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Airway changes during Cesarean hysterectomy

From the Department of Anaesthesia, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 0215, USA.

Address correspondence to: K. Bhavani-Shankar MD. Phone: 617-732-8216; Fax: 617-277-2192; E-mail: bhavani{at}capnography.com

	Abstract

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Purpose: To document whether hemorrhage and fluid administration during peripartum hysterectomy results in changes in the airway that may predispose to subsequent difficult intubation, in the event that intraoperative general anesthesia is required during regional anesthesia.

Clinical features: A 32-yr-old underwent peripartum hysterectomy for placenta accreta. Blood loss of 5.5 L occurred during surgery requiring 6 L crystalloid, 1 L hetastarch, five units packed RBCs and two units fresh frozen plasma. Airway changes were followed using Samsoon's modification of Mallampati airway classification. In addition, airway photographs were obtained using a Polaroid camera. The airway of the patient changed from class 2 preoperatively to class 4 in the immediate postoperative period. The airway gradually returned to normal over the ensuing 48 hr, during which a negative fluid balance of 4 L occurred due to substantial postoperative diuresis.

Conclusion: Peripartum airway changes were detected during Cesarean hysterectomy and fluid resuscitation that gradually returned to normal within 48 hr after surgery.

	Introduction

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PERIPARTUM hysterectomy may be associated with substantial blood loss requiring large quantities of crystalloid and colloid fluid infusions to maintain intravascular volume.^1–4 Peripartum hysterectomy has been performed successfully under general as well as regional anesthesia.¹ However, intraoperative general anesthesia may be required occasionally during the procedures performed under regional anesthesia when associated with prolonged surgery, patient discomfort, or hemodynamic instability.² We evaluated airway changes in a patient scheduled for elective Cesarean hysterectomy to document changes in the airway that could predispose to a subsequent difficult intubation.

	Case report

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A healthy 32-yr-old was scheduled for her fifth elective Cesarean delivery for anterior placenta encroaching towards the bladder. Airway examination revealed a class 2 Samsoon's and Young modification of Mallampti airway class with normal neck mobility and no protruding upper teeth. A photograph of the initial airway evaluation was obtained using an Instant Polaroid camera, Macro 5 SLR. With the patient seated comfortably, the camera was focused on to the uvula from a distance of 25 cm (Figure 1A). Two converging beams of light from the camera ensured that the uvula of the patient was at 25 cm from the camera. Line of focus was parallel to the ground. A lumbar epidural catheter was used to provide anesthesia (lidocaine 2% with epinephrine) and a radial arterial line was placed in anticipation of possible prolonged surgery and blood loss. An attempt to extract the placenta manually after an uneventful baby delivery of a healthy female resulted in uterine inversion and substantial blood loss, resulting in hypotension. Volume infusion and boluses of neosynephine and ephedrine were required to maintain the blood pressure > 90 mm Hg systolic. As the bleeding continued from the placental site, we decided to induce general anesthesia approximately 20 min after commencement of Cesarean section with 75 mg ketamine iv followed by 100 mg succinylcholine to facilitate rapid sequence intubation which was uneventful. General anesthesia was used expecting substantial blood loss as well as prolonged and difficult surgery. Rapid administration of crystalloid, hetastarch 6%, and packed red cells were transfused to maintain systolic blood pressure over 100 mmHg. There was no placental tissue seen on opening the bladder but there was substantial difficulty encountered in separating the anterior uterine wall from the bladder. Hysterectomy was performed and the bladder was repaired. The total blood loss for the procedure was approximately 5.5 L. The patient received 6 L crystalloid, 1 L hetastarch 6%, five units of packed RBCs, and two units fresh frozen plasma. The hematocrit at the end of the three hour procedure was 24%. The patient was hemodynamically stable and the trachea was uneventfully extubated at the end of the procedure. Bupivacaine 0.25%, 9 ml, was titrated to provide postoperative epidural analgesia, followed by 6 ml•hr^–1 infusion of bupivacaine 0.125% with 0.02 mg•ml^–1 hydromorphone. There was obvious facial edema at the conclusion of surgery. When she was alert and able to sit upright comfortably and opened her mouth as wide as she could (4 and 1 hours after commencement of Cesarean section), airway assessment was performed (class 4) and airway photographs obtained as described above (Figure 1B). She received two more units of fresh frozen plasma and 16 units of platelets to correct prolonged prothrombin and partial thromboplastin time, as well as low platelet count (50,000) in addition to 2 L of crystalloid in the immediate postoperative period. The airway was reassessed at 12 hr, 24 hr and at 48 hr following the commencement of surgery. The airway was class 4 at 12 hr, class 3 at 24 hr (Figure 1C), and returned to class 2 after 48 hr (Figure 1D). The patient had substantial postoperative diuresis and the input/output fluid balance sheet showed a negative balance of 1 L during 12-24 hr period and 4 L during 24-48 hr post surgery interval. The epidural catheter was removed 24 hr after surgery when patient's coagulation profile was normal.

View larger version (131K): [in this window] [in a new window]   FIGURE 1 Airway changes during Cesarean hysterectomy. A: Preoperative (airway class 2); B: Immediate postoperative (airway class 4, lips and tongue are swollen); C: 24 hr postoperative (airway class 3); D: 48 hr postoperative (airway class 2).

	Discussion

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A change in airway status has two important clinical implications in the management of parturient for peripartum hysterectomy. First, intraoperative induction of general anesthesia may be required in patients undergoing peripartum hysterectomy under regional anesthesia any time during the course of the procedure and, secondly, general anesthesia may be required to facilitate re-operation to explore and control excessive postoperative hemorrhage. Although it is not a contraindication to perform Cesarean hysterectomy under regional anesthesia, one should carefully take into consideration that the airway may worsen during the course of surgery. The relative risk of experiencing a difficult intubation in comparison to an uncomplicated class I airway increases by four times when the airway class changes from class 2 to class 4 airway.⁷ The risk may increase further if the patient has other risk factors such as obesity, protruding upper teeth, short thyromental distance, and increased weight gain in the pregnancy.⁸ In addition, the laryngeal edema that may accompany upper airway edema can also contribute to a difficult intubation. It may be prudent to induce general anesthesia and secure the airway as soon as substantial hemorrhage, requiring large volume infusion/transfusion, is anticipated. On the other hand, if the airway is not secured, periodic assessment of the airway during the course of surgery is recommended to determine worsening of the airway. If this approach is chosen, contingency plans to deal with a challenging airway should be readily available in case a difficult intubation is encountered during intraoperative induction of general anesthesia.

Accepted for publication January 9, 2000.

	References

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1 Chestnut DH, Dewan DM, Redick LF, Caton D, Spielman FJ. Anesthetic management for obstetric hysterectomy: a multi-institutional study. Anesthesiology 1989; 70: 607–10.[Medline]

2 LaPlatney DR, O'Leary JA. Anesthetic considerations in Cesarean section hysterectomy. Anesth Analg 1970; 49: 328–30.[Free Full Text]

3 Leaphart WL, Schapiro H, Broome J, Welander CE, Bernstein IM. Placenta previa percreta with bladder invasion. Obstet Gynecol 1997; 89: 834–5.[Abstract]

4 Price FV, Resnik E, Heller KA, Christopherson WA. Placenta previa percreta involving the urinary bladder: a report of two cases and review of the literature. Obstet Gynecol 1991; 78: 508–11.[Medline]

5 Wu PY, Udani V, Chan L, Miller FC, Henneman CE. Colloid osmotic pressure variations in normal pregnancy. J Perinat Med 1983; 11: 193–9.[Medline]

6 Hauch MA, Gaiser RR, Hartwell BL, Datta S. Maternal and fetal colloid osmotic pressure following fluid expansion during Cesarean section. Crit Care Med 1995; 23: 510–4.[Medline]

7 Rocke DA, Murray WB, Rout CC, Gouws E. Relative risk analysis of factors associated with difficult intubation in obstetric anesthesia. Anesthesiology 1992; 77: 67–73.[Medline]

8 Bhavani Shankar K, Krishna S, Moseley HSL. Airway changes in pregnancy. Anesthesiology 1997; 87: A895.

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