Kevin Maurice Coleman, MD

• Assistant Professor of Medicine

https://medicine.duke.edu/faculty/kevin-maurice-coleman-md

Thromboembolic complications are not uncommon medicine lyrics cheap ventolin inhalator online visa, and anticoagulation is often recommended medicine 5000 increase ventolin inhalator 100ml order on-line. In advanced stages of this cardiomyopathy medicine 2410 ventolin inhalator 100ml sale, all the signs and symptoms of heart failure can be present medications like xanax ventolin inhalator 100 ml order line, but there is no cardiomegaly symptoms rheumatoid arthritis buy generic ventolin inhalator 100ml line. Cardiac conduction disturbances are particularly common in amyloidosis and sarcoidosis. Over time, this involvement of the conduction system can lead to heart block or ventricular dysrhythmias, resulting in sudden death. Death is usually a result of progression of congestive heart failure or sudden death associated with cardiac dysrhythmias or thromboembolic events. The chest radiograph may show signs of pulmonary congestion and/or pleural effusion, but cardiomegaly is absent. Laboratory tests should be employed as needed to diagnose the systemic disease responsible for the cardiac infiltration. Echocardiography will demonstrate significant diastolic dysfunction and normal systolic function. The atria are enlarged because of the high atrial pressures, but the ventricles are normal in size. In cardiac amyloidosis, the ventricular mass appears speckled, a characteristic sign of amyloid deposition. Various echocardiographic criteria can differentiate secondary cardiomyopathy with restrictive physiology from constrictive pericarditis. Secondary Cardiomyopathies with Restrictive Physiology Secondary cardiomyopathies with restrictive physiology are due to systemic diseases that produce myocardial infiltration and severe diastolic dysfunction. Other systemic diseases such as hemochromatosis, sarcoidosis, and carcinoid may produce a similar type of cardiomyopathy. The diagnosis should be considered in patients who have heart failure but no evidence of cardiomegaly or systolic dysfunction. The condition results from increased stiffness of the myocardium caused by the deposition of abnormal substances. Although there is impaired diastolic function and reduced ventricular compliance, systolic function is usually normal. Cardiomyopathies with restrictive physiology must be differentiated from constrictive pericarditis, which has a similar physiology. A clinical history of pericarditis makes the diagnosis of constrictive pericarditis more likely. It includes administration of diuretics to treat pulmonary and systemic congestion. Excessive diuresis may decrease ventricular filling pressures and cardiac output and result in hypotension and hypoperfusion. Digoxin must be used with great caution, because it is potentially dysrhythmogenic in patients with amyloidosis. The development of atrial fibrillation with loss of the atrial contribution to ventricular filling may substantially worsen diastolic dysfunction, and a rapid ventricular response may further compromise cardiac output. Because stroke volume tends to be fixed in the presence of cardiomyopathy with restrictive physiology, the onset of bradycardia may precipitate acute heart failure. Significant bradycardia or severe conduction system disease may require implantation of a cardiac pacemaker. Anticoagulation may be needed in patients with atrial fibrillation and/or low cardiac output. Cardiac transplantation is not a treatment option because myocardial infiltration will recur in the transplanted heart. Because stroke volume is relatively fixed, it is important to maintain sinus rhythm and to avoid any significant decrease in the heart rate. Maintenance of venous return and intravascular fluid volume is also necessary to maintain an acceptable cardiac output. Anticoagulant therapy will negatively influence the decision to select regional anesthesia. It can also result from idiopathic pulmonary artery hypertension, that is, the pulmonary hypertension that occurs in the absence of left-sided heart disease, myocardial disease, congenital heart disease, or any other clinically significant respiratory, connective tissue, or chronic thromboembolic disease. Right axis deviation and a partial or complete right bundle branch block are often seen with right ventricular hypertrophy. Radiographic signs of cor pulmonale include an increase in the width of the right pulmonary artery and a decrease in pulmonary vascular markings in the lung periphery. On a lateralprojection chest radiograph, right ventricular enlargement is indicated by a decrease in the retrosternal space. It can provide quantitative estimates of pulmonary artery pressure, assessment of the size and function of the right atrium and ventricle, and evaluation of the presence and severity of tricuspid or pulmonic regurgitation. Treatment of cor pulmonale is geared at reducing the workload of the right ventricle by decreasing pulmonary vascular resistance and pulmonary artery pressure. Oxygen supplementation to maintain the Pao2 above 60 mm Hg (oxygen saturation of >90% by pulse oximetry) is useful in both the acute and long-term treatment of right-sided heart failure. Long-term oxygen therapy decreases the mortality of cor pulmonale and improves cognitive function and quality of life. Diuretics and digitalis may be used to treat right-sided heart failure that does not respond to correction of arterial blood gases. Diuretics must be administered very carefully, because diuretic-induced metabolic alkalosis, which encourages carbon dioxide retention, may aggravate ventilatory insufficiency by depressing the effectiveness of carbon dioxide as a stimulus to breathing. Digitalis can be used for treatment of atrial fibrillation, but it must be administered very cautiously because the risk of digitalis toxicity is increased in the presence of hypoxemia, acidosis, and electrolyte imbalances. Pulmonary vasodilators, such as sildenafil and bosentan, have been shown to improve the symptoms of cor pulmonale and reduce right ventricular mass as well as right ventricular remodeling. When cor pulmonale is progressive despite maximum medical therapy, transplantation of one or both lungs or a heart-lung transplantation will provide dramatic relief of cardiorespiratory failure. By various mechanisms, chronic lung disease induces an increase in pulmonary vascular resistance. Chronic alveolar hypoxia (Pao2 <55 mm Hg) is the most important factor in this process. Long-standing chronic hypoxia promotes pulmonary vasculature remodeling and an increase in pulmonary vascular resistance. Even mild hypoxemia may result in vascular remodeling, so it appears that other factors are also involved in the development of cor pulmonale. Because of pulmonary hypertension, the right ventricle has an increased workload, and right ventricular hypertrophy develops. Over time, right ventricular dysfunction occurs, and eventually right ventricular failure is present. Clinical signs occur late in the course of the disease, and the most prominent is peripheral edema. As right ventricular function deteriorates, dyspnea increases and effort-related syncope can occur. Accentuation of the pulmonic component of the second heart sound, a diastolic murmur due to incompetence of the pulmonic valve, and a systolic murmur due to tricuspid regurgitation connote severe pulmonary hypertension. Preoperative measurement of arterial blood gases will provide guidelines for perioperative management. Induction of general anesthesia can be accomplished using any available method or drug. Adequate depth of anesthesia should be present before endotracheal intubation, because this stimulus can elicit reflex bronchospasm in lightly anesthetized patients. Anesthesia is typically maintained with a volatile anesthetic combined with other drugs. Large doses of opioids should be avoided because they can contribute to prolonged postoperative ventilatory depression. Muscle relaxants associated with histamine release should also be avoided because of the adverse effect of histamine on airway resistance and pulmonary vascular resistance. Positive pressure ventilation improves oxygenation, presumably because of better ventilation-perfusion matching. Humidification of inhaled gases helps maintain hydration, liquefaction of secretions, and mucociliary function. Intraoperative monitoring of patients with cor pulmonale is influenced by the complexity of the surgery. An intraarterial catheter permits frequent determination of arterial blood gas concentrations and subsequent adjustments in the inspired concentration of oxygen. A central venous catheter or pulmonary artery catheter may be useful depending on the surgery. Trend values of right atrial pressure can provide some information about right ventricular function. Direct measurement of pulmonary artery pressure helps determine the time to treat pulmonary hypertension and the response to treatment. Transesophageal echocardiography is an alternative method for monitoring right ventricular function and fluid status. However, the need for trained personnel and expensive equipment prevents this monitoring modality from being universally available. Regional anesthetic techniques can be used in appropriate situations in patients with cor pulmonale, but regional anesthesia is best avoided for operations that require high levels of sensory and motor block. Loss of function of the accessory muscles of respiration may be very deleterious in patients with pulmonary disease. In addition, any decrease in systemic vascular resistance in the presence of fixed pulmonary hypertension can produce a very significant degree of systemic hypotension. The respiratory and cardiovascular status of a patient with cor pulmonale must be vigilantly monitored in the postoperative period, and any factors that exacerbate pulmonary hypertension, such as hypoxia and hypercarbia, must be avoided. Heart failure is characterized by specific symptoms (dyspnea and fatigue) and signs of circulatory congestion or hypoperfusion. The principal pathophysiologic derangement in the development and progression of heart failure is ventricular remodeling. The principal treatment goals in heart failure patients are avoiding or decreasing the degree of ventricular remodeling and promoting reverse remodeling. Outflow tract obstruction is managed by maintaining hydration, increasing afterload (phenylephrine), and decreasing heart rate and myocardial contractility (-blockers and calcium channel blockers). Dilated cardiomyopathy is the most common form of cardiomyopathy and the second most common cause of heart failure. The treatment and anesthetic implications are similar to those for chronic heart failure. Cor pulmonale is right ventricular enlargement (hypertrophy and/or dilation) that may progress to right-sided heart failure. The most important pathophysiologic determinant of the development of pulmonary hypertension and cor pulmonale in patients with chronic lung disease is alveolar hypoxia. The best available treatment to improve the prognosis in these patients is long-term oxygen therapy. International Working Group on Acute Heart Failure Syndromes: Acute heart failure syndromes: current state and framework for future research. Contemporary definition and classification of the cardiomyopathies: an American Heart Association scientific statement from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional Genomics and Transplantational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention. Percutaneous left ventricular assist devices: clinical uses, future applications, and anesthetic considerations. Narrative review: pharmacotherapy for chronic heart failure: evidence from recent clinical trials. Acute benign pericarditis is unaccompanied by either a substantial pericardial effusion or cardiac tamponade and rarely progresses to constrictive pericarditis. It most commonly appears 1 to 3 days following a transmural myocardial infarction as a result of the interaction between the healing necrotic myocardium and the pericardium. The chest pain is typically acute in onset and is described as a severe pain localized over the anterior chest. This pain typically worsens with inspiration, which helps to distinguish it from pain caused by myocardial ischemia. Patients often report relief when changing position from being supine to sitting forward. Auscultation of the chest often reveals a friction rub, especially when the symptoms are acute. These high-pitched scratchy sounds occur when volumes in the heart undergo the most dramatic changes, such as during early ventricular filling and ventricular ejection. Pericardial friction rubs are related to the cardiac cycle; this makes it possible to differentiate these sounds from pleural rubs, which are related to inspiration. The three most frequent responses to pericardial injury are characterized as acute pericarditis, pericardial effusion, and constrictive pericarditis. Cardiac tamponade may present whenever pericardial fluid accumulates under pressure. Management of anesthesia in patients with pericardial disease is facilitated by an understanding of the alterations in cardiovascular function produced by pericardial disease. Intermittent pericarditis occurs in patients who have symptomfree intervals of longer than 6 weeks without drug treatment. In many patients, the symptoms of relapsing pericarditis include weakness, fatigue, and headache, and are associated with chest discomfort. Treatment may include the standard therapies for acute pericarditis and/or corticosteroids (prednisone) or immunosuppressive drugs such as azathioprine. Pericarditis after Cardiac Surgery Postcardiotomy syndrome presents primarily as acute pericarditis. The cause of this syndrome may be infective or autoimmune, and it may follow blunt or penetrating trauma, hemopericardium, or epicardial pacemaker implantation. Most commonly, it is seen in patients undergoing cardiac surgery in which pericardiotomy was performed.

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Fiberoptically guided intubation or tracheostomy should be considered in patients Blood in the subarachnoid space most commonly follows rupture of an intracranial aneurysm medications blood donation buy ventolin inhalator cheap. However 4 medications list 100 ml ventolin inhalator buy visa, it can also be seen after trauma and is usually caused by bleeding from cortical blood vessels medicine klimt ventolin inhalator 100ml order amex. It has been found in up to 40% of patients who have moderate or severe head injury treatment 3rd nerve palsy buy ventolin inhalator 100 ml amex. The most common complaint is occipital headache treatment yeast infection home purchase ventolin inhalator line, often extending into the shoulders and arms, with corresponding cutaneous dysesthesias. Signs of syringomyelia are present in approximately 50% of patients with this disorder. Subdural hematoma results from laceration or tearing of bridging veins that bleed into the space between the dura and arachnoid. Patients may view the causative head trauma as trivial or may even have forgotten it. Occasionally, subdural hematoma formation is spontaneous, such as in patients receiving hemodialysis or those being treated with anticoagulants. Signs and symptoms of a subdural hematoma characteristically evolve gradually over several days (in contrast to epidural hematomas) because the hematoma is due to slow venous bleeding. Drowsiness and obtundation are characteristic findings, but the magnitude of these changes may fluctuate from hour to hour. Lateralizing neurologic signs eventually occur, manifesting as hemiparesis, hemianopsia, or language disturbances. Conservative medical management of subdural hematomas may be acceptable for patients whose condition stabilizes, but surgical evacuation of the clot is desirable in most patients. Most subdural hematomas can be drained via burr holes; the procedure can be performed under either general anesthesia, local anesthesia, or monitored anesthesia care. If the subdural hematoma is particularly large, is chronic, or consists of clotted blood, drainage may require craniotomy. Because a subdural hematoma is usually caused by venous bleeding, normocapnia is desirable following evacuation of the hematoma to allow for a larger brain volume, which may help to tamponade any sites of venous bleeding. Pathologically, tuberous sclerosis can be viewed as a condition in which a constellation of benign hamartomatous lesions and malformations occur in virtually every organ of the body. Cardiac rhabdomyoma, although rare, is the most common benign cardiac tumor associated with tuberous sclerosis. An association of Wolff-Parkinson-White syndrome with tuberous sclerosis has been described. Oral lesions such as nodular tumors, fibromas, or papillomas may be present on the tongue, palate, pharynx, and larynx. The prognosis for patients with tuberous sclerosis depends on the organ systems involved and ranges from no symptoms to lifethreatening complications. Anesthesia management must consider the likely presence of mental retardation and a seizure disorder requiring antiepileptic drugs. Impaired renal function may have implications when selecting drugs that depend on renal clearance mechanisms. Although experience is limited, these patients seem to respond normally to inhaled and intravenous drugs, including opioids. An abnormal collection of blood located within the brain tissue proper is referred to as an intraparenchymal hematoma. These lesions can be difficult to treat because of their location and because they often acutely increase in size. Conservative management is usually initiated unless the size or rate of growth of the hematoma is likely to cause brain herniation. Pathologic processes may be diffuse or may involve only those neurons that are anatomically and functionally related. It is characterized by retinal angiomas, hemangioblastomas, and central nervous system (typically cerebellar) and visceral tumors. Although these tumors are benign, they can cause symptoms resulting from pressure on surrounding structures or bleeding. The incidence of pheochromocytoma, renal cysts, and renal cell carcinoma is increased in this syndrome. These patients may require intracranial surgery for resection of hemangioblastomas. Management of anesthesia in patients with von Hippel­ Lindau disease must consider the possible presence of a pheochromocytoma. Preoperative treatment with antihypertensive drugs is indicated if a pheochromocytoma is identified. The possibility of spinal cord hemangioblastomas may limit the use of spinal anesthesia, although epidural anesthesia has been described for cesarean section. Exaggerated hypertension, especially during direct laryngoscopy or sudden changes in the intensity of surgical stimulation, may require intervention with esmolol, labetalol, sodium nitroprusside, or a combination of these drugs. The diversity of clinical features of neurofibromatosis emphasizes the protean nature of this disease (Table 10-8). Café au lait spots (abnormal cutaneous pigmentation) are present in almost every affected individual. Café au lait spots are usually present at birth and continue to increase in number and size during the first decade of life. Although they have an adverse cosmetic effect, café au lait spots pose no direct threat to health. Neurofibromas nearly always involve the skin, but they can also occur in the deeper peripheral nerves and nerve roots and in or on viscera or blood vessels innervated by the autonomic nervous system. These neurofibromas may be nodular and discrete or diffuse with extensive interdigitations into surrounding tissues. Although neurofibromas are histologically benign, functional compromise and cosmetic disfigurement may result from their presence. The airway may be compromised when neurofibromas develop in the laryngeal, cervical, or mediastinal regions. Intracranial tumors occur in 5% to 10% of patients with neurofibromatosis and account for a major portion of the morbidity and mortality of this disease. The bilateral presence of acoustic neuromas in patients with café au lait spots establishes the diagnosis of neurofibromatosis. Congenital pseudoarthrosis-that is, a spontaneous fracture that progresses to nonunion-is commonly encountered in neurofibromatosis. The severity of pseudoarthrosis ranges from an asymptomatic radiographic presentation to a severe nonunion requiring limb amputation. Paravertebral neurofibromas are often present, but their role, if any, in the development of kyphoscoliosis is unclear. Untreated, kyphoscoliosis often progresses, leading to cardiorespiratory and neurologic compromise. These include pheochromocytoma, disturbances in sexual development, medullary thyroid carcinoma, and hyperparathyroidism. Pheochromocytomas occur with a frequency of less than 1% in adults with neurofibromatosis and are not seen in children with neurofibromatosis. The intellectual handicap is usually apparent by school age and does not progress over time. Seizures may complicate neurofibromatosis and may be idiopathic or reflect the presence of intracranial tumors. Treatment of neurofibromatosis consists of drug therapy as needed to treat symptoms, such as antiepileptic drugs, and appropriately timed surgery. Surgical removal of cutaneous neurofibromas is reserved for those lesions that are particularly disfiguring or cause functional problems. The possible presence of a pheochromocytoma should be considered during the preoperative evaluation. Patients with neurofibromatosis and scoliosis are likely to have cervical spine defects that could influence positioning for direct laryngoscopy and the subsequent surgical procedure. These patients have been described as both sensitive and resistant to succinylcholine and sensitive to nondepolarizing muscle relaxants. Selection of regional anesthesia must consider the possible future development of neurofibromas involving the spinal cord. Epidural analgesia is an effective method for producing analgesia during labor and delivery. Patients are often confused and sometimes uncooperative, which makes monitored anesthesia care or regional anesthesia challenging. There is no one single anesthetic technique or drug that is ideal in this group of patients. Shorter-acting sedative-hypnotic drugs, anesthetic agents, and narcotics are preferred since they allow a more rapid return to baseline mental status. One should be aware of potential drug interactions, especially prolongation of the effect of succinylcholine and relative resistance to nondepolarizing muscle relaxants resulting from the use of cholinesterase inhibitors. Increasing age is the single most important risk factor in the development of this disease. There is a characteristic loss of dopaminergic fibers normally present in the basal ganglia, and as a result, regional dopamine concentrations are depleted. Dopamine is presumed to inhibit the rate of firing of the neurons that control the extrapyramidal motor system. Depletion of dopamine results in diminished inhibition of these neurons and unopposed stimulation by acetylcholine. The earliest manifestations may be loss of associated arm swings when walking and absence of head rotation when turning the body. There is facial immobility manifested by infrequent blinking and by a paucity of emotional expressions. Tremors are characterized as rhythmic, alternating flexion and extension of the thumbs and other digits (pill-rolling tremor). Tremors are more prominent during rest and tend to disappear during voluntary movement. Replacement therapy with the dopamine precursor levodopa combined with administration of a decarboxylase inhibitor, which prevents peripheral conversion of levodopa to dopamine and optimizes the amount of levodopa available to enter the central nervous system, is the standard medical treatment. Levodopa is associated with a number of side effects, including dyskinesias and psychiatric disturbances. The increased myocardial contractility and heart rate seen in treated patients may reflect increased levels of circulating dopamine converted from levodopa. It is the most common cause of dementia in patients older than 65 years of age and the fourth most common cause of diseaserelated death in patients older than age 65. Diffuse amyloidrich senile plaques and neurofibrillary tangles are the hallmark pathologic findings. There are also changes in synapses and in the activity of several major neurotransmitters, especially involving acetylcholine and central nervous system nicotinic receptors. In both forms of the disease, patients typically develop progressive cognitive impairment that can consist of problems with memory as well as apraxia, aphasia, and agnosia. Pharmacologic options include cholinesterase inhibitors such as tacrine, donepezil, rivastigmine, and galantamine. Drug therapy should be combined with nonpharmacologic therapy including caregiver education and family support. Selegiline has an advantage over nonspecific monoamine oxidase inhibitors because it is not associated with the occurrence of tyramine-related hypertensive crises. Stimulation of the various nuclei within the basal ganglia via an implanted deep brain stimulating device can relieve or help to control tremor. Pallidotomy is associated with significant improvement in levodopa-induced dyskinesias, although the improvement may be short-lived. However, in certain circumstances, such as in patients with developmental delay or those with severe claustrophobia, the procedure is performed under general anesthesia. The deep brain electrode is then advanced through a burr hole, often with microelectrode recordings taken, since specific nuclei differ in their spontaneous firing patterns. The target tissue is then stimulated via the electrode to determine if clinical symptoms abate. Following successful brain lead placement, a generator pack is implanted below the clavicle or in the abdomen. Of note, deep brain stimulation is currently under investigation for treatment of a variety of other disorders, such as Hallervorden-Spatz disease, depression, and eating disorders. The elimination half-time of levodopa and the dopamine it produces is brief, so interruption of drug therapy for more than 6 to 12 hours can result in an abrupt loss of therapeutic effects. Abrupt drug withdrawal can also lead to skeletal muscle rigidity, which can interfere with ventilation. Therefore, levodopa therapy, including the usual morning dose on the day of surgery, must be continued throughout the perioperative period. Oral levodopa can be administered approximately 20 minutes before induction of anesthesia, and the dose may be repeated intraoperatively and postoperatively via an orogastric or nasogastric tube as needed. The possibility of hypotension and cardiac dysrhythmias must be considered, and butyrophenones. Acute dystonic reactions following administration of alfentanil might indicate an opioidinduced decrease in central dopaminergic transmission. The use of ketamine is controversial because of the possible provocation of exaggerated sympathetic nervous system responses, but ketamine has been administered safely to patients treated with levodopa. Patients undergoing deep brain stimulator implantation may have been told by the surgeon to refrain from taking the usual morning dose of levodopa to facilitate the return of tremors and enhance sensitivity in detecting the efficacy of deep brain stimulation during the procedure. If that is the case, then establishment of intravenous access may prove challenging in an extremity with a significant tremor. Patients should receive minimal sedation during lead placement to prevent interference with microelectrode recordings and clinical assessment.

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For patients with preeclampsia treatment innovations ventolin inhalator 100 ml line, many anesthesiologists are comfortable placing neuraxial blocks with platelet counts as low as 75 medications not to take after gastric bypass discount 100ml ventolin inhalator with visa,000/mm3 symptoms kidney stones buy ventolin inhalator 100ml, provided the count is stable and not falling and that there are no signs of clinical bleeding at venipuncture sites symptoms for mono cheap ventolin inhalator 100ml visa, gums medications on backorder cheap ventolin inhalator 100ml without prescription, or other locations. Thromboelastography can add information if the test is available, but there is still no cutoff value of any variable that predicts complications. Because pregnancy is a prothrombotic state, parturients have significant hemostatic reserves before becoming coagulopathic. Such a low incidence is reassuring, but it remains important to balance the riskbenefit ratio for each patient. Factors supporting regional anesthesia, even with borderline coagulation studies, include a worrisome airway examination, the prospect of a lengthy induction of labor, and the rarity of an epidural hematoma. Factors that support use of intravenous opioids for labor or general anesthesia for cesarean delivery are clinical signs of bleeding, a rapidly worsening platelet count, the need for an urgent cesarean, and a reassuring airway examination. An intravenous bolus loading dose of 2 to 3 µg/kg is administered to make the patient comfortable. As labor progresses and titration is needed, the lockout is decreased from 10 to 5 minutes, and the bolus dose is then increased from 50 to 75 µg. In the past, spinal anesthesia was avoided because of concerns that hypotension would be more severe and less treatable than that seen after sympathectomy from an epidural anesthetic. However, a comparison of women with severe preeclampsia to healthy women (all having a cesarean delivery with spinal anesthesia) found that preeclamptic women had less hypotension (17% versus 53%), despite receiving less fluid preload and (by chance) a larger dose of bupivacaine in their spinal. Clinical studies in humans have consistently shown that use of -agonists such as phenylephrine produce better umbilical pH values in the newborn than use of ephedrine. If general anesthesia is chosen, the areas of concern are attenuating hypertensive responses during laryngoscopy and intubation, managing a difficult edematous airway, and treating complications related to magnesium therapy such as uterine atony and maternal weakness. A number of adjuncts to rapidsequence induction have been described and used successfully to control hypertension associated with laryngoscopy. At 70 Anesthesia Considerations for Complicated Pregnancies 1177 least one should be included as part of a rapid-sequence induction, and they should be immediately available to treat hypertension if it occurs. Magnesium sulfate is a uterine relaxant, and additional oxytocics such as Cytotec or Hemabate should be available to treat uterine atony after delivery in addition to the oxytocin infusion. If the mother has a high level of magnesium and exhibits muscle weakness before induction. Nondepolarizing muscle relaxants such as vecuronium or rocuronium should be avoided due to difficulty with reversal and residual weakness in the presence of magnesium. If the patient cannot meet the criteria for safe extubation at the end of the cesarean, she may require a brief period of mechanical ventilation until she is strong enough to protect her airway. The mother may need acute and long-term blood pressure control with antihypertensives. Fluid mobilization begins to occur during the first 24 hours after delivery, and this is when she is at greatest risk for pulmonary edema. If she has an epidural catheter in place, decide when removal is appropriate based on her platelet count and coagulation studies. A review of 89 cases of eclampsia found that 33% of seizures occurred after delivery and that 79% of those manifested more than 48 hours after the birth. If asked to evaluate a postpartum headache, be vigilant and consider late-presenting preeclampsia in the differential diagnosis. Respiratory Diseases Asthma and pulmonary thromboembolism are two causes of respiratory insufficiency during pregnancy and the postpartum period. Pregnancy is associated with a fourfold increase in the risk of thromboembolism and is a major contributor to maternal mortality. Deaths in the United States due to thrombotic pulmonary embolism have also declined, accounting for 9. Signs or symptoms of a new-onset venous thrombosis in the lower extremities require compression ultrasonography as the recommended diagnostic test. Therapeutic anticoagulation is recommended for women with a thrombotic event during the current pregnancy or a highly thrombogenic thrombophilia. A major consideration for patients receiving heparins is timing for placement of neuraxial blocks and removal of epidural catheters. If these guidelines cannot be met or anticoagulation must be continued, the patient should receive parenteral medications for labor analgesia or general anesthesia for cesarean delivery. Medications to be avoided in asthmatics during labor and delivery are Hemabate, drugs with unopposed 1-antagonist activity, and nonsteroidal antiinflammatory medications if she is aspirin sensitive. Alveolar ventilation increases during pregnancy so that Po2 is higher, whereas increases in minute ventilation decrease Po2 by 8 to 10 mm Hg. A pregnant patient with an asthma exacerbation whose arterial blood gas determinations indicate normal (for nonpregnant women) Po2 and Pco2 levels is already hypoxic, hypercarbic, and decompensating (Table 70-7). Analgesia with neuraxial blocks reduces oxygen consumption and minute ventilation during labor without sedation or decreased respiratory drive. For cesarean delivery, regional anesthesia is preferred to avoid instrumentation of her reactive airway. If general anesthesia is required, induction with ketamine provides bronchodilatation through its sympathomimetic properties, and propofol can suppress airway reflexes better than other induction agents. The volatile anesthetics are excellent bronchodilators, but they can be used only in small doses during cesarean delivery because subsequent uterine atony may occur. When spinal or epidural anesthesia is used for cesarean delivery, the high level of sympathetic blockade can theoretically induce bronchospasm, but that does not seem to occur. Respiratory failure from pulmonary embolism, asthma exacerbation, or other causes may require endotracheal intubation as part of management. The failed intubation rate (1 failed intubation in 275 attempted intubations) for obstetric patients is thought to be about 10 times higher than the rate for general operating room patients. Physiologically, the pregnant patient has reduced functional residual capacity and increased oxygen consumption, which shortens the interval from apnea to desaturation and hypoxia. Although not studied, urgent intubations for respiratory failure in an obstetric patient outside the operating room setting presumably have the potential to be even more difficult. The key to successfully approaching intubation in the pregnant patient is preparation of drugs and equipment and having an algorithm for the next steps if the initial attempt is unsuccessful. If the procedure is taking place outside the operating room, it follows gathering airway equipment, proper positioning, assuring adequate suction, and pre-oxygenation of the patient. The most experienced anesthesia provider should make the first attempt or be ready to immediately take over if the first attempt is unsuccessful. In most cases, a short-acting induction agent is used for hypnosis: propofol or ketamine if bronchospasm is present or etomidate or ketamine if hemodynamic instability is a concern. Succinylcholine provides rapid-onset muscle relaxation to facilitate laryngoscopy. The key to successful treatment of sepsis is early initiation of antibiotics and control of the source of infection. Consultation with infectious disease specialists may be appropriate if the source of infection is unclear or if there is no response to initial antibiotic choices. Sepsis is an infection with a systemic inflammatory response defined as temperature greater than 38° C or less than 36° C, heart rate greater than 90 beats/min, tachypnea greater than 20 breaths/min, and a white blood cell count more than 12,000 cells/mm3 or less than 4000 cells/mm3. However, the physiologic changes of pregnancy and the stress of labor can also cause tachycardia, tachypnea, and an elevated white blood cell count. The systemic inflammatory response in pregnancy results in higher morbidity and mortality rates for conditions such as acute pyelonephritis, varicella infection, and influenza. Renal insufficiency in pregnancy is often associated with systemic lupus, diabetes, preeclampsia, or sepsis. Because creatinine levels in pregnancy are roughly one half that of a nonpregnant patient, mild renal insufficiency is diagnosed at a creatinine level of 0. Drug dosing may need to be altered if the primary route of drug excretion is glomerular filtration. Fluid status should be optimized to maintain renal perfusion, and central monitoring may be necessary to assess filling pressure if urine output is low. Dialysis can be used safely in 70 Anesthesia Considerations for Complicated Pregnancies 1179 Attempted intubation has failed. If this is an elective or non-emergent cesarean, consider letting the patient awaken, then proceed with neuraxial anesthesia or awake intubation techniques. This approach is applicable when intubation is required for respiratory failure or cesarean delivery. The initial resuscitation of the patient with sepsis should include the following: large-bore intravenous access, blood drawn for cultures, intravenous antibiotics given within 1 hour of diagnosis, fluid resuscitation, and consultation from the critical care service, including perinatologists, anesthesiologists, and intensivists. Blood drawn from a central venous line can be used as a surrogate for true mixed venous saturations, and it represents the balance between global oxygen delivery and oxygen consumption. Future work will be aimed at determining how to attenuate the systemic inflammatory response and how it is different in pregnancy. Blood products may be preferable, especially when anemia or coagulopathy require treatment. If ventilation is needed to maintain oxygenation, intubate early in her course before the airway becomes edematous. Arterial lines are low-risk, useful for obtaining blood samples, and necessary when using pressors and inotropes. Central venous access may be needed for administering pressors and inotropes, but are less useful for monitoring. Pulmonary artery catheters increase risk of complications and have shown no improvement in outcomes. These mothers were also found to abuse other substances and have higher rates of domestic violence and adoption. The anesthesia considerations for parturients abusing amphetamines or cocaine are primarily the control of hemodynamics. Hypotension often responds better to the direct effects of phenylephrine than to ephedrine, which acts through the release of catecholamines. If general anesthesia is needed for urgent cesarean delivery, techniques should be used to attenuate the hemodynamic response to intubation. This may include a combined - and -blocking agent such as labetalol to control heart rate and provide vasodilation. Using a vasodilator such as hydralazine to treat hypertension could lead to severe tachycardia and arrhythmias unless there is accompanying -blockade. Other adjuncts to prevent hypertension during induction of general anesthesia may include short-acting opioids such as remifentanil (1 µg/kg) or lidocaine (1. Methamphetamine abuse is associated with severe tooth decay ("meth mouth"), and the preanesthesia airway examination should include documentation of any loose teeth that may be dislodged during laryngoscopy. Mothers taking methadone for management of opioid dependence at the time of delivery tend to be younger smokers who receive late prenatal care. The use of opioid analgesics during early pregnancy is associated with cardiac and other anomalies, including ventricular septal defects, atrial septal defects, hypoplastic left heart syndrome, spina bifida, and 70 Anesthesia Considerations for Complicated Pregnancies 1181 gastroschisis. A comparison of methadone with buprenorphine for treatment of opioid dependence during pregnancy found that neonates had better outcomes with buprenorphine, including a shorter hospital stay, lower morphine requirement, and shorter duration of treatment for the neonatal abstinence syndrome, but mothers discontinued treatment more often in the buprenorphine group (33% versus 18% of mothers in the methadone group). The anesthesia goals for the patient with opioid tolerance are preventing withdrawal by providing adequate amounts of opioids and maintaining adequate intrapartum and postpartum analgesia. Mixed agonist-antagonist opioids such as butorphanol and nalbuphine must be avoided to prevent precipitating withdrawal. Neuraxial analgesia should be used if the patient is cooperative because of the high tolerance these patients have to parenteral opioids. In addition to the local anesthetic and opioid mixtures normally used in neuraxial infusions, the addition of clonidine can be considered. Preoperative gabapentin (Neurontin, 600 mg given orally) can improve postcesarean analgesia and maternal satisfaction, although increased sedation is a recognized side effect of gabapentin. If the fetus is previable or dead, care should focus on optimizing the maternal condition. In most circumstances, the mother can tolerate induced labor at a later time better than an immediate laparotomy for cesarean delivery. The anesthesia considerations focus on protection of her airway, maintaining oxygenation by intubation and ventilation if necessary, stabilizing the cervical spine when indicated, and maintaining hemodynamic stability through uterine displacement, fluid administration, and blood product replacement. The need for large-bore intravenous access and invasive hemodynamic monitoring is assessed on an individual basis. In collaboration with the obstetric team and the trauma surgeons, the anesthesiologist continues to provide care for the woman if she requires an operative procedure or delivery of the fetus. Often, alternatives can be suggested that are more appropriate for the pregnant patient. Anesthesiologists bring their experience with parturients in the labor and delivery unit, a strong critical care background, and expertise in providing medical care to a wide variety of patients in the operating room. A communication system should be in place to encourage early and ongoing contact between obstetric providers, anesthesiologists, and other members of the multidisciplinary team. An ultrasound study should be performed early in the emergency room to determine gestational age and fetal viability, and fetal monitoring should be continued if the fetus is living and of a viable gestational age. Pregnancy should not alter any necessary evaluations or treatments for the mother. She should receive all needed diagnostic tests to optimize her management, with shielding for the fetus when possible. James D, Steer P, Weiner C, et al: Pregnancy and laboratory studies: a reference table for clinicians, Obstet Gynecol 114:1326, 2009. Grumebaum A, Chervenak F, Skupski D: Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events, Am J Obstet Gynecol 204:97, 2011. Knight M, Tuffnell D, Brocklehurst P, et al: Incidence and risk factors for amniotic-fluid embolism, Obstet Gynecol 115:910, 2010. Davies S: Amniotic fluid embolus: a review of the literature, Can J Anesth 48:88, 2001. Hidano G, Uezono S, Terui K: A retrospective survey of adverse maternal and neonatal outcomes for parturients with congenital heart disease, Int J Obstet Anesth 20:229, 2011.

Diseases

• XY Female
• Adrenal insufficiency
• Occupational asthma - grains, flours, plants and gums
• Mental retardation multiple nevi
• Willebrand disease, acquired
• Pseudomyxoma peritonei
• Lymphoma, AIDS-related
• Hepatitis
• Mental retardation macrocephaly coarse facies hypotonia
• Listeria infection

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