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Anesth Analg 2003;96:859-861 © 2003 International Anesthesia Research Society
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Abstract |
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 Top Abstract IntroductionCase ReportDiscussionReferences |
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IMPLICATIONS: This case report describes an allergic reaction attributed to colloid administration before a semi-urgent cesarean delivery. The most challenging part of this event was related to the anesthetic and obstetric treatment options to avoid further compromise of both mother and fetus.
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Introduction |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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Prehydration before cesarean delivery is the subject of much debate (1). Several studies have demonstrated that colloids, in particular hydroxyethylstarch, may be superior to crystalloids for hydration before spinal anesthesia for cesarean delivery because they increase the circulating blood volume while also preserving the oncotic pressure (2–4). However, because these substances may cause allergic reactions, they are not used in some countries during obstetric anesthesia. We report an allergic reaction to pentastarch before initiation of spinal anesthesia for cesarean delivery.
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Case Report |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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A 28-year-old nulliparous patient, weighing 85 kg with a height of 157 cm was admitted to our hospital because of a worsening preeclampsia at 28 wk gestation. Her blood pressure was 187/92 mm Hg on admission despite the administration of oral atenolol 50 mg twice a day (bid). Additional therapy with oral felodipine 5 mg bid was initiated. However, on the fourth hospital day, all liver tests were abnormally increased (Table 1) whereas the platelet count had decreased from 157,000 to 121,000/mm3. On the fifth day, her platelet count further decreased to 88,000/mm3 and all liver function test results worsened. Coagulation tests and fibrinogen level, however, remained normal. She also complained of scotoma and epigastric pain. Her blood pressure, which was initially showing signs of improvement, increased again to 171/117 mm Hg despite increased doses of felodipine 10 mg, bid, and additional treatment with IV magnesium sulfate. Although the fetal condition was stable, it was decided to perform a semi-urgent cesarean delivery for worsening severe preeclampsia.
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With a platelet count of 88,000/mm3 and no clinical signs of coagulopathy, a single-shot spinal technique was chosen.
As per our standard practice, upon arrival in the operating room, a 6% pentastarch infusion was started. Within the first minute after administration of <20 mL, she developed moderate bronchospasm, erythema, perifascial edema, and hypotension. The blood pressure gradually decreased to 100/77 mm Hg and oxygen saturation to 90%. An indwelling radial artery catheter was placed. Despite initial treatment with oxygen 5 L/min by facemask, ephedrine in increments of 5–10 mg and ranitidine 50 mg, her edema increased whereas the blood pressure continued to decrease and oxygen saturation remained at approximately 88%. Additional medical treatment consisted of tranexaminic acid 1500 mg, promethazine 25 mg, methylprednisolone 125 mg, and aminophylline 240 mg. The total dose of ephedrine was 40 mg. Although the maternal condition was initially unstable, the fetal heart rate tracings remained reassuring with a rate of 160 bpm and good beat-to-beat variability. A decision was therefore made to delay surgery until the mother’s condition improved. Forty-five minutes after the allergic event, the patient was transferred to the intensive care unit. Upon arrival, an internal jugular venous catheter was inserted and showed a central venous pressure of 5 mm Hg. Oxygen saturation had increased to 95%. An aerosol containing 250 µg ipratropium bromide was started. Over the next 4 h, her condition significantly improved. Urine output averaged 60 (range, 32–86) mL/h. The edema required approximately 10 h to subside. At that time, her liver function tests and platelet count were better than they had been before the originally intended surgical delivery. Because of transcapillary fluid loss, her hematocrit of 35% before surgery increased to 44% 1 h after the allergic reaction, but returned to baseline (36%) 6 h later. Uterine activity and fetal heart rate were monitored continuously and remained within normal limits. The following morning, the patient was again scheduled for cesarean delivery. At that time, the liver function tests had improved, the platelet count remained stable at 77,000/mm3, and the blood pressure was 200/115 mm Hg. Based on clinical examination, a stable platelet count, and a normal thromboelastogram (maximal amplitude values 65 mm), a single-shot spinal anesthetic was chosen. After the spinal administration of 7 mg of hyperbaric bupivacaine with sufentanil 4 µg, she developed a T6 block and underwent an uneventful delivery without development of hypotension. The blood pressure decreased to 175/100 mm Hg and 145/90 mm Hg, before and after delivery, respectively. The baby weighed 1040 g, had Apgar scores of 7/8/8, but needed to be intubated within the first hour because of respiratory distress. Both mother and neonate recovered uneventfully.
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Discussion |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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This is the first case report of an allergic reaction to pentastarch during emergent cesarean delivery. The case presents several aspects for further debate such as the use of colloids for prehydration before cesarean section, the use of neuraxial anesthesia in a patient with severe preeclampsia and decreasing platelet counts, and obstetric and anesthetic options after the development of anaphylaxis.
This patient had symptoms and signs of severe preeclampsia and seemed to be developing the HELLP syndrome (hemolysis, elevated liver tests, low platelet count) requiring obstetric intervention. Although recent studies have suggested that either spinal or epidural anesthesia may be safely used in severe preeclampsia (5,6), the platelet count may determine the final anesthetic preference. Despite a series of uncomplicated epidural catheter placements in patients with platelets counts between 69,000 and 98,000/mm3 (7), we preferred a less traumatic single-shot spinal technique (8). The value of thromboelastography in these cases remains the subject of debate (9,10).
Whereas the experience with crystalloids to prevent spinally induced hypotension has been somewhat discouraging (11,12), studies using colloids have shown better results (2–4). Hydroxyethylstarch seems to be a good choice because it decreases the allergic risk associated with gelatins (13). An allergic event may present the anesthesiologist with a serious dilemma. Proceeding with a regional technique in a hypotensive patient may be unwise. General anesthesia, however, may allow ventilatory control but may enhance bronchospasm because of airway manipulation. Additionally, endotracheal intubation is often difficult in parturients, but may be particularly problematic in patients with obesity, preeclampsia, and perifascial edema. Aspiration of gastric acid contents during intubation may pose additional problems.
In the present case, general anesthesia was avoided because the condition of the mother stabilized with the use of oxygen and medication. This allowed us to decide that the cesarean delivery could be postponed until the patient’s condition improved. It may be argued that epinephrine might have been a better choice for initial treatment. We chose to continue with ephedrine because the patient was responding. In addition, there is a lack of experience with regard to the response to epinephrine in severely preeclamptic patients.
Eighteen hours after the allergic reaction, the liver function tests of the patient had nearly returned to normal. It is likely that the administration of methylprednisolone was responsible for this significant improvement.
When it was finally performed on a more stable patient, the spinal anesthetic was uneventful and the patient remained stable intraoperatively.
In conclusion, the present case demonstrates that anaphylaxis can occur in a parturient receiving colloids and that postponing surgical delivery after a severe allergic reaction is an action that should be considered. If delivery is to be delayed, however, close monitoring of both mother and fetus is mandatory. Although the use a colloid in obstetric anesthesia remains the subject of debate, its use in our department has continued because of its superiority in preventing hypotension. Ultimately, this benefit has to be weighed against the potential for life-threatening consequences of an allergic reaction.
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References |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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- Rocke DA, Rout CC. Volume preloading, spinal hypotension and caesarean section. Br J Anaesth 1995; 75: 257–9.
[Free Full Text] - Riley ET, Cohen SE, Rubenstein AJ, Flanagan B. Prevention of hypotension after spinal anesthesia for cesarean section: six percent hetastarch versus lactated Ringer’s solution. Anesth Analg 1995; 81: 838–42.[Abstract]
- Vercauteren M, Hoffmann V, Coppejans H, et al. Hydroxyethylstarch compared with modified gelatin as volume preload before spinal anaesthesia for caesarean section. Br J Anaesth 1996; 76: 731–3.
[Abstract/Free Full Text] - Ueyama H, He YL, Tanigami H, et al. Effect of crystalloid and colloid preload on blood volume in the parturient undergoing spinal anesthesia for elective cesarean section. Anesthesiology 1999; 91: 1571–6.[Web of Science][Medline]
- Hood DD, Curry R. Spinal versus epidural anesthesia for cesarean section in severely preeclamptic patients: a retrospective survey. Anesthesiology 1999; 90: 1276–82.[Web of Science][Medline]
- Ramanathan J, Vaddadi AK, Arheart KL. Combined spinal and epidural anesthesia with low dose of intrathecal bupivacaine in women with severe preeclampsia: a preliminary report. Reg Anesth Pain Med 2001; 26: 46–51.[Web of Science][Medline]
- Beilin Y, Zahn J, Comerford M. Safe epidural analgesia in thirty parturients with platelet counts between 69,000 and 98,000 mm-3. Anesth Analg 1997; 85: 385–9.[Abstract]
- Tryba M. European practice guidelines: thromboembolism prophylaxis and regional anesthesia. Reg Anesth Pain Med 1998; 23: 178–82.[Web of Science][Medline]
- Wong CA, Liu S, Glassenberg R. Comparison of thromboelastography with common coagulation tests in preeclamptic and healthy parturients. Reg Anesth 1995; 20: 521–7.[Web of Science][Medline]
- Sharma SK, Philip J, Whitten CW, et al. Assessment of changes in coagulation in parturients with preeclampsia using thromboelastography. Anesthesiology 1999; 90: 385–90.[Web of Science][Medline]
- Jackson R, Reid TA, Thorburn J. Volume preloading is not essential to prevent spinal-induced hypotension at caesarean section. Br J Anaesth 1995; 75: 262–5.
[Abstract/Free Full Text] - Husaini SW, Russell IF. Volume preload: lack of effect in the prevention of spinal-induced hypotension at caesarean section. Int J Obstet Anesth 1998; 7: 76–81.[Web of Science][Medline]
- Laxenaire M, Charpentier C, Feldman L. Anaphylactoid reactions to colloid plasma substitutes: incidence, risk factors, mechanism—a French multicenter prospective study. Ann Fr Anesth Reanim 1994; 13: 301–10.[Web of Science][Medline]
This article has been cited by other articles:
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  W. D. Ngan Kee, K. S. Khaw, F. F. Ng, and B. B. Lee Prophylactic Phenylephrine Infusion for Preventing Hypotension During Spinal Anesthesia for Cesarean Delivery Anesth. Analg., March 1, 2004; 98(3): 815 - 821. [Abstract] [Full Text] [PDF]
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