postoperative evolution of Osteogenesis Imperfecta patient submitted to total intravenous general anesthesia. Disease complexity has shown the need for anesthesiologists adequate evaluation and monitoring.
Key Words: ANESTHESIA, Intravenous: total; DISEASES: Osteogenesis Imperfecta
JUSTIFICATIVA Y OBJETIVOS: La Osteogénesis
Imperfecta es una rara enfermedad genética del tejido conjuntivo, con prevalencia
de 1/10000, que primariamente envuelve la osificación endocondral, resultando
en huesos frágiles, múltiplas fracturas e deformidades esqueléticas.
El objetivo de ese artículo fue relatar un caso de paciente portador de
Osteogénesis Imperfecta, sometido a anestesia venosa total para tratamiento
quirúrgico de fractura de fémur.
RELATO DEL CASO: Paciente del sexo masculino, 15 años, 41 kg, 140 cm, con historia de Osteogénesis Imperfecta y cardiopatía, programado para tratamiento quirúrgico de fractura del fémur. En la sala de operación fue monitorizado con ECG, FC, PANI y SpO2 y sometido a anestesia general venosa total con propofol, alfentanil y cisatracúrio. Después de IOT, fue acrecentada monitorización de la PETCO2 y de la temperatura esofágica. En el período intra-operatorio y en la sala de recuperación pos-anestésica no presentó complicaciones. Tuvo alta hospitalar en el 5º día de post operatorio.
CONCLUSIONES: El presente relato mostró una buena evolución intra y post operatoria de paciente con Osteogenesis Imperfecta sometido a anestesia general venosa total. La complexidad de la enfermedad mostró la necesidad de evaluación y monitorización adecuada por el anestesiologista.
Osteogenesis Imperfecta is an uncommon genetic connective tissue disease with prevalence of 1/10000, primarily involving endochondral ossification, resulting in brittle bones, multiple fractures and skeletal deformities 1-4. Mutation of one or two type 1 collagen genes, COL1A1 or COL1A2 1, leads to abnormal synthesis of type 1 collagen, which is the predominant bone matrix protein, leading to osteopenia 3-5.
Osteogenesis Imperfecta is classically divided in 4 types, according to clinical severity: I - affects patients without major bone deformities; II - the most severe and patients die in the perinatal period; III - moderately to severely affected patients, being most severe in children; IV - heterogeneous group, with variable severity and clinical characteristics 2,6,7. DNA analysis techniques, however, have shown in several cases the existence of patients who, although clinically diagnosed as Osteogenesis Imperfecta, have no mutations in genes coding collagen production 6. So, there are patients suffering from the so-called Osteogenesis Imperfecta with hypertrophic callus, with pseudoglioma and rhizomelia 6.
This article aimed at reporting a case of Osteogenesis Imperfecta patient submitted to total intravenous anesthesia for fractured femur surgical repair.
Male patient, 15 years old, 41 kg, 140 cm, scheduled for fractured femur surgical repair. At preanesthetic evaluation patient presented history of Osteogenesis Imperfecta, cardiopathy and use of vitamin D (125 UL/day), calcium (500 mg/day) and sodium alendronate (10 mg/day). Patient was relaxed, eupneic, hydrated, normally colored mucosa, anicteric, blood pressure 110 x 60 mmHg, heart rate = 96 bpm. Subsidiary exams revealed hemoglobin = 14.8 g.dL-1, hematocrit = 45.3%, leucometry = 16600/mm3, glycemia = 100 mg.dL-1, platelets = 266000/mm3 and echocardiogram with mild mitral and tricuspid failure, unchanged pericardium and normal left ventricle systolic function.
Monitoring in the operating room consisted of EEG (MC5), heart rate, peripheral oxyhemoglobin saturation (SpO2) and noninvasive blood pressure (NIBP) measured at 5-minute intervals, with data within normality range. Venous puncture was achieved with 18G catheter, hydration with lactated Ringers solution and anesthesia was induced with intravenous propofol (100 mg), alfentanil (2000 µg) and cisatracurium (6 mg). Tracheal intubation was performed with 7.5 mm internal diameter tube.
Then, monitoring was complemented with end tidal CO2 (PETCO2) and esophageal temperature. Anesthesia was maintained with target-controlled propofol infusion (3.5 µg.mL-1), with satisfactory intraoperative cardiovascular stability. At surgery completion, patient was medicated with intravenous atropine (500 µg), neostigmine (1 mg), metoclopramide (10 mg) and nalbuphine (10 mg). After extubation patient was referred to the post-anesthetic care unit with maintenance of the same intraoperative monitoring care (ECG, HR, NIBP, SpO2 and axillary temperature) and nasal oxygen therapy (3 L.min-1), where he has remained for 120 minutes without intercurrences. Patient was discharged in the 5th postoperative day.
There are three possible areas for orthopedic Osteogenesis Imperfecta therapeutic approach: measures to prevent the number of fractures, treatment of fractures, and surgical repair of deformities 6; anesthesia is needed for the two latter.
Anatomic and physiologic abnormalities may determine intraoperative problems 5. Although being clinically characterized by a triad made up of brittle bones, bluish sclera and hearing loss or impairment, there are several aggravating possibilities for Osteogenesis Imperfecta, depending on associated diseases. Congenital cardiopathies, valve injuries, renal lithiasis, neurological disorders, metabolic disorders, platelet dysfunction, cor pulmonale, joint, dermatologic and dental diseases may be part of clinical presentation 1-4. So, preoperative evaluation should be very judicious.
Anesthetic difficulties start from the choice of the technique because Osteogenesis Imperfecta patients have a trend to develop hyperthermia, which may be malignant 1,5, and anatomic abnormalities may complicate regional anesthetic induction. Vogel et al. 2 have reported anesthesia in two severe Osteogenesis Imperfecta pregnant patients, one of them submitted to continuous epidural block with 2% lidocaine, fentanyl (50 µg) and 1:200,000 epinephrine in fractional doses aiming at reaching sensory block in T4, and cesarean section went on without complications. The presence of deformities, such as kyphoscoliosis, predisposes to a higher chance of accidental dural puncture, low stature makes difficult the estimate of sensory block level, and coagulopathies and platelet changes should be considered for the indication of regional anesthesia 2.
In general anesthesia there may be questions about agents and difficult tracheal intubation. In choosing agents, intravenous technique has been proposed because inhalational agents and succinylcholine may trigger malignant hyperthermia 1.
Typical Osteogenesis Imperfecta facies, with short neck, temporal and occipital projections, and prominent mandible, may lead to difficult tracheal intubation. Fractured cervical spine, mandible and teeth, mucosal contusions and hemorrhages are possible complications after several tracheal intubation attempts 4,5. Laryngeal mask is a good alternative for this situation because it may be inserted with patient in neutral cervical position, being a useful and easy method for airway maintenance 5 because it prevents laryngoscopy sympathico-cardiac stimulation, which may be desirable for patients with associated cardiopathy 5.
Care with manipulation and monitoring should also be considered. Patients should be carefully positioned on the operating table with protection of areas subject to compression. Tourniquet or pressure cuffs may lead to vascular and tissue fractures and/or trauma. Arterial catheterization for pressure measurement should be preferred for severe Osteogenesis Imperfecta patients 5.
Hemorrhage is an expected Osteogenesis Imperfecta complication 4 in 10% to 30% of patients 3, because collagen defect results in brittle tissues, small vessels which do no adequately contract, deficient platelet response and decreased factor VIII 4. Predisposition to hemorrhages is multifactorial and there are numerous factors related to disseminated intravascular coagulation 3,4.
During preoperative evaluation, history of recurrent purpura may be indicative of coagulation disorders. Subsidiary exams, including thromboelastogram, may be useful to predict the possibility of hemorrhages 3,4.
Desmopressin, antidiuretic hormone synthetic analog, may improve platelet function and decrease blood loss 3. Desmopressin has significant antidiuretic effect mediated by via V2 receptors and minor or none vasoconstrictor effect. Via V2 effect releases von Willebrand factor in endothelial cells, activates tissue plasminogen and factor VIII:C 3. There is hemostatic effect almost immediately after 0.3 µg.kg-1 intravenous dose, which may be infused in 20 minutes to prevent hypotension. Side effects include: flare, headache, hypotension, tachycardia and possibility of thrombosis 3.
Antidiuretic effect impairs intravascular volume evaluation and there are reports on hyponatremia and seizures, especially in pediatric patients 3.
This report has shown satisfactory intra and postoperative evolution of Osteogenesis Imperfecta patient submitted to total intravenous general anesthesia. Disease complexity has shown the need for anesthesiologists adequate evaluation and monitoring.
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07. Zeitlin L, Rauch F, Plotkin H et al - Height and weight development during four years of therapy with cyclical intravenous pamidronate in children and adolescents with osteogenesis imperfecta types I, III and IV. Pediatrics, 2003;111:1030-1036. [ Links ]
Dr. José Francisco Nunes Pereira das Neves
Rua da Laguna, 372 Jardim Glória
36015-230 Juiz de Fora, Brazil
Submitted for publication December 1, 2003
Accepted for publication January 8, 2004
* Received from Hospital Monte Sinai, hospital agregado ao CET/SBA da Universidade Federal de Juiz de Fora, MG