case : managing an Eclampsia patient questions

[ketap]

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hello, i met a young eclamptic patient a few days ago and she had very often seizure attack despite given MgSO4 preoperatively...so, the decision to terminate the pregnancy was made as soon as possible, ...my teacher decided to manage this patient with General anesthesia with RSI (with muscle relaxant)... During the operation, the patient given maintenance dose muscle relaxant and show no sign of seizure ( but no EEG was available), the MgSO4 stopped during the operation and the baby delivered well (though the neonate wasn't well), and after the operation, the patient transferred immediately to the ICU...
now, my questions are :

1. is that already a right way to manage this patient? i mean, so the patient is having a frequent active seizure...and we know that giving a muscle relaxant (especially the maintenance muscle relaxant) will damp the signs of the seizure...without EEG, how can we know that this patient is having a seizure?
because as i know that the seizure would increase the CMRO2 and it means need more delivery of O2 and it is quiet labile to have if we need the anesthetics still going on (MAP usually quiet low) ..am i right?

2. if i can't use the muscle relaxant in this patient, should i use the awake intubation or fiberoptic intubation instead (considering that a pregnant woman also have some difficult airway)?

3. Can i still use the MgSO4 intraoperatively to prevent the seizure? how can i combine it with the intraoperative fluid since the MgSO4 would increase the risk of water intoxication (as well as the oxytocin) too?

4. Considering that the eclamptic patient still had a quiet risk of having another seizures in variable few days (or weeks) after the operation....when is the right time to extubate the patient?

sorry if all those questions are very simple and even might be a silly questions...please help discuss this case..thx u

regards, Ketap

 

[Planktonmd]

If the patient is actively seizing then the right management is to terminate the pregnancy under GA which you guys did.
As for the concern about undetected seizures because you used a muscle relaxant, it is possible but general anesthesia would most likely suppress the seizure.
As for Magnesium, I would not stop magnesium intra-op on an eclamptic patient who was actively seizing.
As for when to extubate, you can do that in an hour or two provided that the BP is well controlled and the patient is not showing any signs of end-organ damage (Awake, no more seizures, no CHF, good urine out put).

 

[ketap]

hi,Planktonmd: thx u for the reply..🙂 it means so much 🙂
any other comments are welcome 🙂

 

[gtb]

Rapid sequence intubation with thiopental and succinylcholine would be my strategy.

If a typical induction dose of thiopental (4-5mg/kg) was used, this will also likely terminate any active seizures. Additionally, the antiseizure effect will persist beyond the neuromuscular blockade effect from succinylcholine (assuming no significantly altered metabolism). Ten minutes out from the SCC dose, if the patient has a seizure, you should notice it and and can then bolus another 50 - 100mg of thiopental.

In addition to its antiseizure activity, therapeutic magnesium levels will mildly relax the uterine smooth muscle, and this diminished uterine tone might further increase blood loss. I imagine many other management issues were contemplated by the attending physician including: was the patient hypertensive, hypotensive, volume depleted, coagulopathic, was she hypercarbic and having signs of elevated ICP from the seizures, etc.. Cesarean sections, especially in emergent cases, are very fast procedures, so stopping the magnesium at the beginning of the case should have no significant influence on the plasma levels at the end of the case. Let the OB physicians restart it post operatively (which they will). That is my management strategy, however, Chestnut's Obstetric anesthesia book advises to continue Mg++ intraop for PREeclampsia.

For a rapid sequence intubation, I would secure the airway by direct laryngoscopy as a first choice (Eschmann stylet as backup), glidescope as a secondary pathway. Fiberoptic might be too slow for an RSI, and I imagine there is not time to dry up the secretions with glycopyrolate. So, unless the patient had some other known difficulty with their airway, other than pregnancy, FOB is not my first or second choice.

Assuming no ongoing seizures, hemodynamically stability, adequate spontaneous ventilation and oxygenation with minimal O2 support; then extubate the patient when they are awake and able to protect their airway.

To me, it sounds like your attending had a good strategy, and a successful outcome for the mother validates this.

 

[cb3221]

as an aside, (since i recently presented an M&M on this topic) the ACOG guidlines for eclamptic pts recommends an expedited vaginal delivery unless the baby shows signs of trouble. In the particular case I presented , the mother seized 3-4 times in the course to delivery. I figure in a private practice setting these go straight to c/s. Anyone ran into similar cases?

 

[Planktonmd]

as an aside, (since i recently presented an M&M on this topic) the ACOG guidlines for eclamptic pts recommends an expedited vaginal delivery unless the baby shows signs of trouble. In the particular case I presented , the mother seized 3-4 times in the course to delivery. I figure in a private practice setting these go straight to c/s. Anyone ran into similar cases?

When people have grand mal seizures they tend to have problems especially if they are pregnant and have fully blown eclampsia:
During a seizure they actually quit breathing, they frequently vomit and aspirate and their BP that is already high will increase dramatically.
Waiting for such patients to deliver vaginally is not a very elegant thing to do IMHO.
Remember we are not talking about pre-eclampsia here, we are talking about real eclampsia.

 

[hoyden]

as an aside, (since i recently presented an M&M on this topic) the ACOG guidlines for eclamptic pts recommends an expedited vaginal delivery unless the baby shows signs of trouble. In the particular case I presented , the mother seized 3-4 times in the course to delivery. I figure in a private practice setting these go straight to c/s. Anyone ran into similar cases?

Interesting. Especially the wording of expedited vaginal delivery and imagining that in actively seizing patient with a sky-high BP and coagulopathy actively boiling.... with the statistics that preeclampsia ( and eclampsia, obviously), occurs more often in a primigravid or in a multigravid pregnancy.

I've been searching the web for at least half an hour looking for those guidelines and haven't found anything so strictly recommended.
Do you have any links for those?

PS. For our oral boards questions would still imagine that RSI and GA and CS are the right choices... with all the collateral situations inevitably occurring at the exam.

 

[cb3221]

2007 ACOG practice bulletin-
“Pts with eclampsia should be delivered in a timely fashion .Fetal bradycardia frequently occurs during a seizure; usually this can be managed by maternal treatment and cesarean delivery is not necessary”
Decision to C/S should be based on gest. Age, cervical exam, fetal presentation.

Of course if the mother isnt protecting her airway intubation and c/s is the next step. In the case im refering to the mother maintained her sats but was in a combative post-ictal state. I had the OR set for c/s under G.A. when the O.B stated we are going to "ride it out" and to be on standby.
I have a feeling this only occurs in academia.

 

[gtb]

I've been searching the web for at least half an hour looking for those guidelines and haven't found anything so strictly recommended.
Do you have any links for those?

http://mail.ny.acog.org/website/SMIPodcast/DiagnosisMgt.pdf

Here is a link for: ACOG Practice bulletin - Diagnosis and Management of Preeclampsia and Eclampsia, Clinical Management Guidelines for Obstetrician-Gynecologists, number 33, Jan 2002 - Reaffirmed 2008

One paragraph states: "The patient with eclampsia should be delivered in a timely fashion. Fetal bradycardia frequently occurs during an eclamptic seizure; usually, this can be managed by maternal treatment, and cesarean delivery is not necessary. Once the patient is stabilized, the method of delivery should depend, in part, on factors such as gestational age, fetal presentation, and the findings of the cervical examination"

Fortunately the OB physicians make the call for CSX or vaginal delivery. If their decision is CSX, but all other possible causes for seizure have not yet been ruled out (most concerning is intracranial hemorrhage), then GA with an RSI is my plan.

 

[hoyden]

2007 ACOG practice bulletin-
“Pts with eclampsia should be delivered in a timely fashion .Fetal bradycardia frequently occurs during a seizure; usually this can be managed by maternal treatment and cesarean delivery is not necessary”
Decision to C/S should be based on gest. Age, cervical exam, fetal presentation.

Of course if the mother isnt protecting her airway intubation and c/s is the next step. In the case im refering to the mother maintained her sats but was in a combative post-ictal state. I had the OR set for c/s under G.A. when the O.B stated we are going to "ride it out" and to be on standby.
I have a feeling this only occurs in academia.

I have the same feeling ))))

 

[IlDestriero]

I don't think I ever met an OB who would not do an urgent c/s on a seizing patient. The risks are too high to be cavalier. Stabilize the patient, in the hall on the way to the OR, pent, sux, tube, baby. Than run damage control and figure out what's going on w/ mom. Labs, ct, etc. Dead babies cost alot, dead moms cost more. If you find yourself in a "wait and see" situation, write a note in the chart noting that you recommended a c/s, were worried about aspiration, and were prepared to go to the OR, but the OB attending chose to wait. If it all goes bad, they can't try to say that you were part of the delay if you documented that you were standing by and ready to roll. If you think that they won't recollect things that way you are fooling yourself. I would also place an Aline to monitor BP and recheck labs, rarely a patient may also need a swan, especially if they are sounding wet and have some hypoxia. You don't want her to bleed to death in another hour when she seizes again, aspirates and goes back. You can at least have the blood products ready or pretreat her with platelets if she is really low.