|Year : 2019 | Volume
| Issue : 2 | Page : 104-107
Takayasu's arteritis: Anesthetic implications and management of a patient for cesarean section using combined spinal-epidural technique
Adrish Banik, K S H Sandeep, N Ratan Singh
Department of Anaesthesiology, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Submission||29-Apr-2019|
|Date of Acceptance||26-Aug-2019|
|Date of Web Publication||11-Feb-2020|
K S H Sandeep
Department of Anaesthesiology, RIMS, Imphal, Imphal West - 795 004, Manipur
Source of Support: None, Conflict of Interest: None
Takayasu's arteritis (TA) or pulseless disease is a rare, idiopathic, chronic granulomatous vasculitis that affects mainly aorta and its major branches. We report herewith the anesthetic management of a parturient who suffered from TA scheduled for elective cesarean section by using combined spinal-epidural technique, which offers the combined advantage of both spinal and epidural anesthesia and postoperative analgesia. Anesthesia for patients with TA is complicated by severe uncontrolled hypertension, end-organ dysfunction, stenosis of major branches of aorta, and difficulties in monitoring hemodynamic parameters. Our patient was a full-term, 29-year-old female weighing 60 kg, of height 154 cm, gravida 1, and para 0 scheduled for elective lower segment cesarean section. The intraoperative period was uneventful with minimal rise in blood pressure (BP) which was managed accordingly with antihypertensive medications. The patient was stable in the postoperative period with minor rise in BP from baseline and was shifted to ward after being monitored in the intensive care unit for 24 h.
Keywords: Combined spinal-epidural technique, parturient, Takayasu's arteritis
|How to cite this article:|
Banik A, Sandeep K S, Singh N R. Takayasu's arteritis: Anesthetic implications and management of a patient for cesarean section using combined spinal-epidural technique. J Med Soc 2019;33:104-7
|How to cite this URL:|
Banik A, Sandeep K S, Singh N R. Takayasu's arteritis: Anesthetic implications and management of a patient for cesarean section using combined spinal-epidural technique. J Med Soc [serial online] 2019 [cited 2020 Feb 28];33:104-7. Available from: http://www.jmedsoc.org/text.asp?2019/33/2/104/278100
| Introduction|| |
Takayasu's arteritis (TA) is a chronic, progressive vasculitis of unknown etiology. It is a form of granulomatous arteritis, which affects large- and medium-sized arteries, primarily the aorta and its large branches as well as the proximal portions of pulmonary, coronary, and renal arteries. These lesions result in segmental stenosis, occlusion, dilatation, and aneurysmal formation in the affected vessels. Diminished or absent pulses are present in 84%–96% of patients, associated with limb claudication and blood pressure (BP) differences between the two limbs. The symptoms are secondary to the involved arteries, and they may evolve into life-threatening condition. Involvement of the carotid artery results in ophthalmic arterial hypoperfusion and causes ocular ischemic syndrome. Hence, TA is also called aortic arch syndrome, pulseless disease, or occlusive thromboaortopathy. It predominantly affects women of reproductive age. We report herewith the anesthetic management of a parturient who suffered from TA scheduled for elective cesarean section.
| Case Report|| |
A full-term, 29-year-old female, weighing 60 kg, of height 154 cm, gravida 1, and para 0, was scheduled for elective lower segment cesarean section. She was diagnosed as a case of TA with left renal arterial stenosis in angiography for which superior mesenteric arterial stenting was done in October 2008. She was advised tablet aspirin 75 mg and prednisolone 40 mg once a day, but she stopped medication after 1 year and not followed up for the same. Preoperative investigations revealed hemoglobin of 12.7 g%, total leukocyte count of 8120/mm3, platelet count of 1.6 lakh/mm3, prothrombin time/international normalized ratio of 11.3 s/0.8, urea of 17 mg%, creatinine of 0.6 mg%, serum sodium of 132 mEq/L, serum potassium of 4.3 mEq/L, fasting blood sugar of 77 mg/dl, and postprandial blood sugar of 97 mg/dl. Urinary routine examination showed urinary protein of 3.8 mg/dl. Liver function test was within normal range. Fundus examination was normal. Echocardiography and electrocardiogram (ECG) revealed mild concentric left ventricular hypertrophy, borderline dilated left atrium, early left ventricular diastolic dysfunction and normal left ventricular systolic function, and ejection fraction >60%. She was advised on tablet labetalol 100 mg TDS and nifedipine 20 mg OD. Serial abdominal ultrasound examination at 18, 24, and 36 weeks showed normal fetal development and the last ultrasound showed a live fetus in cephalic presentation with borderline polyhydramnios. On physical examination, peripheral pulses were present in both upper and lower limbs, but difference in BP was noted between the two upper limbs (right side 180/100 mmHg and left side 170/120 mmHg). Respiratory system examination and neurological examination showed normal findings. Her airway was graded as Mallampatti Class II, and she was accepted for surgery in the American Society of Anesthesiologists Grade III.
Because of term gestation and chronic uncontrolled hypertension, she was taken up for elective cesarean section. She was kept nil per oral from 8 pm the day before the surgery and started on 100 ml/h ringer lactate from 8 pm, and tablet ranitidine was given at bedtime. On the day of surgery, the patient had taken a morning dose of antihypertensive and was premedicated with ranitidine 50 mg intravenous (IV), hydrocortisone 100 mg IV, and metoclopramide 10 mg IV before shifting to the operation theater (OT). The IV access was secured with an 18G IV cannula on the dorsum of both hands. The patient was preloaded with 500 ml ringer lactate and shifted to the OT. After shifting to the OT, BP cuff, ECG electrodes, and pulse oximeter were connected and baseline hemodynamic parameters were recorded. Under aseptic condition, a central venous catheter was inserted in the right internal jugular vein to give emergency drug intraoperatively and for the possibility of hemodynamic monitoring. The baseline arterial pressure, heart rate (HR), respiratory rate, and room air oxygen saturation were 180/108 mmHg, 92 beats/min, 14/min, and 98%, respectively. Then, under antiseptic and aseptic precautions, after local anesthetic infiltration (2% lignocaine), an 18G epidural catheter was introduced through a 16G Touhy needle via L2–L3 interspace using the loss of resistance to air technique, followed by a subarachnoid block with 1.5 ml (7.5mg) of 0.5% hyperbaric bupivacaine and 25 microgram fentanyl were injected intrathecally via L3-L4 interspace using a 25G Quincke's needle. The patient was then placed supine, and oxygen (5 l/min) was administered via a facemask. A head ring was placed under the patient's head, and 15° left lateral tilt was maintained by applying a wedge under the right hip. The sensory level of the block was maintained at T6 level by positioning the OT table. There was a slight fall in BP following spinal anesthesia. However, there was no significant hypotension which necessitated the use of vasopressor during the entire surgery. Instead, there were episodes of increase in BP, which were managed with small boluses of injection nitroglycerin 50 μg and injection labetalol 4 mg aliquots (300 μg of injection nitroglycerin and 12 mg of injection labetalol were used intraoperatively). Instead of antihypertensive infusion, small boluses were preferred in this case owing to the short duration of surgery and the risk of hypotension, which were expected to compound the effect of spinal anesthesia. Following delivery of a single live baby, injection oxytocin 3 units IV bolus and 5 units intramuscular bolus were administered followed by infusion (20 units in 500-ml crystalloid at a rate of 8-10 drops/min). There was no major fall in BP intraoperatively. The surgery lasted for around 1 h and was uneventful. During the entire period of surgery, the variation in BP was maintained within 20% of basal BP level. Epidural test dose was given to check the position of the catheter. Both the mother and the new born were stable in the postoperative period. Epidural analgesia was started with 8 ml of 0.125% bupivacaine after continuous hemodynamic monitoring in the postanesthetic care unit (PACU). The patient was monitored for another 30 min in the PACU and was later shifted to the intensive care unit (ICU) for vigilant monitoring and management.
Postoperative pain was managed with injection paracetamol 1 g IV 8 hourly and epidural analgesia with 8 ml of 0.125% bupivacaine 8 hourly for 48 h. In the ICU, fluctuations in BP and HR were noted, which were managed with titrated doses of labetalol infusion. Other blood parameters were within normal limits, and the patient was shifted to the ward after stabilization of BP on the 1st postoperative day. Later, the epidural catheter was removed in the ward after aseptic precaution.
| Discussion|| |
Takayasu's disease was first described in 1908 by two Japanese ophthalmologists, Takayasu and Onishi, who observed retinopathy occurring with absent limb pulses. The disease is recognized as a rare (2–3/million) granulomatous vasculitis of aorta and major vessels. Takayasu's disease appears to be more common in persons of Asian ethnic origin although it has a worldwide occurrence. In Japan, an autopsy survey suggested the disease frequency of 1 in 3000 persons. Its incidence in the Indian population is not known. It is more common in women than men (8:1), with the peak incidence in the second and third decades, although a substantial minority, including this patient, may present in their teens. The exact etiology remains unknown, but it may have an autoimmune basis. As it is more prevalent in women of childbearing age, sex hormones may be involved in the pathogenesis.
TA is rare and difficult to diagnose. Initially, the symptoms are vague; the disease may progress considerably until an angiogram is performed. Conditions to consider in the differential diagnosis of TA include aortic coarctation, atherosclerosis, giant cell arteritis, Wegener granulomatosis, Kawasaki disease, and thromboangiitis obliterans.
The new angiographic classification of TA includes the following (Takayasu conference, 1994):
- Type I – Involves the aortic arch and its major branches
- Type IIa – Involves the ascending aorta and aortic arch and its branches
- Type IIb – Involves the ascending aorta, aortic arch and its branches, and descending thoracic aorta
- Type III – Involves thoracic descending aorta, abdominal aorta, and/or renal arteries
- Type IV – Involves abdominal aorta and/or renal arteries
- Type V – Combined features of Types IIB and IV.
According to this classification system, involvement of the coronary or pulmonary arteries should be designated as C (+) orP (+), respectively.
Anesthesiologists may encounter these patients during obstetrical anesthesia, incidental surgery, or corrective vascular procedure. Clinically, the patient may present with the absence of various pulses in the upper half of the body. Anesthesia in patients with TA can be associated with severe uncontrolled hypertension leading to end-organ dysfunction and stenosis of major blood vessels, affecting regional circulation.
During the preoperative visit, patients should be evaluated for clinical features of carotid involvement, such as dizziness and syncope on head extension, and should be checked for carotid bruit. During general anesthesia, it is always better to keep the head in neutral position avoiding hyperextension of the head during laryngoscopy as it can lead to postoperative visual disturbances, vertigo, hemiparesis, and seizures. These patients usually have a lower BP recording in the upper limb as compared with the lower limb, and hence, it is advisable to record BP from both the upper and lower limbs during preoperative visit and also during intraoperative period.
Perioperative steroid replacement is warranted to prevent the occurrence of addisonian hypotensive crisis as they are usually on long-term steroid replacement and may present with cushingoid features preoperatively.
Literature review confirms that both regional and general anesthesia have been used successfully in these cases. Regional anesthesia is safe, as an awake and communicating patient is the best clinical neurological monitor. However, the associated sympathetic blockage-induced hypotension may compromise the regional circulation. The graded blockage with epidural anesthesia avoids precipitous falls in BP and also lowers the rate of thrombosis. Although sympathetic blockage is avoided with the use of general anesthesia, sophisticated monitoring of the cerebral function is needed as it may be associated with hypertensive crisis and consequent cerebral and cardiac events.
Vaginal delivery usually with epidural anesthesia is acceptable for patients in Groups I and IIa, although the duration of second stage of labor is shortened by instrumental delivery, particularly in hypertensive patients. Operative delivery is preferred for patients in Stage IIb or III but reserved for specific obstetric indications in less severely affected individuals. Its aim is to avoid the increase in blood volume and arterial pressure found during uterine contractions. In association with the increased cardiac output normally seen during pregnancy and labor, the likelihood of cardiac decompensation is increased further and is best avoided in susceptible individuals.
In our case, central venous pressure (CVP) monitoring was done by inserting a triple-lumen central line in the right internal jugular vein and the arrangement of arterial line insertion was present at the operation theatre (OT), but owing to the fact that arterial BP could be well monitored using automated noninvasive BP monitor, it was not inserted. The intravascular volume status was assessed by CVP, and it was maintained between 8 and 12 cmH2O.
The mean arterial pressure (MAP) in these patients should be maintained within 20% of the preoperative values. We preloaded the patient with 10 ml/kg of ringer lactate and also co-loaded with another 10 ml/kg of ringer lactate as these type of patients may not tolerate hypotension. This is because diffuse arteritis results in stenotic and noncomplaint vessels, which interfere with compensatory mechanisms to increase BP. In these cases, a pillow is placed under the patient's head to prevent any extension of neck, which may reduce the carotid blood flow by stretching the arteries, and a left lateral tilt is maintained to prevent aortocaval compression.
| Conclusion|| |
We recommend meticulous preoperative evaluation of these patients before taking up for surgery. Proper intraoperative planning is necessary for the successful management of such cases. The choice of the anesthetic technique in a parturient having TA should be decided according to the presentation of the patient. Subarachnoid block using low-dose local anesthetic and adequate preloading can be safely performed in patients with TA. The maintenance of MAP close to preoperative value should be the goal to achieve favorable outcome. Regional anesthesia is a safe technique as it obviates the need for neurological monitoring and avoids major changes in BP during intubation and general anesthesia.
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.
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Conflicts of interest
There are no conflicts of interest.
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