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214: Regional anesthesia for caesarean delivery in a parturient with severe myasthenia gravis
Posters
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Obstetrics
188. Analgesic effect of pre-incisional celecoxib, ketamine and their combination for caesarean section
214. Regional anesthesia for caesarean delivery in a parturient with severe myasthenia gravis
P.H. Tan1, J.I. Wu2, L.C. Yang1 1Department of Anesthesiology, E-DA Hospital, I-Shou University, Kaohsiung, Taiwan, 2Department of Anesthesiology, Kaohsiung Municipal Min-Sheng Hospital, Kaohsiung, Taiwan
R. Siegmeth, A. Kamani, R. Preston Department of Anesthesia, BC Women’s Hospital and Health Centre, Vancouver,BC, Canada
Background and Aims: Trimodal therapy with cyclo-oxygenase-2 inhibitor, ketamine, and a local anesthetic field block administered before surgery has been reported to reduce pain scores and analgesic use after surgery. We determined whether pre-incisional administration of celecoxib alone, ketamine alone or their combination have equal analgesic effect for caesarean section under spinal anesthesia. Methods: Eighty patients scheduled for caesarean section under spinal anesthesia received celecoxib 400 mg PO (group C; n⫽20), ketamine 0.2 mg/kg IV(group K, n⫽20), or their combination (group CK, n⫽20) before incision. Patients in placebo group (group P, n⫽20) received placebo capsule and 1ml saline before incision. The time to first morphine use, 24 h morphine consumption, pain score, and side effects during postoperative 24 h period were recorded. Results: Analgesic duration, defined as the time from completion of surgery until first morphine use were significant longer in group C (471⫾46 min) and group CK (499⫾52 min) compared with Group K (261⫾36 min). Compared with group P and group K, pain scores were lower in group C and group CK at 12 and 24 hours postoperatively. The 24 h morphine use was lower in group C and group CK than in group P and group K. Conclusion(s): We conclude that the administration of 400 mg celecoxib alone or combined with ketamine 0.2 mg/kg before surgery provides equal postoperative analgesia. A single dose of ketamine 0.2 mg/kg fails to potentiate analgesic effects of celecoxib.
81
Introduction: While epidural and CSE techniques have been used for labour analgesia in parturients with severe myasthenia gravis (1), literature review still advocates general anesthesia with endotracheal intubation for those with respiratory compromise or bulbar dysfunction requiring caesarean delivery (2,3). We report the successful use of epidural anesthesia in such a situation. Case: A 31 year old primip underwent cesarean delivery for worsening myasthenia. She had multiple previous ICU admissions for respiratory compromise although PFTs in pregnancy were normal. Symptoms included dysphonia, dysphagia and severe gastroesophageal reflux. Body mass index was normal. Mallampati score was 1 with excellent mouth opening and jaw protrusion. Following aspiration prophylaxis an epidural was sited L3/4. 20mls 2% Lidocaine with 1 in 200,000 epinephrine and 100micrograms of fentanyl was incrementally administered achieving a T6 pinprick block bilaterally. Surgery proceeded uneventfully, she experienced no dyspnea and saturations were maintained at 96 – 99% on air. 3mg of epidural morphine provided good postoperative analgesia. Following 48 hours of intense monitoring she was discharged to a postnatal ward. On postoperative day 3 she suffered an acute myasthenic exacerbation with excessive drooling and deterioration in pulmonary function (peak flow rate reduced from 400l/min to 130l/min). She underwent plasmapheresis and was discharged two weeks later. Discussion: Epidural anesthesia provided sufficient anesthesia for cesarean section without compromising respiratory function in a patient with severe myasthenia gravis. This avoided using muscle relaxants, narcotics, barbiturates and inhalational anesthetics all of which can exacerbate myasthenia and result in postoperative ventilation. This case also highlights the unpredictable nature of myasthenia gravis in pregnancy and the need for careful monitoring particularly postpartum (4).
References 1. 2. 3. 4.
Reg Anesth Pain Med 23: 201-3 1998 Rev Esp Anestesiol Reanim 45: 41-5 1998 Anesth Analg. 57: 441-7 1978 Eur J Obstet Gynecol Reprod Biol. 121: 129-38 2005
•
Obstetrics
188. Analgesic effect of pre-incisional celecoxib, ketamine and their combination for caesarean section
214. Regional anesthesia for caesarean delivery in a parturient with severe myasthenia gravis
P.H. Tan1, J.I. Wu2, L.C. Yang1 1Department of Anesthesiology, E-DA Hospital, I-Shou University, Kaohsiung, Taiwan, 2Department of Anesthesiology, Kaohsiung Municipal Min-Sheng Hospital, Kaohsiung, Taiwan
R. Siegmeth, A. Kamani, R. Preston Department of Anesthesia, BC Women’s Hospital and Health Centre, Vancouver,BC, Canada
Background and Aims: Trimodal therapy with cyclo-oxygenase-2 inhibitor, ketamine, and a local anesthetic field block administered before surgery has been reported to reduce pain scores and analgesic use after surgery. We determined whether pre-incisional administration of celecoxib alone, ketamine alone or their combination have equal analgesic effect for caesarean section under spinal anesthesia. Methods: Eighty patients scheduled for caesarean section under spinal anesthesia received celecoxib 400 mg PO (group C; n⫽20), ketamine 0.2 mg/kg IV(group K, n⫽20), or their combination (group CK, n⫽20) before incision. Patients in placebo group (group P, n⫽20) received placebo capsule and 1ml saline before incision. The time to first morphine use, 24 h morphine consumption, pain score, and side effects during postoperative 24 h period were recorded. Results: Analgesic duration, defined as the time from completion of surgery until first morphine use were significant longer in group C (471⫾46 min) and group CK (499⫾52 min) compared with Group K (261⫾36 min). Compared with group P and group K, pain scores were lower in group C and group CK at 12 and 24 hours postoperatively. The 24 h morphine use was lower in group C and group CK than in group P and group K. Conclusion(s): We conclude that the administration of 400 mg celecoxib alone or combined with ketamine 0.2 mg/kg before surgery provides equal postoperative analgesia. A single dose of ketamine 0.2 mg/kg fails to potentiate analgesic effects of celecoxib.
81
Introduction: While epidural and CSE techniques have been used for labour analgesia in parturients with severe myasthenia gravis (1), literature review still advocates general anesthesia with endotracheal intubation for those with respiratory compromise or bulbar dysfunction requiring caesarean delivery (2,3). We report the successful use of epidural anesthesia in such a situation. Case: A 31 year old primip underwent cesarean delivery for worsening myasthenia. She had multiple previous ICU admissions for respiratory compromise although PFTs in pregnancy were normal. Symptoms included dysphonia, dysphagia and severe gastroesophageal reflux. Body mass index was normal. Mallampati score was 1 with excellent mouth opening and jaw protrusion. Following aspiration prophylaxis an epidural was sited L3/4. 20mls 2% Lidocaine with 1 in 200,000 epinephrine and 100micrograms of fentanyl was incrementally administered achieving a T6 pinprick block bilaterally. Surgery proceeded uneventfully, she experienced no dyspnea and saturations were maintained at 96 – 99% on air. 3mg of epidural morphine provided good postoperative analgesia. Following 48 hours of intense monitoring she was discharged to a postnatal ward. On postoperative day 3 she suffered an acute myasthenic exacerbation with excessive drooling and deterioration in pulmonary function (peak flow rate reduced from 400l/min to 130l/min). She underwent plasmapheresis and was discharged two weeks later. Discussion: Epidural anesthesia provided sufficient anesthesia for cesarean section without compromising respiratory function in a patient with severe myasthenia gravis. This avoided using muscle relaxants, narcotics, barbiturates and inhalational anesthetics all of which can exacerbate myasthenia and result in postoperative ventilation. This case also highlights the unpredictable nature of myasthenia gravis in pregnancy and the need for careful monitoring particularly postpartum (4).
References 1. 2. 3. 4.
Reg Anesth Pain Med 23: 201-3 1998 Rev Esp Anestesiol Reanim 45: 41-5 1998 Anesth Analg. 57: 441-7 1978 Eur J Obstet Gynecol Reprod Biol. 121: 129-38 2005