Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1590/S0034-70942003000400007
Brazilian Journal of Anesthesiology
Clinical Information

Hiperreflexia autonômica em gestante tetraplégica: relato de caso

Autonomic hyperreflexia in tetraplegic pregnant patient: case report

Ricardo Francisco Simoni; Marcello Roberto Leite; Renata Fófano; Marcelo Giancoli; Luiz Marciano Cangiani

Downloads: 2
Views: 1456

Resumo

JUSTIFICATIVA E OBJETIVOS: As complicações da gestante com lesão medular incluem infecções urinárias, calculose renal, anemia, úlceras de decúbito, espasmos musculares, sepsis, hiperatividade uterina e a hiperreflexia autonômica. Durante a anestesia a hiperreflexia autonômica é a complicação mais importante, que deve ser, antes de tudo, prevenida. Ela é freqüentemente desenvolvida em pacientes com transecção medular ao nível da quinta à sétima vértebra torácica, ou acima. Nosso relato tem com objetivo apresentar um caso de gestante tetraplégica, com lesão ao nível da sexta vértebra cervical, que se submeteu à operação cesariana sob anestesia peridural contínua com bupivacaína a 0,25% sem vasoconstritor, associada ao fentanil. RELATO DO CASO: Paciente tetraplégica, primigesta à termo, idade gestacional de 39 semanas, branca, 22 anos, 63 kg, 168 cm de altura, estado físico ASA II, internada para ser submetida a cesariana eletiva. Relatava trauma raquimedular ao nível de C6 há 3 anos. Após hidratação prévia com 1500 ml de solução fisiológica, procedeu-se à anestesia peridural com punção mediana no espaço L3-L4 com a paciente em decúbito lateral, agulha Tuohy descartável calibre 17G e sem botão anestésico prévio. Imediatamente após a introdução da agulha, observou-se contração da musculatura paravertebral adjacente, aumento da pressão arterial (PA = 158 x 72 mmHg) e aumento da freqüência cardíaca (FC = 90 bpm). No entanto, a paciente não relatava dor. Retirou-se agulha e fez-se o botão anestésico, dando-se seqüência ao bloqueio peridural, com injeção de 20 ml de bupivacaína a 0,25% sem vasoconstritor associados a 100 µg de fentanil espinhal e passagem de cateter peridural em sentido cefálico (3 a 4 cm). A cirurgia transcorreu sem intercorrências, não havendo necessidade de complementação do bloqueio em nenhum momento. Houve dois episódios de hipotensão arterial nas primeiras 24 horas do pós-operatório, tratados com infusão de solução de Ringer com lactato. O cateter peridural foi mantido por 48 horas. A alta hospitalar ocorreu após três dias de internação. CONCLUSÕES: Para gestantes paraplégicas ou tetraplégicas a anestesia peridural contínua com baixa concentração de anestésico local sem vasoconstritor associado ao fentanil é uma boa indicação para condução do parto normal instrumentado ou não, como o parto cesariano, a fim de evitar a hiperreflexia autonômica. Deve-se dar importância também à permanência do cateter peridural no pós-operatório por pelo menos 24 horas após o parto, com a intenção de bloquear a aferência simpática, caso venha desencadear alguma crise.

Palavras-chave

CIRURGIA, CIRURGIA, DOENÇAS,, DOENÇAS,, TÉCNICAS ANESTÉSICAS, TÉCNICAS ANESTÉSICAS

Abstract

BACKGROUND AND OBJECTIVES: Complications of pregnant patients with medullary injury include urinary infection, renal stones, anemia, decubitus ulcers, muscle spasms, sepsis, uterine hyperactivity and autonomic hyperreflexia. Autonomic hyperreflexia is the most severe anesthetic complication and should, before all, be prevented. It is often developed in patients with medullary transection at the level of the 5th to 7th thoracic vertebra or above. This report aims at presenting a case of tetraplegic pregnant patient with injury at the level of the 6th cervical vertebra, submitted to Cesarean section under continuous epidural anesthesia with 0.25% bupivacaine without vasoconstrictor associated to fentanyl. CASE REPORT: Caucasian, tetraplegic primiparous term patient, 39 weeks of gestational age, 22 years old, 63 kg, 168 cm, physical status ASA II, admitted for elective Cesarean section. Patient reported spinomedullary trauma at C6, three years ago. After previous hydration with 1500 ml saline, epidural anesthesia was induced with medial puncture at L3-L4 interspace with the patient in the lateral position, disposable 17G Tuohy needle and without previous local infiltration anesthesia. Immediately after needle insertion, there was adjacent paravertebral muscles contraction, blood pressure increase (BP = 158 x 72 mmHg) and heart rate increase (HR = 90 bpm). Patient, however, did not refer pain. Needle was removed and local anesthesia was induced. Epidural block proceeded with 20 ml of 0.25% bupivacaine without vasoconstrictor associated to 100 µg spinal fentanyl and epidural catheter insertion in the cephalad direction (3 to 4 cm). Surgery went on without intercurrences with no need for blockade complementation. There were two arterial hypotension episodes in the first 24 postoperative hours, which were treated with lactated Ringer’s solution. Epidural catheter was maintained for 48 hours. Patient was discharged three days after. CONCLUSIONS: For paraplegic or tetraplegic pregnant patients, continuous epidural anesthesia with low local anesthetic concentration without vasoconstrictor and associated to fentanyl is a good indication for instrumented or not vaginal delivery, and Cesarean sections to prevent autonomic hyperreflexia. It is also important that the epidural catheter remains for at least 24 hours after delivery to block sympathetic afference in case a crisis is triggered.

Keywords

ANESTHETIC TECHNIQUES, ANESTHETIC TECHNIQUES, DISEASE,, DISEASE,, SURGERY, SURGERY

References

Young BK. Pregnancy in Women with Paraplegia. Neurological Complications of Pregnancy. 1994:209-214.

Hambly PR, Martim B. Anaesthesia for chronic spinal cord lesions. Anaesthesia. 1998;53:273-289.

Saraiva RA, Piva Jr L, Paz Jr AC. As bases fisiopatológicas para a anestesia no paciente com lesão medular. Rev Bras Anestesiol. 1995;45:387-398.

Watson DW, Downey GO. Epidural anesthesia for labor and delivery of twins of a paraplegic mother. Anesthesiology. 1980;52:259.

Stirt JA, Marco A, Conklin KA. Obstetric anesthesia for a quadriplegic patient with autonomic hyperreflexia. Anesthesiology. 1979;51:560.

Atterbuty JL, Groome LJ. Pregnancy in women with spinal cord injury. Nurs Clin North Am. 1998;33:603-613.

Obstetric Management of Patients with Spinal Cord Injury. 1993;121.

Evans DE, Kobrine AI, Rizzoli HV. Cardiac arrhythmia’s accompanying acute compression of the spinal cord. Neurosurg. 1980;52:52-59.

Albin MS. Spinal Cord Injury. Anesthesia and Neurosurgery. 1994:713-743.

Alderson JD. Chronic Care of Spinal Cord Injury. Spinal Cord Injuries: Anaesthetic and Associated Care. 1990:104-125.

Bishop MN. Autonomic Hyperreflexia. Anesthesiology Review. 1991:345-346.

Head H, Riddoch G. The autonomic bladder, excessive sweating and some other reflex conditions in gross injury of the spinal cord. Brain. 1917;40:188-263.

Kendrick W, Scott J, Jousse A. Reflex sweating and hypertension in traumatic transverse myelitis, treatment serv bull. 1953;8:437-448.

Gimovsky M, Ojeda A, Ozaki R. Management of autonomic hyperreflexia associated with a low thoracic spinal cord lesion. Am J Obstet Gynecol. 1985;153:223-224.

Cross LL, Meythaler JM, Tuel SM. Pregnancy, labor and delivery post spinal cord injury. Paraplegia. 1992;30:890-892.

Brian J, Clark R, Quirk J. Autonomic hyperreflexia, cesarean section and anesthesia: A case report. J Reprod Med. 1988;33:645-648.

McGregor J, Meeuwsen J. Autonomic hyperreflexia: a mortal danger for spinal cord damaged women in labor. Am J Obstet Gynecol. 1985;151:330-333.

Roussan M, Abramson A, Lippman H. Somatic and autonomic responses to bladder filling in patients with complete transverse myelopathy. Arch Phys Med. 1966;47:450-456.

Tabsh K, Brinkman C, Reff R. Autonomic dysreflexia in pregnancy. Obstet Gynecol. 1982;60:119-121.

Huges SJ, Short DJ, Usherwood MM. Management of the pregnant woman with spinal cord injuries. Br J Obstet Gynaecol. 1991;98:513-518.

Baker ER, Diana MD, Cardenas MD. Pregnancy in spinal cord injured women. Arch Phys Med Rehabil. 1996;77:501-507.

Kurnick N. Autonomic hyperreflexia and its control in patients with spinal cord lesions. Ann Intern Med. 1956;44:678-686.

Pardina A, Metje T, Villalonga A. Embarazo y parto en la mujer con lesión medular em fase crónica. Rev Esp Anest Rean. 2001;48:93-96.

Owen MD, Stiles MM, Opper SE. Autonomic hyperreflexia in a pregnant paraplegic patient. Case Report. Reg Anesth. 1994;19:415-417.

Greenspoon JS, Paul RH. Paraplegia and quadriplegia: special considerations during pregnancy and labor and delivery. Am J Obstet Gynecol. 1986;155:738-741.

Nygaard I, Bartscht KD, Cole S. Sexuality and reproduction in spinal cord injured women. Obstet Gynecol Surg. 1990;45:727-732.

Boucher M, Santerre L, Menard L. Epidural and labor in paraplegics. Can J Obstet Gynecol. 1991;3:130-132.

management of labor and delivery for patients with spinal cord injury. Am Coll Obstet Gynecol Committee. 1993;121:1-2.

Agostini M, Giorgio E, Beccaria P. Combined Spinal-epidural anaesthesia for caesarian section in a paraplegic woman: difficulty in obtaining the expected level block. Eur J Anaesth. 2000;17:329-331.

Kobayyashi A, Mizobe T, Tojo H. Autonomic hyperreflexia during labour. Can J Anaesth. 1995;42:1134-1136.

Crosby E, St-Jean B, Reid D. Obstetrical anaesthesia and analgesia in chronic spinal cord injured women. Can J Anaesth. 1992;39:487-494.

Abouleish EI, Hanley ES, Palmer SM. Can Epidural fentanyl control autonomic hyperreflexia in a quadriplegic patient?. Anesth Analg. 1989;68:523-526.

Huges SC. Anesthesia for the Pregnant Patient with Neuromuscular Disorders. Anesthesia and Obstetrics. 1993:563-580.

Eisenach JC, Castro MI. Maternally administered esmolol produces fetal beta-adrenergic blockade and hypoxemia in sheep. Anesthesiology. 1989;71:718-722.

Sauer PM, Harvey CJ. Spinal cord injury and pregnancy. J Perinatal Neonatal Nursing. 1993;7:22-27.

Perkash A, Brown M. Anemia in patients with trauma spinal cord injury. Paraplegia. 1982;20:235-236.

5ddd32410e88255f771da3e9 rba Articles
Links & Downloads

Braz J Anesthesiol

Share this page
Page Sections