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Epidural Anesthesia and Dysautonomia during Pregnancy
Abstract Number: T2D-7
Abstract Type: Case Report/Case Series
Introduction: Dysautonomia is an umbrella term used to describe disorders of the autonomic nervous system. Dysautonomia can be caused by a range of medical conditions including Diabetes Mellitus, Multiple System Atrophy and Familial Dysautonomia. Regardless of the underlying pathophysiology, patients with dysautonomia share common clinical features such as orthostatic hypotension, supine hypertension, altered drug sensitivity and exaggerated response to cardiovascular vasopressor drugs. Devising anesthetic plans for autonomic failure patients can be particularly challenging due to their complex, and often unpredictable, physiological response to both surgical stimuli and anesthesia. Furthermore, there is insufficient data about the effects of pregnancy and neuraxial anesthesia on dysautonomia. This report illustrates a case of severe and refractory hypotension after epidural anesthesia in a patient with dysautonomia during pregnancy.
Case: A 34-year old gravida 1, para 0 patient at 36 weeks gestational age presented for external cephalic version (ECV) in setting of breech presentation. Patient has history of dysautonomia with frequent syncopal episodes and gastroparesis. Decision was made to place a lumbar epidural catheter during ECV in preparation for potential cesarean section. An epidural catheter was placed in sitting position at the L3-4 interspace while receiving 500 ml of crystalloid fluid bolus. A total of 15 ml of Lidocaine 2% with Epinephrine 1:200,000 was administered rapidly through the epidural catheter to achieve a T5-6 level of analgesia. Five minutes after drug administration, the patient became hypotensive with systolic blood pressure reaching as low as 80 mmHg. She became nauseous and had two episodes of emesis with near syncope. Hypotension persisted for three hours requiring a total of 1280 mcg of Phenylephrine boluses in divided doses and 3 L of Lactated Ringers intravenous fluid infusion. Subsequently, the patient’s blood pressure normalized and she no longer had any further hypotensive episodes. Throughout this hypotensive episode, the patient had unremarkable fetal heart tracings. External cephalic version was not successful and patient was scheduled for cesarean section in the near future.
Conclusion: Patients with dysautonomia lack the compensatory mechanisms to maintain homeostasis in response to physiological stress. As a result, they often display exaggerated hemodynamic response to the effects of anesthesia, most commonly manifested in the form of labile blood pressure. Management strategy for dysautonomia in perioperative setting involves adequate hydration, preoperative pharmacologic optimization, conservative use of anesthetic agents, maintenance of euvolemia and adequate preparation for potential hemodynamic instability.
1. Mustafa, HI, et al. (2012) Anesthesiology 116(1):205-215
2. Rabbitts, JA, et al. (2010) Journal of Clinical Anesthesia 23, 384-392