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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

Peripartum Anesthesia Management for Elective Repeat Cesarean Section in a Parturient with Mastocytosis

Abstract Number: F5C-7
Abstract Type: Case Report/Case Series

Sheena Hembrador MD1 ; Laurent Bollag MD2

Background

Mastocytosis is a rare condition with a prevalence quoted between 0.013 - 0.4% [1,2]. It is characterized by increased mast cell activity causing anaphylactoid reactions. Anaphylactoid reactions are known to be triggered by insect stings, drugs, foods, stress, and mechanical stimulation [1]. However, these reactions can still be difficult to predict, prevent, and identify the cause. Thus surgery and anesthesia should be carefully performed to prevent mast cell degranulation.

Case

We present the case of a 34-year-old term G4P1 scheduled for elective repeat cesarean delivery (CD). She has a known diagnosis of mastocytosis symptomatically treated chronically with the antihistamines ranitidine and cetirizine. The patient tolerated general and regional anesthesia in the past, but developed anaphylactoid reactions postoperatively to codeine and aspirin. Her first CD, due to breech presentation, was performed with a combined spinal epidural using 12 mg intrathecal bupivacaine, 100 mcg epinephrine, and 10 mcg fentanyl, and routine pre-incisional IV cefazolin. She required minimal pressor support, and the CD was uneventful. Postoperatively, she had anxiety and a pain crisis since her epidural was likely too caudad resulting in uncontrolled postsurgical pain and leg weakness while running the lumbar epidural catheter.

Prior to the scheduled repeat CD, she received 8mg IV dexamethasone and her home doses of ranitidine and cetirizine. Various cardioactive drugs and vasopressors were brought to the CD suite. First, a T9-10 epidural catheter was placed for postoperative pain control and to minimize stress from potential leg weakness. Then a routine spinal with identical drugs and doses to her prior spinal was performed, and a phenylephrine (PHE) drip was initiated at 0.2 mcg/kg/min. Shortly after skin incision and completion of slow administration of 2 g of cefazolin IV, profound hypotension was noted despite initiation of PHE. The patient required several 10 mcg boluses of epinephrine, and epinephrine and norepinephrine infusions with doses as high as 0.1 and 0.08 mcg/kg/min, respectively, to maintain a systolic pressure around 100 mmHg. The patient reported mild nausea, but no other symptoms. Her postoperative course was uncomplicated. Her pain was well managed with by thoracic epidural analgesia using only bupivacaine 1/10% at 10 ml/hr.

Discussion

Successful general and regional anesthetic techniques for parturients with mastocytosis for both elective and emergent CD have been reported [3]. In this case we only used drugs and anesthetic techniques that were previously well tolerated, yet an anaphylactoid reaction still occurred. Our case illuminates how the clinical triggers of mastocytosis can fluctuate, requiring the anesthesiology team to always be prepared to treat anaphylaxis and severe hypotension perioperatively.

[1] Ciach 2016

[2] Klein 2013

[3] Villenueve 2006

SOAP 2018