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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 8  |  Issue : 1  |  Page : 58-59

Anaesthesia for an emergent caesarean section in a patient with acute transverse myelitis


Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, United States of America

Date of Web Publication13-Apr-2018

Correspondence Address:
Dr. Samuel A Hunter
Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai
United States of America
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacc.JOACC_45_17

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  Abstract 


We present a 32-year-old G1P0 woman at 32 weeks and two days gestation with new onset paraplegia, hyperreflexia, and sensory disturbance that gradually progressed over the past month and acutely worsened over the last 24 hours. MRI revealed a demyelinating process of the thoracic spine and diffuse cervicothoracic cord oedema. After 7 days, her foetus developed recurrent heart rate decelerations and an emergent caesarean section was performed. On airway exam, she was Mallampati 3 with a short thyromental distance. She reported fasting overnight and into the morning. Our choice was between performing neuraxial anaesthesia in the setting of an acute demyelinating process of her spinal cord versus general anaesthesia on a patient at risk of aspiration with a potentially difficult airway. Given the potential complications of neuraxial anaesthesia, we utilized rocuronium to perform a rapid sequence induction of general anaesthesia with endotracheal intubation.

Keywords: Acute transverse myelitis, emergent caesarean section, general anaesthesia with endotracheal intubation, neuraxial anaesthesia


How to cite this article:
Hunter SA, Katz D, Riley KJ, Anderson M. Anaesthesia for an emergent caesarean section in a patient with acute transverse myelitis. J Obstet Anaesth Crit Care 2018;8:58-9

How to cite this URL:
Hunter SA, Katz D, Riley KJ, Anderson M. Anaesthesia for an emergent caesarean section in a patient with acute transverse myelitis. J Obstet Anaesth Crit Care [serial online] 2018 [cited 2020 Dec 1];8:58-9. Available from: https://www.joacc.com/text.asp?2018/8/1/58/230064




  Introduction Top


While reports of successful use of neuraxial and general anaesthesia on patients with histories of autoimmune demyelinating diseases are not uncommon, far rarer are reports of management involving acute demyelinating disease. To our knowledge, this is the first case report of an obstetric patient with acute transverse myelitis who has the complicating factor of a potentially difficult airway. While the recommendation to avoid neuraxial anaesthesia and depolarizing muscle relaxants in such a scenario is well-described, this case report is unique in its discussion of the risk-benefit calculus of these choices in the presence of more challenging airway management.


  Case History Top


A previously healthy 32-year-old G1P0 woman at 31 weeks and two days gestation presented to the emergency department due to sudden onset numbness of legs and abdomen, along with complaints of three months of neck pain and left arm paraesthesia, one month of worsening headache, and two weeks of progressing bilateral lower extremity pain and difficulty ambulating. She denied recent bacterial or viral infections, drug use, and personal or family history of autoimmune disease. Her initial examination showed bilateral lower extremity paraplegia, loss of cutaneous sensation to a T4 level, and upper and lower extremity hyperreflexia. She was incontinent of bowel and bladder and required urethral catheterization. An MRI revealed patchy, diffuse lesions at T7-8 and T10-11 consistent with a demyelinating process and diffuse cord oedema from C5 to T3. Lumbar puncture and cerebrospinal fluid (CSF) analysis revealed elevated opening pressure of 29 cm H2O, but no clear infectious aetiology was identified on CSF gram stain or cultures. The neurology and obstetric services suspected an autoimmune process affecting her spinal cord but no exact diagnosis was made. Treatment with pulse-dose methylprednisolone and plasmapheresis produced minimal improvement in neurological function. Seven days after admission, her foetus experienced recurrent heart rate decelerations, and an emergent caesarean section was decided upon.

The patient arrived to the OR appropriately fasted. Airway assessment revealed a potentially challenging airway in this woman with a BMI of 35, adequate mouth opening but a thick neck, short thyromental distance, and Mallampati grade of 3. Given the urgency of the procedure and the uncertain nature of her neurological condition with regards to potential complications of neuraxial anaesthesia, a rapid sequence induction of general anaesthesia with endotracheal intubation was decided upon. Automated blood pressure cuffs were set to cycle every one minute. After pre-oxygenation, general anaesthesia was induced with Propofol 1.5 mg/kg and rocuronium 1.2 mg/kg. A 7.0-mm endotracheal tube was inserted via direct laryngoscopy with video laryngoscope backup available. After EtCO2 and bilateral breath sounds were confirmed, maintenance of general anaesthesia was carried out with 50% NO2 and 0.6% isoflurane. Vasopressors and nitro-glycerine were kept on hand, but no hemodynamic derangements necessitating intervention occurred. Three minutes after surgical start, delivery of a female infant occurred. At time of skin closure, train of four monitoring revealed zero twitches. She was successfully extubated in the ICU the following morning. Postoperatively, the patient continued plasmapheresis and steroids and began to note return of motor function in her lower extremities, but her sensory changes persisted with the new onset of paraesthesia in a band-like distribution at T4. Thereafter, she was diagnosed with idiopathic acute transverse myelitis. Repeat imaging demonstrated improvement in the previously seen spinal cord lesions and oedema. Her neurological deficits continued to improve, and on postoperative day ten, she was discharged to the acute rehabilitation unit.


  Discussion Top


Concern about neurological complications after neuraxial anaesthesia have existed for many years, with earlier practitioners recommending against performing these techniques in patients with pre-existing neurological disease.[1] Traditional beliefs about neuraxial anaesthesia were countered by a 2006 retrospective review, which demonstrated the safety of neuraxial anaesthesia in 139 patients with pre-existing neurological disease,[2] but the majority of patients studied had post-poliomyelitis or multiple sclerosis, not transverse myelitis. The review included only four patients with an acute (
General endotracheal anaesthesia is the alternative option. Airway management may be more difficult in obstetric patients as a consequence of more challenging airway anatomy, the increased likelihood of an emergency situation, or providers' relative inexperience with general anaesthesia in an obstetric patient.[3],[4] Obstetric patients are commonly managed as 'full stomachs' given the physiologic changes of pregnancy. Transverse myelitis is associated with bowel dysfunction and may further predispose these patients to an increased gastric volume. Rapid sequence induction and intubation is the strategy of choice in this population, and is likely a prudent option in an emergency setting. The choice of neuromuscular blocking drug in this patient is complicated by her demyelinating condition with resultant flaccid paralysis. The use of succinylcholine in patients with demyelinating lesions may be complicated by life-threatening hyperkalaemia.[5] We opted to use rocuronium to avoid this complication. Even in the presence of a non-reassuring airway exam, we believe that rocuronium may be a safer choice for optimization of intubating conditions. While its prolonged duration of action is a disadvantage, sugammadex can rapidly reverse the effects of rocuronium. Patients with pre-existing weakness from conditions such as transverse myelitis may be more sensitive to non-depolarizing relaxants; nevertheless, sugammadex has been found to effectively reverse residual paralysis and facilitate prompt extubation in this population.[6]

Although general anaesthesia in obstetric patients may be complicated by difficulty in airway management, in this instance, we believe that the presence of a well-defined risk profile that may be modified (backup airway equipment, choice of neuromuscular blocking drug and availability of reversal agents) is preferable to the nebulous risks associated with neuraxial anaesthesia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vandam LD, Dripps RD. Exacerbation of Pre-Existing Neurologic Disease after Spinal Anesthesia. N Engl J Med 1956;255:843-9.  Back to cited text no. 1
    
2.
Hebl JR, Horlocker TT, Schroeder DR. Neuraxial Anesthesia and Analgesia in Patients with Preexisting Central Nervous System Disorders. Anesth Analg 2006;103:223-8.  Back to cited text no. 2
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3.
Rucklidge M, Hinton C. Difficult and failed intubation in obstetrics. Crit Care Pain 2012;12:86-91.  Back to cited text no. 3
    
4.
Kinsella SM, Winton AL, Mushambi MC, Ramaswamy K, Swales H, Quinn AC, et al. Failed tracheal intubation during obstetric general anaesthesia: A literature review. Int J Obstet Anesth 2015;24:356-74.  Back to cited text no. 4
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5.
Martyn JAJ, Richtsfeld M. Succinylcholine-induced hyperkalemia in acquired pathologic states: Etiologic factors and molecular mechanisms. Anesthesiology 2006;104:158-69.  Back to cited text no. 5
    
6.
Weekes G, Hayes N, Bowen M. Reversal of prolonged rocuronium neuromuscular blockade with sugammadex in an obstetric patient with transverse myelitis. Int J Obstet Anesth 2010;19:333-6.  Back to cited text no. 6
[PUBMED]    



This article has been cited by
1 Anesthetic management of an obstetric patient with idiopathic transverse myelitis: A unique approach!
KirtiN Saxena,Amrita Kaul,Mohammad Shakir
Journal of Obstetric Anaesthesia and Critical Care. 2019; 9(2): 99
[Pubmed] | [DOI]



 

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