eclampsia patients

Started by jean, March 17, 2010, 04:39:26 PM

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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, the decision to terminate the pregnancy was made as soon as possible, 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) 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 ..i am new to anesthesia and really want to learned anesthesia :) ...please help..thx u :)

regards, Jean



PRE- ECLAMPTICS usually improve on termination of pregnancy
Seizures are possible but not common after termination.

If you are planning to terminate the pregnancy
Then seizure control can be done with
MgSO4 – is alone enough to control seizures
Phenytoin bolus + Infusion
Benzodiazepine ( Keep Flumenazil and ventilatory support) ready for baby
Thiopentone infusion
Controversy about Propofol – although it has been used
NDP relaxants are also part of management protocol

Once pregnancy is terminated seizures usually stop

Benzodiazepines and Thiopentone raise seizure threshold

How do you ensure adequate CMRO2
You could monitor jugular venous saturation or do a TCD.
All high sounding stuff that I have no idea how to use

So what do I do
1.   CPP is > 90 mmHg by maintaining MAP around 100 mmHG and controlling ICP if any
2.   Ensure SaO2 and PaO2 are well within normal limits
If you do this basic things , even without advanced monitoring we can ensure adequate O2  to the brain

Intubation would be a "on the spot" decision looking at the possible edema of tongue and laryngopharynx
Call for senior help
Adequate pre-O2
Keep 5.5 mm ETT ready
Cricoid pressure, RSI
If you anticipate difficulty
FOB awake may be agood choice
Just remember that all awake intubation produce more stress response and can push the BP out of the roof.
Thankfully MgSO4 infusion can decrease the stress response
SO INTUBATE according to your expertise, experience and equipment available

It is prudent to definitely continue MgSO4 infusion through the intra-operative & post-operative period. IT will reduce seizures and stress response.
With MgSO4 one will be more worried about delayed neuromuscular recovery rather than water retention
Also most eclamptics deserve CVP Monitoring because the can be hypovolemic and at the same time prone to LVF
SO it is recommended to  manage fluids with CVP monitoring and  aim to keep the CVP a little low between 3 to 5 mm HG.

Post-operatively, the patient will benefit with elective post-op ventilation to allow seizures, cerebral edema and heamodynamic instability to settle down.
Continue with MgSO4 infusion.
After 12 hours, let them wake up and assess them
All criteria met, you can proceed to wean and extubate
Best to have a 12 hour seizure free period form the last seizure

With regard to possible residual laryngeal edema, one could try any of the following
Awake look prior to extubation
Extubation over FOB or AEC

Those are my 2 bits on this topic

People,   learning can never be one sided
So lets here views of other people too

Jean, you have all of us on the site working up our grey cells as we return to basic topics in anaesthesia
That's the way anaes goes



thx u Jafo1964... thx u very much for the concern ..the answers really really enjoyable to understand ..thx u :)

warm regards too,Jean :)