///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

Anaesthesia for cesarean section in a patient with Gitelmans Syndrome.

Abstract Number: 243
Abstract Type: Case Report/Case Series

Sumant Shanbhag FRCA1 ; James Neil FRCA2; Charlotte Howell FRCA3

Introduction:

Gitelmans syndrome is a rare inherited defect in the renal tubule of the kidneys. This defect causes the kidney to waste magnesium, sodium, potassium and chloride in the urine, instead of reabsorbing it back into the bloodstream. These patients have a significant risk of perioperative complications.

Case Report:

A 37 year old parturient diagnosed with Gitelmans syndrome presented for elective cesarean section at 38 weeks gestation. She had history of recurrent muscle cramps associated with hypochloremic metabolic alkalosis, hypokalemia and hypocalciuria. The patient was prescribed oral potassium and chloride supplements which had kept her symptom-free. At the time of delivery her blood results were unremarkable apart from potassium of 3.4 mmol/ litre and magnesium of 0.57 mmol/ litre. Further electrolyte supplementation was not given preoperatively as the patient was normally asymptomatic at these blood levels. Spinal anaesthetic was planned after discussing the risks and benefits with the patient. The subarachnoid block was performed with 2.6 ml of hyperbaric 0.5% bupivacaine and 300μg of diamorphine. Intraoperative period was uneventful apart from mild hypotension occurring before delivery treated with intravenous fluids and phenylephrine. Postoperatively the patient was prescribed supplemental potassium in her intravenous fluids. Regular oral potassium chloride supplements were recommenced later and electrolyte concentrations were monitored twice daily. The patient was discharged after an uneventful postoperative course 3 days later.

Discussion:

The term Bartter syndrome denotes a group of renal diseases which share a common denominator of hypokalemia and metabolic alkalosis. Gitelmans syndrome is one of the subgroups caused by defect in the thiazide-sensitive sodium-chloride cotransporter in the distal convoluted tubule of the nephron. It is associated with hypokalemia, hypomagnesemia, decreased calcium excretion, and activation of the renin-angiotensin-aldosterone axis. The renal tubular defect cannot be corrected, so the treatment of Gitelman's syndrome is based on replacement of magnesium, potassium and chloride salts to ensure normal plasma concentration. Drug treatments that may interfere with blood levels of magnesium or potassium may also need to be reviewed. Perioperative complications associated with the hypokalemia or hypomagnesemia include laryngeal spasm, stridor, paresthesia, tetany, convulsions, coma, hypotension and ventricular arrhythmias. Anaesthetic management require careful planning and preoptimisation. Regional anaesthetic techniques are more suitable in these patients avoiding use of muscle relaxants, which can have a variable response.

References

1) Amirlak I, Dawson KP. Bartter syndrome: an overview. QJM 2000 Apr; 93(4):207-15.

2) Ferrandis Capella P, Gargallo Maicas C, et.al. Anesthesia for cesarean section in Gitelman's syndrome. Rev Esp Anestesiol Reanim. 2002 Oct; 49(8):437-8.

SOAP 2009