Anaesthetic dilemma: spinal anaesthesia in an eclamptic patient with mild thrombocytopenia and an “impossible” airway

Evaluating hemostatic thresholds for neuraxial anesthesia in adults with hemorrhagic disorders and tendencies: A scoping review

Neuraxial anesthesia can be complicated by spinal or epidural hematoma and may result in permanent neurologic injury. There is a paucity of literature characterizing this serious complication in patients with congenital and acquired hemorrhagic disorders or tendencies. The objective of this scoping review was to describe the hemostatic laboratory parameters where neuraxial anesthesia has been administered with and without spinal and epidural hematoma in patients with preexisting hemorrhagic disorders and tendencies, including immune thrombocytopenia, gestational thrombocytopenia, thrombocytopenia associated with hypertensive disorders of pregnancy, platelet function disorders, von Willebrand disease, coagulation factor deficiencies, and fibrinogen disorders. A systematic search of Ovid MEDLINE, CINAHL, Embase, Scopus, and Web of Science was performed. Two authors independently reviewed all titles, abstracts, and full texts to determine study eligibility and extract data. Qualitative synthesis of 91 studies revealed significant gaps in our understanding of the risk of spinal and epidural hematoma in patients with hemorrhagic disorders and tendencies, including few studies of males and in nonobstetric settings. Most reviewed articles were small, retrospective studies at high risk for potential bias. With such low-quality data, we were unable to provide any true estimates of the risk of spinal or epidural hematoma for these patients, nor could we attribute any specific hemostatic or laboratory values to increased risk of hematoma. There is a need both for larger and more rigorously designed and reported studies on this subject and for structured, comprehensive recommendations for safe administration and removal of neuraxial anesthesia in patients with hemorrhagic disorders and tendencies.

Spinal anaesthesia in a restless eclamptic with undiagnosed second twin: case report

The use of sub-arachnoid block in a restless eclamptic is not very common. Studies have demonstrated some benefits of sub-arachnoid block over general anaesthesia in stable eclamptic but its role in the management of unstable eclampsia has not been established. Reported below is an eclamptic parturient who was restless despite magnesium sulphate regimen and possesed features suggestive of difficult airway who had uneventful subarachnoid- block for caesarean section.

Anesthesia implications of coagulation and anticoagulation during pregnancy

Coagulation is an organized and well-orchestrated process that depends on the intrinsic balance between procoagulants, anticoagulants, and fibrinolytic systems. During pregnancy, this balance is affected in various ways and becomes more critical due to the physiologic changes and obligate hemorrhage after delivery. In some instances, this equilibrium will be disrupted. In this article, we describe the anesthetic implications of bleeding disorders, thrombophilias, and anticoagulation for the safe management of the parturient, with an emphasis on how this impacts decision-making by the anesthesiologist.

[Anesthesia and preeclampsia]

An assessment of the patient must take place as early as possible in view of anaesthesia. It is recommended to perform a clotting screen as close as possible to the performing of an epidural anaesthesia. The use of aspirin, if indicated for the prevention of PE, does not as such, constitute a contraindication to performing an epidural anaesthesia if: With regards to the minimum platelet count, the recommended cut-off value for the performing of an epidural and spinal anaesthesia are 75 & 50 x 10(9)/l respectively, only if all of the following conditions are met: It is recommended to quickly set up an epidural anaesthesia because this will improve the blood pressure as well as the utero-placenteric haemodynamics and also because this will facilitate the management in case of a caesarean section. Whereas methylergometrine (Methergin) is contraindicated in the preeclamptic patient, it is possible to use oxytocin (Syntocinion) during and after labour. Before performing a spinal anaesthesia, it is recommended to restrain the administration of crystalloids to a maximum of 1000 ml. Also the i.v. antihypertensive treatment should be reduced or interrupted until complete establishment of the anaesthetic. In case a general anaesthesia is to be performed, an assessment of the criteria for difficult intubation should be performed immediately prior to the induction. The technique employed should be a rapid sequence induction with intubation, while preventing a surge in blood pressure induced by the tracheal intubation. Difficulties to extubate should systematically be anticipated. It is possible to perform a loco-regional anaesthesia following an eclamptic crisis if the following conditions are met: In case of overlapping seizures and/or impaired consciousness, a general anaesthesia is recommended.