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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.55 no.1 Campinas Jan./Feb. 2005
Anesthesia in pregnant patient with intracranial hypertension due to tuberculous meningitis. Case report*
Anestesia en gestante con hipertensión intracraneal por meningitis tísica. Relato de caso
Vanessa Breitenbach, M.D.I; David Henry Wilson, M.D.II
IAnestesiologista do Serviço
de Anestesia e Analgesia (SAA) de Porto Alegre
IIProfessor de Anestesia da Universidade Luterana do Brasil (ULBRA), Canoas, Chefe do Serviço de Anestesia e Analgesia
BACKGROUND AND OBJECTIVES: It is a well-established
fact today that the technique of choice for elective cesarean delivery is regional
anesthesia. However, in patients with intracranial hypertension and central
nervous system infection, this technique should be avoided. This paper aimed
at reporting the anesthetic management of a pregnant patient with intracranial
hypertension due to tuberculous meningitis submitted to elective cesarean delivery.
CASE REPORT: Caucasian patient, 32 years old, 1.62 m height and 60 kg weight, in the 36th week of gestational age admitted to the obstetrics unit to have her pregnancy interrupted by cesarean delivery because she had become quadriparetic with hydrocephalus due to tuberculous meningitis. The chosen technique was general anesthesia with rapid sequence induction and Sellick maneuver for intubation. Drugs were intravenous thiopental (250 mg), rocuronium (50 mg), fentanil (100 µg) and lidocaine (60 mg). Anesthetic induction was very smooth, with minor changes in vital signs. Anesthesia was maintained with isoflurane until the beginning of incision suture. The baby was delivered quickly and received an Apgar score of 8 e 9 in the 1st and 5th minutes, respectively, and patient woke up as soon as the procedure ended without any additional neurological deficits.
CONCLUSIONS: General anesthesia is still the best anesthetic technique for Cesarean delivery in patients with intracranial hypertension. Choice of drugs should include those with short half-life and with minor effects on intracranial pressure and on the newborn.
Key words: ANESTHESIA, General; COMPLICATIONS: intracranial hypertension; SURGERY, Obstetric: cesarean section
JUSTIFICATIVA Y OBJETIVOS: Está bien
establecido que la técnica anestésica de elección para cesárea
electiva es la anestesia regional. Sin embargo, en gestantes con hipertensión
intracraneal e infección del sistema nervioso central esta técnica
debe ser evitada. El objetivo de este artículo es relatar el manejo anestésico
de una gestante, con hipertensión intracraneal secundaria a la meningitis
tísica, que fue sometida a la cesárea electiva.
RELATO DEL CASO: Paciente blanca, 32 años, 60 kg, 1,62 m de estatura, en la 36ªsemana de edad gestacional, agendada para interrupción quirúrgica de la gestación por presentarse tetraparética, con hidrocefalia consecuente de meningitis tísica, (tuberculosa). Se escogió la anestesia general para la cesárea con inducción en secuencia rápida y maniobra de Sellick para la intubación traqueal. Las drogas utilizadas fueron tiopental (250 mg), rocuronio (50 mg), fentanil (100 µg) y lidocaína (60 mg) por vía venosa. La inducción anestésica fue suave y mantenida con isoflurano hasta el inicio del encerramiento de la piel de la paciente, con mínimas alteraciones de sus señales vitales y del recién nacido, que recibió índice de Apgar 8 y 9, en el 1º y 5º minutos, respectivamente. La paciente despertó precozmente, sin deficiencias neurológicas adicionales.
CONCLUSIONES:La anestesia general aún es la técnica anestésica preferida para cesárea en gestantes con hipertensión intracraneal, utilizándose drogas de media-vida corta y que tengan mínima interferencia en la presión intracraneal y en el recién nacido.
Anesthetic procedure of choice for elective Cesarean section is regional anesthesia, since general anesthesia poses high risks on pregnant patients. These patients have potentially difficult airways 1,2 with delayed gastric emptying, which are factors increasing the possibility of pulmonary aspiration after general anesthetic induction 3. However, regional anesthesia should be avoided in patients with intracranial hypertension and central nervous system infection due to the risk of worsening an early transtentorial herniation, thus their neurological symptoms.
In this case, general anesthesia was induced with rapid sequence technique and Sellik maneuver, using fentanyl, lidocaine, thiopental, rocuronium and isoflurane to assure maternal and fetal wellbeing and prevent significant intraoperative hemodynamic changes.
Caucasian patient, 32 years old, 1.62 m height and 60 kg weight, in the 36th week of gestational age, scheduled for surgical interruption of gestation and admitted to the hospital 3 days before with history of fatigue, lack of appetite, paresia and paresthesia of upper and lower limbs. Patient denied previous surgeries, allergies, transfusions, use of medication, drugs, smoking or drinking. Patient has referred two hospitalizations due to meningitis: the first in October 2001 and the second in March 2002 with no identification of etiologic agent. Patient has denied other previous diseases.
Gestation 1, delivery 0, abortion 0. Prenatal period had no intercurrences up to that point. Routine tests were normal with negative HIV.
Lucid, oriented and coherent. Cardiac auscultation: regular rhythm, normophonetic sounds, without murmur. Pulmonary auscultation normal. Tetraparetic with neck stiffness, lateral Babinski. Remaining physical evaluation results were normal. Mallampati I.
CSF was obtained by the surgeon via sub-occipital puncture and was clear with lymphocytic pleocytosis, increased proteins and hypoglycorrhachia. Contrasted MRI revealed extensive spinal ingurgitation of possible vascular or inflammatory origin, hydrocephalus and chronic meningitis with severe leptomeningeal thickening.
Patient arrived to the operating room receiving O2 via nasal catheter, with peripheral venous access and in 12-hour fast. Patient was informed that anesthesia would be general so that she would not be conscious at delivery. After obtaining her consent, the procedure was started. Patient was positioned in the supine position with a pad under right hip. Monitoring consisted of cardioscopy, pulse oximetry (SpO2) and noninvasive blood pressure. Baseline pressure of 110/70 mmHg, with HR of 85 bpm and SpO2 of 98% with 2 L.min-1 oxygen. Patient was oxygenated under mask for 5 minutes with 100% O2.
Intravenous 10 mg metoclopramide, 60 mg of 1% lidocaine without vasoconstrictor and 100 µg fentanyl were administered 5 minutes before tracheal intubation. 5 mg rocuronium were administered as priming dose and followed by rapid sequence induction with intravenous 250 mg thiopental and 45 mg rocuronium. Sellik maneuver was performed after loss of consciousness.
Tracheal intubation was successfully achieved in 40 seconds with 7 mm trachead tube under direct view and cuff was inflated. Pulmonary auscultation was normal and mechanically controlled ventilation was instituted with 100% O2 and 1% isoflurane, 500 mL.min-1 tidal volume and respiratory rate of 13 breathes per minute. Patient remained stable throughout the procedure. Delivery took place 5 minutes after beginning of surgery. Then, intravenous 100 µg fentanyl, 1 g cephazolin and oxytocin 5UI were administered. At hysterorrhaphy completion, isoflurane concentration was decreased to 0.5% and was withdrawn at incision suture. Neuromuscular blockade was reverted with 2 mg prostigmine and 1 mg atropine only after patient presented spontaneous ventilatory movements with adequate tidal volume and after 60 mg lidocaine administration before extubation. Patient had a smooth emergence, without intercurrences or pain. Newborn Apgar scores were 8 and 9 in the 1st and 5th minute, respectively.
Patient was referred to the intensive care unit to start the treatment of meningitis.
It is a well-established fact today that the technique of choice for elective cesarean delivery is regional anesthesia. In our case, two factors had to be taken in consideration when deciding for the anesthetic technique: central nervous system infection and increased intracranial pressure.
Patient presented two absolute counterindications for neuraxial block: increased intracranial pressure (tetraventricular hydrocephalus) and central nervous system infection. Previous neurological deficit (quadriparesia) is a relative counterindication based not necessarily on medical criteria, but rather on legal issues. The risk of neuraxial puncture in patients with increased intracranial pressure is worsening early transtentorial herniation. Some physicians could consider epidural anesthesia a low risk procedure because it does not puncture meninges.
However, the risk of accidental dural puncture is increased both by gestation-related factors (epidural vessels ingurgitation) and by increased intracranial pressure. It has been related the volume of lumbar epidural injection with increased intracranial pressure by a cerebrospinal fluid shift to the brain 4. For these reasons we had indicated general anesthesia, that is the safer option when the patient has intracranial hypertension 4,6. In addition, neuraxial blocks may produce sympathetic block and result in hypotension, with consequent decrease in brain perfusion. This decrease becomes critical in patients with increased intracranial pressure 5.
In our case, we decided to intravenously administer a low opioid with lidocaine at early oxygenation because it was considered fundamental to attenuate pressure response associated to laryngoscopic maneuvers during rapid sequence induction, to prevent intracranial pressure increase. Literature indicates intravenous 1 to 1.5 mg.kg-1 lidocaine 1 to 2 minutes before tracheal intubation to attenuate hemodynamic responses to laryngoscopy, but some authors question its benefits in patients with intracranial hypertension7. Bedford et al. have compared the effectiveness of sodium thiopental (3 mg.kg-1) and lidocaine (1.5 mg.kg-1) to control acute intracranial pressure increase. Both regimens were equivalent 8. So, bolus lidocaine is an adjuvant treatment recommended to prevent intracranial pressure increase associated to airway manipulation 9.
Thiopental was chosen for induction because it decreases brain blood flow and intracranial pressure, maintaining perfusion pressure associated to decreased brain oxygen consumption. Propofol, which also decreases brain blood flow and intracranial pressure, may promote adverse effects in patients with intracranial hypertension by critically decreasing brain perfusion pressure 10.
Succinylcholine may increase intracranial pressure and, in patients with intracranial hypertension, it should be replaced by non-depolarizing neuromuscular blockers. Rocuronium is an non-depolarizing agent which, in doses of 0.9 to 1.2 mg.kg-1, may promote adequate intubation conditions in 60 seconds. Rocuronium was chosen because it may replace succinylcholine during rapid sequence induction without changing intracranial pressure 11,12. Neuromuscular blocker priming dose consists in the administration of 10% of its intubation dose approximately 2 to 4 minutes before administering the remaining dose, to obtain tracheal intubation conditions in a shorter time, in general 30 to 60 seconds less than normal time, depending on the drug. In our case, optimal intubation conditions were obtained in 40 seconds with rocuronium priming dose and total dose of approximately 0.9 mg.kg-1.
Authors questioning priming dose are concerned with the development of muscle weakness, which could lead to anxiety and leave unpleasant memories of the procedure. Patients should be oriented to inform the presence of diplopia, moment in which one may conclude that priming dose has been installed 13.
In our case, the choice of the anesthetic technique and of the drugs was critical for the successful outcome without worsening patient's neurological deficit.
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Submitted for publication January 5, 2004
Accepted for publication October 21, 2004
* Received from Serviço de Anestesia e Analgesia de Porto Alegre, RS