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Zahavi I, Fons M, Meir M, Volevich M, Guasch E, Nunnally M, Einav S. Anesthetic approach to pregnant patients with malaria: a narrative review of the literature. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:48. [PMID: 39060922 PMCID: PMC11282754 DOI: 10.1186/s44158-024-00185-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 07/22/2024] [Indexed: 07/28/2024]
Abstract
INTRODUCTION Anesthesiologists play an important role in the management of labor and delivery during acute malaria infection. The peripartum anesthesia considerations for such cases remain unclear. FINDINGS Important peripartum considerations include the severity of thrombocytopenia and coagulopathy, hemodynamic status and cardiac disease, and the likelihood of central nervous system (CNS) involvement. Several antimalarial drugs may interact with perioperative medications, causing hypoglycemia, methemoglobinemia, or QT prolongation. Labor should usually not be induced. Patient volume status should be optimized pre-induction, but fluids should be administered with caution given the risk of cerebral edema. In case of CNS involvement intracranial pressure should be maintained. Case reports describe the successful use of neuraxial anesthesia but this approach requires further confirmation of safety. Despite the risks accompanying airway management in pregnancy, in some cases, general anesthesia was preferred due to the chance of CNS infection and disease complications. Tight postoperative assessments of neurological and bleeding status are indicated regardless of the mode of delivery. CONCLUSIONS Despite the prevalence of malaria, the perioperative risk and preferred mode of anesthesia for pregnant patients with acute malaria remain under-researched and outcome data are limited.
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Affiliation(s)
- Itay Zahavi
- The Bruce and Ruth Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
| | - Meir Fons
- The Faculty of Medicine of the Hebrew University, Jerusalem, Israel
| | - Michal Meir
- The Bruce and Ruth Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- The Pediatric Infectious Disease Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus and Bruce and Ruth Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Mark Volevich
- The Bruce and Ruth Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Emilia Guasch
- Anaesthesia and Reanimation Department, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Mark Nunnally
- Departments of Anesthesia, Perioperative Care and Pain Medicine, Neurology, Surgery and Medicine, New York University, New York City, NY, USA
| | - Sharon Einav
- The Hebrew University Faculty of Medicine, Jerusalem, Israel
- Maccabi Healthcare Services, Sharon Region, Israel
- Medint Medical Intelligence Ltd, Tel-Aviv, Israel
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Bauer ME, Arendt K, Beilin Y, Gernsheimer T, Perez Botero J, James AH, Yaghmour E, Toledano RD, Turrentine M, Houle T, MacEachern M, Madden H, Rajasekhar A, Segal S, Wu C, Cooper JP, Landau R, Leffert L. The Society for Obstetric Anesthesia and Perinatology Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients With Thrombocytopenia. Anesth Analg 2021; 132:1531-1544. [PMID: 33861047 DOI: 10.1213/ane.0000000000005355] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Because up to 12% of obstetric patients meet criteria for the diagnosis of thrombocytopenia in pregnancy, it is not infrequent that the anesthesiologist must decide whether to proceed with a neuraxial procedure in an affected patient. Given the potential morbidity associated with general anesthesia for cesarean delivery, thoughtful consideration of which patients with thrombocytopenia are likely to have an increased risk of spinal epidural hematoma with neuraxial procedures, and when these risks outweigh the relative benefits is important to consider and to inform shared decision making with patients. Because there are substantial risks associated with withholding a neuraxial analgesic/anesthetic procedure in obstetric patients, every effort should be made to perform a bleeding history assessment and determine the thrombocytopenia etiology before admission for delivery. Whereas multiple other professional societies (obstetric, interventional pain, and hematologic) have published guidelines addressing platelet thresholds for safe neuraxial procedures, the US anesthesia professional societies have been silent on this topic. Despite a paucity of high-quality data, there are now meta-analyses that provide better estimations of risks. An interdisciplinary taskforce was convened to unite the relevant professional societies, synthesize the data, and provide a practical decision algorithm to help inform risk-benefit discussions and shared decision making with patients. Through a systematic review and modified Delphi process, the taskforce concluded that the best available evidence indicates the risk of spinal epidural hematoma associated with a platelet count ≥70,000 × 106/L is likely to be very low in obstetric patients with thrombocytopenia secondary to gestational thrombocytopenia, immune thrombocytopenia (ITP), and hypertensive disorders of pregnancy in the absence of other risk factors. Ultimately, the decision of whether to proceed with a neuraxial procedure in an obstetric patient with thrombocytopenia occurs within a clinical context. Potentially relevant factors include, but are not limited to, patient comorbidities, obstetric risk factors, airway examination, available airway equipment, risk of general anesthesia, and patient preference.
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Affiliation(s)
- Melissa E Bauer
- From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Katherine Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Yaakov Beilin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Terry Gernsheimer
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Juliana Perez Botero
- Department of Medicine, Medical College of Wisconsin and Versiti, Milwaukee, Wisconsin
| | - Andra H James
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Edward Yaghmour
- Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee
| | - Roulhac D Toledano
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Health, New York, New York
| | - Mark Turrentine
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, Liaison for the American College of Obstetricians and Gynecologists
| | - Timothy Houle
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Mark MacEachern
- Taubman Health Sciences Library, University of Michigan Medical School, Ann Arbor, Michigan
| | - Hannah Madden
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Anita Rajasekhar
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Scott Segal
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Christopher Wu
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Jason P Cooper
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Ruth Landau
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Lisa Leffert
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Leffert L, Butwick A, Carvalho B, Arendt K, Bates SM, Friedman A, Horlocker T, Houle T, Landau R, Dubois H, Fernando R, Houle T, Kopp S, Montgomery D, Pellegrini J, Smiley R, Toledo P. The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Anesthetic Management of Pregnant and Postpartum Women Receiving Thromboprophylaxis or Higher Dose Anticoagulants. Anesth Analg 2018; 126:928-944. [DOI: 10.1213/ane.0000000000002530] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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