Anesthetic management for cesarean delivery in a Guillain-Barré syndrome patient -A case report-
A 32-year-old, 162 cm, 68 kg, gravida 1, para 1, pregnant woman received cesarean delivery due to failure of labor progression at 33 weeks and 6 days of pregnancy. The patient was diagnosed with gestational diabetes mellitus at 27 weeks of pregnancy with insulin therapy. She had a history of gastroenteritis at 17 weeks from gestation. Dysarthria and diplopia occurred after recovery from the gastroenteritis (18 weeks from gestation) and she was admitted to the emergency room (ER) and was diagnosed with Guillain-Barré syndrome. In the ER, the patient suffered from ongoing respiratory insufficiency (decreased oxygen saturation and CO2 retention) along with mental decline. She was intubated shortly after admission, transferred to the intensive care unit (ICU) and received mechanical ventilator care (Pressure controlled ventilation with synchronized intermittent mandatory ventilation mode, pressure support 8 cmH2O, tidal volume 600 ml, frequency 12 per minute, FiO2 0.4). TPN started at 19 weeks from gestation for expecting prolonged fasting period. At 20 weeks from gestation, she eventually received tracheostomy (T-cannula I.D. 7.0) for prolonged ventilator care due to progressive respiratory muscle weakness. At 27 weeks from gestation, mechanical ventilaton was converted to home ventilation Bi-level positive airway pressure (BPAP, BiPAP®). The setting was inspiratory positive air way pressure (IPAP) 8 cmH2O, expiratory positive airway pressure (EPAP) 4 cmH2O . And gradually started intermittent BPAP during night (29 weeks from gestation). At 33 weeks from gestation patient presented dyspnea and desaturation then continous BPAP ventilation was applied again until delivery.\nShe underwent intravenous immunoglobulin (IVIG) therapy twice to prevent disease progression and enoxaparin therapy for the prevention of thrombosis. However, enoxaparin therapy was stopped due to the elevation of liver enzymes at 28 weeks from gestation. The patient suffered from various neurologic symptoms including binocular diplopia, dysarthria, facial diplegia and muscle weakness in upper and lower extremities (both upper and lower extremities: 3 to 4 of 5, Medical research council scale for muscle strength). The nerve conduction study showed electrophysiologic abnormalities suggesting motor-dominant polyneuropathy in bilateral upper and lower extremities. In the cerebrospinal fluid study, albumin level was 13.1 (10-30) mg/dl, and IgG 2.17 (0-8) mg/dl. Magnesium infusion started at 34 weeks from gestation for prevention of eclamptic seizure.\nAt 34 weeks from gestation the attending obstetrician judged that it was no longer possible to maintain the pregnancy due to further mental decline, elevation of liver enzymes, and respiratory difficulty. At first, induction of delivery was tried, but emergency cesarean section was decided to be performed with retardation of fetal heart rate. Preoperative evaluation was within normal limits, except elevation of liver enzymes (AST/ALT 372/458) and sinus tachycardia (120 beats per minute) on electrocardiogram.\nWithout premedication the patient was transferred from ICU to the operating room with manual ventilation via tracheostomy. Standard monitoring including electrocardiogram, pulse oxymeter and noninvasive blood pressure measurement was started. Upon arrival at the operating room, the blood pressure was 124/90 mmHg, heart rate was 118 beat per minute with pulse oxygen 98%. A bispectral index (BIS) was placed on the patient's forehead to monitor depth of anesthesia and the leads for the nerve stimulator were placed at the ulnar side of the patient's left forearm to monitor muscle relaxation. Under gentle manual assisted ventilation with 100% oxygen, approximately 500 ml of gastric juice was aspirated from the nasogastric tube. After the sterile surgical drape was confirmed, 250 mg of thiopental was injected via the intravenous line and ventilated manually with sevoflurane 1.5 vol% and oxygen. Muscle relaxation was checked with a nerve stimulator on 40mV stimulus. When the train of four (TOF) count of 4/4 was confirmed, 10 mg of rocuronium was administered and mechanical ventilation via tracheostomy was started, after the TOF count was 0/4 and BIS score was 55. Arterial catheter was placed at the patient's right radial artery with a 20 Gage angiocatheter to monitor arterial blood pressure. Anesthesia was maintained with oxygen, medical air and sevoflurane 1.5 vol% on mechanical ventilation (tidal volume: 500 ml, frequency: 12/min, FiO2: 0.5). The BIS score and TOF count were serially monitored ().\nThe baby (3,390 g, Apgar score; 5-7) was delivered at 8 minutes from the start of the surgery, and the placenta was extracted 2 minutes later. Oxytocin 30 IU (mixed with normal saline 100 ml) was administered intravenously slowly. Arterial blood gas analysis and blood sugar test (glucose 137 mg/dl) were performed 20 minutes after the induction of anesthesia. Arterial blood gas analysis data and other electrolyte levels were in the normal range (pO2 146.3 mmHg, pCO2 40.7 mmHg, pH 7.425 at FiO2 0.5, EtCO2 35 mmHg). Intraoperative hemodynamic changes are shown in . No additional muscle relaxant was administered during surgery. Post-surgery TOF count was 4/4 and atropine 1 mg, and neostigmine 1.5 mg was administered to reverse the muscle relaxation. Fifteen minute after administration of reverse agents, patient's spontaneous ventilation was recovered and she was sent to the ICU with assisted manual ventilation. The motor score evaluated upon ICU arrival was 3 to 4 in all extremity, similar to that of preoperative values. Total operation time was 55 minutes and anesthesia time was 75 minutes. Total infused crystalloid, colloid, estimated blood loss, and urine output were 200 ml, 500 ml, 500 ml and 100 ml, respectively.\nWeaning of mechanical ventilation was tried on postoperative day (POD) 7 and successfully done on POD 25. Abrupt chest pain and respiratory difficulty with desaturation occurred on POD 32. CT angiography showed severe pulmonary thrombosis in both pulmonary arteries and deep vein thrombosis in the left lower extremity. She was diagnosed with pulmonary thromboembolism and treated with warfarin targeted at INR 2-2.5. Two months later, she was discharged and has been on outpatient department follow-up to the department of internal medicine, neurology, and rehabilitation medicine.