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Fogang D C, Martin G, Boehlen F, Savoldelli GL. Anaesthetic management for caesarean section in a patient with hereditary haemorrhagic telangiectasia and severe epistaxis during pregnancy. BMJ Case Rep 2023; 16:e255530. [PMID: 37788916 PMCID: PMC10551871 DOI: 10.1136/bcr-2023-255530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 10/05/2023] Open
Abstract
A primigravida patient, with a history of hereditary haemorrhagic telangiectasia (HHT) manifesting as nasal angiodysplasia and hepatic arteriovenous malformations (AVM), presented for delivery planning and anaesthetic evaluation at 29 weeks of gestation. She was hospitalised several times during the second and third trimester for serious recurrent epistaxis, leading to severe anaemia. In total, she required the transfusion of 20 units of packed red blood cells during her pregnancy as well as surgical nasal haemostasis under general anaesthesia (GA). The patient was referred to our tertiary centre for delivery. In the context of recurrent severe epistaxis and high cardiac output (due to hepatic AVM) in the third trimester, a multidisciplinary decision was made to plan an elective caesarean section at 35 4/7 weeks combined with nasal packing under GA. This report discusses the implications of HHT, the multidisciplinary planning of the caesarean section, intraoperative anaesthetic management and patient follow-up.
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Affiliation(s)
- Claudie Fogang D
- Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Gallice Martin
- Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Françoise Boehlen
- Division of Angiology and Hemostasis, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
- University of Geneva, Faculty of Medicine, Geneva, Switzerland
| | - Georges L Savoldelli
- Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
- University of Geneva, Faculty of Medicine, Geneva, Switzerland
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Hiyoshi T, Shimizu K, Kimura S, Naritani T, Morimatsu H. Anesthetic management of a patient with Osler-Weber-Rendu syndrome with multiple pulmonary arteriovenous malformations and pheochromocytoma for femoral artificial bone replacement: a case report. JA Clin Rep 2023; 9:6. [PMID: 36750473 PMCID: PMC9905392 DOI: 10.1186/s40981-023-00600-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Osler-Weber-Rendu syndrome is characterized by mucocutaneous telangiectasia and arteriovenous malformations in organs. Anesthesia for patients with Osler-Weber-Rendu syndrome is challenging due to complications and physiological changes. CASE PRESENTATION The case was a 49-year-old female with Osler-Weber-Rendu syndrome, multiple pulmonary arteriovenous malformations and pheochromocytoma who presented for femoral bone head fracture with metastatic adenocarcinoma. The patient was scheduled to undergo bone tumor resection and artificial bone replacement, being positioned laterally with a planned operation duration of 5 h. Anesthesia was managed with spinal and epidural anesthesia, combined with sedation by sevoflurane using a supraglottic airway (SGA) device under spontaneous breathing. Her intraoperative and postoperative courses were uneventful. CONCLUSION Neuraxial anesthesia combined with general anesthesia using an SGA device to maintain spontaneous ventilation in order to minimize the risk of rupture of pulmonary arteriovenous malformations could be an option.
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Affiliation(s)
- Toshiharu Hiyoshi
- grid.412342.20000 0004 0631 9477Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558 Japan
| | - Kazuyoshi Shimizu
- grid.412342.20000 0004 0631 9477Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558 Japan
| | - Satoshi Kimura
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
| | - Toshiki Naritani
- grid.412342.20000 0004 0631 9477Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558 Japan
| | - Hiroshi Morimatsu
- grid.412342.20000 0004 0631 9477Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558 Japan
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Walsh E, Zhang Y, Madden H, Lehrich J, Leffert L. Pragmatic approach to neuraxial anesthesia in obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system. Reg Anesth Pain Med 2020; 46:258-267. [PMID: 33115718 DOI: 10.1136/rapm-2020-101792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/21/2020] [Accepted: 08/22/2020] [Indexed: 11/04/2022]
Abstract
Neuraxial anesthesia provides optimal labor analgesia and cesarean delivery anesthesia. Obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system present unique challenges to the anesthesiologist. Potential concerns include mechanical interference, patient injury and the need for imaging. Unfortunately, the existing literature regarding neuraxial anesthesia in these patients is largely limited to case series and rare retrospective studies. The lack of practice guidance may lead to unwarranted fear of patient harm and subsequent avoidance of neuraxial anesthesia for cesarean delivery or neuraxial analgesia for labor, with additional risks of exposure to general anesthesia. In this narrative review, we use available evidence to recommend a framework when considering neuraxial anesthesia for an obstetrical patient with neuraxial pathology.
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Affiliation(s)
- Elisa Walsh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yi Zhang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hannah Madden
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James Lehrich
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lisa Leffert
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Morales VP, Tuñón OA, Fuentes Pradera MÁ, Linero IB. Anesthetic Considerations in Hepatic Transplant in a Patient With Rendu-Osler-Weber Syndrome: A Case Report. Transplant Proc 2020; 52:589-591. [PMID: 32059941 DOI: 10.1016/j.transproceed.2019.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 11/27/2019] [Accepted: 12/26/2019] [Indexed: 10/25/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT), or Rendu-Osler-Weber syndrome, is an autosomal dominant vascular disorder with low prevalence that presents a wide variety of clinical manifestations due to multiple vascular lesions in a wide variety of organs and tissues. Orthotopic liver transplantation is the only treatment option for arteriovenous malformation in HHT. These patients require complicated anesthetic management. We present the case of a 63-year-old woman with HHT of 18 years' evolution, intrahepatic portal systemic shunts, and severe pulmonary hypertension, with dyspnea at minimum effort.
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Affiliation(s)
- Vicente Padilla Morales
- Department of Anesthesiology, Resuscitation and Pain Management, Virgen del Rocío University Hospital, Seville, Spain.
| | - Ordoño Alonso Tuñón
- Department of Anesthesiology, Resuscitation and Pain Management, Virgen del Rocío University Hospital, Seville, Spain
| | - María Ángeles Fuentes Pradera
- Department of Anesthesiology, Resuscitation and Pain Management, Virgen del Rocío University Hospital, Seville, Spain
| | - Inmaculada Benítez Linero
- Department of Anesthesiology, Resuscitation and Pain Management, Virgen del Rocío University Hospital, Seville, Spain
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Crawford M, Burns R, Cooper S, Mackay T. Hereditary haemorrhagic telangiectasia in pregnancy: regional and general anaesthesia. Int J Obstet Anesth 2018; 33:84-86. [DOI: 10.1016/j.ijoa.2017.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 11/01/2017] [Accepted: 11/09/2017] [Indexed: 11/16/2022]
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Weingarten TN, Hanson JW, Anusionwu KO, Moncrief ML, Opdahl TJ, Schneider DD, Sprung J. Management of patients with hereditary hemorrhagic telangiectasia undergoing general anesthesia: a cohort from a single academic center's experience. J Anesth 2013; 27:705-11. [PMID: 23558470 DOI: 10.1007/s00540-013-1601-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 03/17/2013] [Indexed: 12/28/2022]
Abstract
PURPOSE Hereditary hemorrhagic telangiectasia is a rare autosomal dominant disease characterized by capillary malformation leading to multisite cutaneomucosal telangiectasias and multiorgan arteriovenous malformations, which can present challenges to anesthetic care. The primary aim of this report is to present a large cohort of patients with hereditary hemorrhagic telangiectasia undergoing general anesthesia at our institution in regard to comorbid conditions and complications of surgical and anesthetic management. METHODS A computerized search from January 1, 2002 through December 31, 2011 of the Mayo Clinic medical records database was performed for patients with hereditary hemorrhagic telangiectasia who underwent general anesthesia. Medical records were reviewed. Eligibility criteria included patients with definite or suspected hereditary hemorrhagic telangiectasia based on the Curacao diagnostic criteria who underwent general anesthesia during the study period. RESULTS We identified 74 patients with hereditary hemorrhagic telangiectasia who underwent 163 surgeries. The majority had pulmonary arteriovenous malformations (56.7%) and iron deficiency anemia (64.7%), and high levels of disease burden with a median American Society of Anesthesiologist Physical Status score of 3. Most surgeries were related to treating conditions associated with hereditary hemorrhagic telangiectasia, with the majority being procedures to the nasal mucosa for recurrent epistaxis (47.2%). A sizeable proportion of procedures to the nasal mucosa required transfusion of blood (12/77). One case of epistaxis required 11 units of blood until it was successfully controlled. Another notable complication included migration of a coil to pulmonary arteriovenous malformations into the cerebral circulation. CONCLUSION Surgical patients with hereditary hemorrhagic telangiectasia often present with multiorgan involvement. The anesthesia provider needs to be aware of the high prevalence of pulmonary arteriovenous malformations, which may be asymptomatic but can lead to embolic complications. Hemorrhage from epistaxis can be severe, and relatively focal procedures to the nasal mucosa can require blood transfusions.
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Affiliation(s)
- Toby N Weingarten
- Department of Anesthesiology, Mayo Clinic College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA,
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Gludovacz K, Vlasselaer J, Mesens T, Van Holsbeke C, Van Robays J, Gyselaers W. Early neonatal complications from pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: case report and review of the literature. J Matern Fetal Neonatal Med 2011; 25:1494-8. [DOI: 10.3109/14767058.2011.629250] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Lai CF, Dennis A, Graham J. High output cardiac failure in a parturient with hereditary haemorrhagic telangiectasia. Anaesth Intensive Care 2010; 38:381-6. [PMID: 20369778 DOI: 10.1177/0310057x1003800224] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hereditary haemorrhagic telangiectasia is a genetic condition which results in arteriovenous malformations involving the skin, mucous membranes, lung, brain, gastrointestinal tract, liver and spinal canal. The shunting of blood through arteriovenous malformations, especially in the liver,; leads to maldistribution of cardiac output. In order to supply blood to vital organs, cardiac output is increased through vasodilation, elevated stroke volume and elevated heart rate. Pregnancy can worsen the effects of the arteriovenous malformations. We present the peripartum management of a woman with hereditary haemorrhagic telangiectasia predominantly involving the liver that resulted in high output cardiac failure during two consecutive pregnancies.
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Affiliation(s)
- C F Lai
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia.
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