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Unformatted text preview: Case presentation on Pulmonary Edema Complicating Severe Preeclampsia Complicating Presented by Dr. Nicole Hodge Faculty Advisor Dr. Norman Bolden 6 June 06 Overview Overview Severe preeclampsia – pathophysiology, Dx, Severe maternal/fetal issues, Treatment maternal/fetal Standards of care and goals of anesthetic management Case - Ante partum flash Pulmonary edema Case Discussion Discussion PREECLAMPSIA PREECLAMPSIA A syndrome characterized by the new onset of hypertension and syndrome proteinuria after 20 weeks gestation. Additional signs and symptoms that can occur include edema, visual disturbances, headache, epigastric pain, thrombocytopenia, and abnormal liver headache, function. These clinical manifestations are the results of function. mild to severe microangiopathy of target organs such as brain, liver, kidney, and placenta. liver, PATHOPHYSIOLOGY OF PREECLAMPSIA PATHOPHYSIOLOGY A state of endothelial dysfunction secondary to excessive amounts of state circulating factors released from the diseased placenta. These factors effect the establishment of a suitable vascular network of the placenta needed to supply oxygen and nutrients to the fetus. needed Molecular/Cellular level Abnormal expression of VEGF and sFlt-1 (Vascular endothelial growth factor – proangiogenic and soluble fms-like tyrosine kinase 1- anti-angiogenic factors proangiogenic respectively) appear to play a central role. respectively) Increased expression of cytokines, angiotensin, catecholamines, and pro-coagulant Increased factors. factors. Anatomic level Anatomic Increased vascular tone Increased vascular permeability Coagulopathy Ischemia of target organs (brain, liver, kidney, placenta) Multisystemic Disease Multisystemic CNS – Cortical blindness, cerebral edema, cerebral hemorrhage, and seizures CNS Cardiovascular – Hypovolemia, increased SVR, LVH, increase sensitivity to catecholamines, sympathomimetics, and oxytocin catecholamines, Respiratory – pulmonary edema, V/Q mistmatch, airway edema Respiratory Renal – Decreased renal blood flow, increased GFR, proteinuria, increased BUN and creatinine and Hepatic – subscabular hemorrhage, abnormal LFTs, decreased plasma cholinesterase levels cholinesterase Hematologic – Prolonged bleeding time, platelet dysfunction, thrombocytopenia, DIC DIC Placenta – Uteroplacental insufficiency, placental abruption, chronic fetal hypoxia, IUGR, premature labor, premature birth. hypoxia, Diagnosis of Severe Preeclampsia Diagnosis If one or more of the following criteria are present: Systolic blood pressure > 160 mmHg Systolic Diastolic blood pressure greater than 110 mmHg Diastolic Proteinuria greater than 5 g/24 hrs Proteinuria Evidence of end organ damage Evidence Oliguria (<500ml/24hr) Cerebral or visual disturbances Pulmonary edema or cyanosis Epigastric pain or right upper-quadrant pain Impaired liver function Fetal growth restriction Thrombocytopenia *ACOG Compendium of Selected Publications Goals Goals The goal of the anesthesiologist Control CNS irritability Control Magnesium sulfate – anti-convulsant; reduces irritability of the neuromuscular Magnesium jxn. jxn. Restore intravasuclar fluid volume Strictly monitor urine output CVP monitor with goal 4-6 cm H20 Normalize blood pressure Magnesium sulfate – direct vasodilating action on smooth muscles of arterioles Magnesium and uterus. and Labetolol, Hydralazine, nifedipine, SNP (in extreme circumstances due to fetus Labetolol, susceptability to cyanide toxicity) susceptability Correct coagulation abnormalities Correct Platelets, FFP, Cryoprecipitate Platelets, Effects of Increasing Plasma Magnesium Levels Effects MgSO4 in excess of therapeutic range Skeletal muscle weakness Respiratory depression Cardiac arrest (Ca++ can counter-act this) MgSO4 potentiates NMB and sedative effects of opiods Observed Condition Normal Plasma level Therapeutic Range ECG Changes (Prolonged P-Q, widened QRS) Loss of deep tendon reflexes SA and AV node block Respiratory Paralysis Cardiac Arrest mEq/L 1.5-2.0 4.0-8.0 5.0-10 10 15 15 25 Anatomical Effects Functional Effects Functional effects Airway edema friability Widened AP and Transverse diameter Elevated Diaphragm Increased respiratory drive Minimal change in TLC Increased Minute ventilation Reduced FRC Increased cardiac output Normal diaphramatic Fxn Widened Subcostal angle Enlarging uterus Increased O2 consumption and CO2 production www.medtau.org Management Management Definitive treatment for Preeclampsia is delivery of the fetus and placenta. Vaginal Delivery – Lumbar epidural No fetal distress Before catheter placement, r/o coagulopathy and insure adequate volume replacement. Cesarean Delivery – Regional or GA Maternal/and or fetal status dictates the urgency for delivery Use epidural if in place. Maintain volume status. Typically, drops in BP improve Use placental blood flow. placental Spinal anesthesia, in the past, has been controversial due to possibility of severe Spinal hypotension. However, it has been shown to be a safe technique for cesarean delivery in severe preeclampsia. severe General anesthesia is an acceptable way to manage preeclamptic pts, however, there are General associated risks. associated Apiration Airway compromise Cerebral hemmorrhage Pulmnary Edema Case Report Case 38 yo G1P0, 25 wks gestation, was transferred to MHMC/High Risk Pregnancy (from OSH) for management of acute on chronic hypertension (systolic >200 mm Hg). Her pressures were stabilized with magnesium sulfate and hydralazine. No fetal distress. After approx. 48 hrs., pt started to c/o of chest pressure and shortness of breath. Also intermittent episodes of variable decelerations/severe fetal bradycardia occurred. Cardiology consult with echocardiogram was obtained. Pt BP required prn labetolol. High risk team plan was to continue BP control and requested for anesthesia to place an arterial line. Case Report Case Anesthesia Preoperative Assessment PMH/SH – Chronic HTN, Anxiety, Depression/Breast biopsy MEDS – Methyldopa 500mg po bid ALLERGIES – Sulfa, erythromycin SH/FH – quit smoking prior to conception/HTN ROS – intermittent HA, occasional blurry vision, RUQ/epigastric, ankle swelling Case Report Case Anesthesia Preoperative Assessment Exam VS – BP-184/93, HR-94, R-22, T-37.0, SpO2 – 97%, A&Ox3,No acute distress Airway exam - MPII, TMD>4FW, FROM Cardiac – RRR, no murmur appreciated, no JVD, Cardiac Pulmonary – CTA B Pulmonary Extremeties - +3 pedal edema Neuro – grossly intact. No clonus Labs CMP – 136/3.6/107/24/3/161 Mg – 3.0 CBC – 9.62/10.7/32.8/289 PT/PTT/INR – 12.5/26.8/1.05 TnI – 0.38/0.37/0.39 AST/ALT -16/16 Case Report Case Anesthesia Preoperative Assessment CXR (on admission) Heart is borderline in size. No focal infiltrate or pleural effusion is seen. Heart The pulmonary vasculature is normal in appearance. The Trans-thoracic Echocardiogram Dilated left atrium. Concentric left ventricular hypertrophy, significant Dilated mitral valve regurgitation, mild pulmonary hypertension (40-50 mm Hg), Hg), LVEF -60% ECG On admission (1/9/06) – sinus tachycardia Day of consult (1/11/06) – NSR, LAE Pre-operative Events Pre-operative The patient became extremely anxious and tachypneic after failed initial The attempts at A-line placement. Base line sats 96-98%. (recall h/o anxiety attacks) attacks) Put on 100% mask non-rebreather. Good color and breath sounds were Put clear bilaterally. Pulse oximetry was 91-97%, but unreliable because she was moving around. Further attempts for A-line placement aborted until anxiety diminished. After approx 3-5 min, pt started complaining that her “lungs were filling up”. Auscultation revealed crackles to mid lung fields bilaterally. Sats decreased to 80%. Airway supported with ambu bag. . CRISIS!!! CRISIS!!! A-line placed immediately, ABGs drawn.. Continued O 2 support, PCXR ordered. ordered. BP – 269/125 mmHg MAP – 182 mmHg, HR-111 ABG – 7.28/48.8/70.4/90.2/22.2/-4.2 CXR – Opacities in mid and lower lung fields. Pulmonary edema. Increased distress/respiratory function worsened in supine position Increased Anesthesia High Risk/OB Conference Anesthesia Assessment Severe Preeclampsia complicated by flash pulmonary edema Recent echo showed LVEF 60% Pulmonary edema likely secondary to malignant hypertension Pt’s inability to lie supine lends immediate c/s technically difficult Fetal status reassuring Plan Continue Continue Oxygen support BP control Monitor UOP Monitor ABG’s Monitor Fetus When oxygenation is acceptable and patient can lie supine, proceed with c/s under regional, When proceed with GA if BP intractable or fetal distress. proceed Crisis Management Crisis Based on this information, O2 continued with 100% NRB, BP was aggressively treated with Labetolol (~ 120 mg). Lasix administered to resolve pulmonary edema. resolve Continued monitoring of O2 sats Monitor UOP BP’s under better control. NTG gtt started. ABG after 3 hours – 7.411/37.5/174/99.0/23.4/-0.5 Plan for c-section Intraoperative Events Intraoperative Pt in sitting position for prep/placement of epidural. Pt noted to have 3+ Pt pitting edema in lumbar area. pitting 1% local and Touhy needle placed at L3-4. + LOR, -heme/CSF. Catheter 1% advanced easily. Negative aspiration. Test dose negative. advanced Catheter was secured. Patient placed in supine w/left uterine displacement. Catheter Lidocaine 2% w/1:200K epi and HCO3, total of 22 cc’s was given over 20 minutes. No sensory level was achieved. minutes. Anesthetic plan was converted to GA/RS; Thiopental 250 mg, Sux 120 mg Anesthetic and Isoflurane. and Surgeons proceeded with CS. Intraoperative Events Intraoperative MAC line was placed in the right internal jugular vein. CVP 20-30 mmHg. Swan-Ganz catheter placed. PAP avg 35/25 mmHg. Cardiac output not assessed Swan-Ganz due to equipment unavailability. due Prior to delivery Sys >170 / > 100mmHg After delivery, Sys 110-170 /70-100 mmHg. Surgery completed w/o complication. Fluids – LR 500 ml, EBL – 700, UOP – 250. Pt remained intubated. Transferred to the CICU for cardiac care/post-op mgmt. Delivery of Fetus Delivery of fetus Post-operative Events Post-operative Pt was extubated POD#1. Remained in ICU for several days for mgmt of BP and continued diuresis. Role of Invasive Hemodynamic Monitoring with Severe Preeclampsia Preeclampsia Most women with severe preeclampsia or eclampsia can be managed Most without invasive hemodynamic monitoring. without A review of 17 women with eclampsia reported that use of a pulmonary review artery catheter aided in clinical management decisions. (ACOG Compendium of Selected Publicatins; J Clin Invest 1993;91:950-960) of No randomized trials support their use in severe preeclamptic patients. Invasive hemodynamic monitoring may prove beneficial in preeclamptics Invasive with severe cardiac disease, renal disease, refractory hypertension, oliguria, or pulmonary edema. (ACOG Compendium of Selected Publications Am J Ostet ACOG Gyn 2000; 182:1397-1403) Gyn **Level III Research – Opinions based on respected authorities, clinical experience, **Level descriptive studies, or expert committees. descriptive Acute Pulmonary Edema in Pregnancy Acute Cohort study – 62,917 consecutive pregnancies from 1989-1999, to Cohort describe the incidence, predisposing factors contributing to pulmonary edema in the pregnant patient. edema Fifty-one women (0.08%) were diagnosed with acute pulmonary edema during Fifty-one ante partum - post partum period. ante 24 patients (47%) antepartum 7 patients (14%) intrapartum 20 patients (39%) post partum Most common causes: Tocolytics (25.5%) most commonly MgSO4 and SC terbutaline Cardiac disease (25.5%) Fluid overload (21.5%) Preeclampsia (18%) Risk Factors Risk Preeclampsia/eclampsia Tocolytic therapy Sever infection Cardiac disease Iatrogenic fluid overload Multiple gestation EBM Discussion on Anesthetic Technique for Cesarean Section for Severe Preeclampsia for Randomized comparison of general and regional anesthesia for cesarean Randomized delivery in pregnancies complicated by severe preeclampsia (1995) delivery Eighty women who required C/S Randomized - epidural/CSE/General Intra-operative BP compared in all groups No statistical or clinical difference in maternal or fetal outcome Aside from logistical implications, general as well as regional were Aside shown to be equally acceptable if steps are taken to ensure careful approach to either method. approach EBM Discussion on Anesthetic Technique for Cesarean Section for Severe Preeclampsia for Prospective cohort study; Patients with severe preeclampsia experience Prospective less hypotension during spinal anesthesia for elective cesarean delivery than healthy parturients (2003). than Compared incidence and severity of spinal anesthesia assoaicated hypotension Compared in severe preeclamptic (n=30) vs. healthy parturients (n=30). in Under spinal, mean BP decreased by 32-39% in severe preeclamptics and 3360% in the healthy parturient. Healthy patients were given more ephedrine than the preeclamptics for Healthy hypotension. Possible explained by increased sensitivity of pressor drugs in the preeclamptic. the Findings suggest that the incidenc of severity of spinal hypotension in Findings preeclamptic patients with severe hypertension may be less than previously believed. believed. Discussion Discussion Most likely cause of pulmonary edema is multifactorial. No Most specific etiology was assigned. specific Unsuspected cardiac findings were common, and there was a Unsuspected high incidence of valvular disease. high Most pts had severe systolic dysfunction and LVH and not Most cardiac disease. cardiac Underlying cardiac disease is most likely under-diagnosed and Underlying under-reported due to under-use of echocardiography. under-reported References References Journals A. Sciscione et al. Acute Pulmonary Edema in Pregnancy. Obstetrics & A. Acute Obstetrics Gynecology 2003;103:511-14. Gynecology D. Wallace et. al. Randomized Comparison of General and Regional Anesthesia D. for Cesarean Delivery in Pregnancies Complicated by Severe Preeclampsia . for Obstetrics & Gynecology 1995;86:198-98. Obstetrics A. Aya et al. Patients with Severe Preeclampsia Experience Less Hypotension A. During Spinal Anesthesia for Elective Cesarean Delivery than Healthy Parturients: A Prospective Cohort Comparison. Anesthesia & Analgesia 2003;97:867-72 Texts/Other Baresh, Paul G. Clinical Anesthesia. Stoelting, R. Anesthesia and Coexisting Disease Up to Date – www.uptodate.com ; keyword – severe preeclampsia to Questions???? Questions???? ...
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