Emergency LSCS – Past H/o GBS
Submitted by: Dr. S. Giridharan, Consultant Anaesthesiologist
30 year old female Primi admitted to hospital at 38 weeks of gestation for safe confinement. She is booked Antenatal patient on regular checkups. No significant history from conception to present admission. Patient was admitted with pains and labor progressing well. Due to fetal distress patient was posted for emergency C section.
On pre anesthetic assessment , patient came up with the history of hospital admission around three years back for GBS (Gullian bare syndrome ). The episode started with a URI infection then followed by weakness in both lower limbs after a week, then patient got admitted . Diagnosed to be GBS, LP done. Patient was treated with IVIG and supportive care. There was no respiratory compromise. Patient was discharged after a week . No residual sequalae .
Patient was taken up for C section under spinal anesthesia since she was on full stomach. Complete neurological examination done and recorded. Risk of spinal anesthesia and chance for neurological adverse outcomes explained. Need for post op ICU care and Ventilator care (in case of respiratory compromise ) explained.
Patient was preloaded with Ringer lactate 15ml/kg. Spinal anesthesia was given at the level of L2-L3 in lateral position with 27 g quincke needle . Bupivacaine heavy 0.5% 1.8 ml used. Sensory level T8 achieved. Surgery uneventful. Post Op patient shifted to ICU and monitored for 24 hours. Intra or post operative hemodynamics were stable. No respiratory compromise.
This case leaves us with following questions
Chance of recurrence of GBS
Can surgery or anesthesia can precipitate GBS
Will Post GBS patient will pose specific risk for anesthesia ??
GA vs SA in post GBS patient
Discussion by Dr. S. Sri Vikram Prabu, Consultant Anaesthesiologist
Patient with history of GBS who comes for operation, presents with a wide range of clinical challenges to anaesthesiologist. Guillain-Barré syndrome (GBS) is an acute, frequently severe, and fulminant polyradiculoneuropathy that is autoimmune in nature. Approximately 85% of patients with GBS achieve a full functional recovery within several months to a year, although minor findings on examination (such as areflexia) may persist. About 30 percent of those with Guillain-Barré still have a residual weakness after 3 years. Between 5 and 10% of patients with typical GBS have one or more late relapses Approximately 3% of patients with acute idiopathic polyneuropathy have one or more clinically similar relapses, sometimes several years after the initial illness.
The choice of the anaesthesia for caesarean section in pregnant women recovered from GBS should be carefully evaluated because both the techniques are known for high risk in this population. The potential risk of regional anaesthesia in patients with neurological disease should not be underestimated. Good documentation of patient’s neurological deficit prior to regional anaesthesia is important for future monitoring for deterioration, as well as for medico legal reasons
Regional anaesthesia in patients with GBS has following disadvantages.
1) These patients have greater sensitivity to local anaesthetics.
2) Spread of sympathetic block may be greater than expected with unexpected hemodynamic effects
3) Patient’s fear of loss of sensation and paralysis
Administration of general anaesthesia in patient with GBS or history of it in the past is associated with potential risks. Followings are the anaesthesia concerns when administrating GA to these patients
1) Administration of succinylcholine should be avoided because of its risk of exaggerated hyperkalemia
2) Non-depolarizing muscle relaxant may result in prolonged neuromuscular block and postoperative mechanical or assisted ventilation.
3) The TOF count should be monitored from the beginning of induction of anaesthesia to prevent overdosing of muscle relaxant.
It is essential to remember that patients who have recovered from GBS may manifest an adverse reaction to anaesthesia and surgery. Careful evaluation and documentation of the patient’s baseline neurological status and timely discussion with patient regarding risk and benefits of various anaesthetic techniques will help in achieving safe perioperative outcome in a recovered case of GBS.
REFERENCES
1. Bhosale et.al/ Perioperative Management of a Recovered Case of Guillain Barre Syndrome for Emergency LSCS : Anaesthetic Implications
2. Harrison’s Principles of Internal Medicine 17th ed.
3. Current Medical Diagnosis and Treatment 2011
Chief editor Dr. V. Nagaswamy’s comment
The article is well written and I would like to add the following:
1. Choice of anaesthetic technique for emergency LSCS in both acute as well as recovered GBS patients is controversial as both RA and GA have been used with no untoward side effects.
So one has to decide on the merits of the case.
2. As for the question of relapse of GBS following RA,cases have been reported following epidural by steiner et al in 1985. But detailed information on the severity and recovery pattern following the first attack will help to take a decision regarding administration of RA.
But administration of preservative free LA drugs with less motor blockade eg. Ropivacaine can a safer option.
One DD in case of a clinical picture of relapse is CIDP- chronic inflammatory demyelanating polyradiculoneuropathy.