182
Correspondence Sonia Vaida, MD1 Department of Anesthesia Penn State Hershey Medical Center Hershey, PA,USA Corresponding author. Department of Anesthesia Penn State Hershey Medical Center PO Box 850, H187 Hershey, PA 17033 Tel.: +1 717 531 8433; fax: +1 717 531 6221 1
Conflicts of interest: None
http://dx.doi.org/10.1016/j.jclinane.2014.11.013
Fig. 1
Previous version of LMA Supreme.
References [1] Eschertzhuber S, Brimacombe J, Hohlrieder M, Keller C. The laryngeal mask airway Supreme–a single use laryngeal mask airway with an oesophageal vent. A randomised, cross-over study with the laryngeal mask airway ProSeal in paralysed, anaesthetised patients. Anaesthesia 2009;64:79-83. [2] Cook T, Lee G, Nolan GP. The ProSeal™ laryngeal mask airway: a review of the literature. Can J Anaesth 2005;52:739-60. [3] Brimacombe J, Kennaugh S, Berry A, Keller C. Malposition of the ProSeal laryngeal mask (Letter,reply). Anesth Analg 2001;93:1367. [4] http://www.lmana.com/files/lma8972_r01_011209supreme.pdf. [last accessed 10.20.2014].
Whose deceleration is it?☆,☆☆
Fig. 2
The new version of LMA Supreme.
Letter to the Editor,
were made using an Ohaus Pioneer analytical balance; Ohaus Corporation, Parsippany, NJ). We also found differences in the thickness of the distal cuff. Comparative measures are: (1) new version: superior part, 1.5 mm; inferior part, 1 mm; lateral left and right, 1.2 mm; and (2) previous version: superior part, 2.5 mm; inferior part, 1.5 mm; lateral left and right, 1.4 mm (measurements were made using a Mitutoyo 530-108 Vernier Micrometer Caliper [Mitutoyo Corporation, Kawasaki, Japan]). We wonder if the softer, thinner, redesigned tip could potentially lead to an increased incidence of the fold-over malposition. Is this change an advantage or a disadvantage? Obviously, clinical evidence is needed to detect a possible increased incidence of fold-over malposition. The purpose of this letter is to increase our colleagues' awareness of such a possible complication.
An otherwise healthy 31-year-old primigravida parturient had an uneventful intrapartum course with placement of an L4/5 epidural for labor analgesia. After an initial 10 mL 0.1% ropivicane + 2 μg/mL fentanyl bolus, patient-controlled epidural analgesia was commenced with a basal infusion of 8 mL/h and a 6-mL bolus available every 8 minutes. One hour after epidural placement, a nonreassuring fetal heart rate (FHR) with variable and late decelerations on the external FHR monitor prompted placement of an intrauterine fetal scalp monitor, which also allowed for continuous maternal heart rate (MHR) monitoring. Unexpectedly, MHR mimicked fetal nonreassuring patterns with profound, cyclical bradycardia (from 120-90 beats per minute) corresponding to each uterine contraction (Figure—fetal strip upper, yellow; maternal strip middle, white). We postulated that the bradycardia was due to relative hypovolemia induced by epidural analgesia, with contraction-induced increase in venous return triggering the
Luis Gaitini, MD (Former Director)1 Department of Anaesthesia, B'nai Zion Medical Center Haifa, Israel E-mail address: [email protected]
Supported only by department resources. Presented as a medically challenging case at the American Society of Anesthesiologists annual meeting, October 2014, New Orleans, LA.
☆
☆☆
Correspondence
183 Sugammadex and pregnancy, is it safe? To the Editor:
Figure Intrauterine FHR (yellow, upper line) and MHR (white, second line) corresponding to uterine contractions (lower strip). Maternal heart rate baseline 120, decreasing to below 90.
Bezhold-Jarisch reflex. Stimulation of these cardiac receptors by stretch resulted in increased parasympathetic activity and maternal bradycardia. Administration of 500 mL colloid resulted in resolution of both maternal bradycardia and fetal decelerations. Labor continued uneventfully with a normal abdominal delivery. Potential confusion of maternal and FHRs has been reported [1,2], and maternal decelerations may predict nonreassuring fetal status [3]. We present an image of significant contraction-related maternal bradycardia, which caused consternation to nursing and obstetric colleagues and suggest a possible physiologic explanation.
Kaitlin J. Herald, DO (Resident) Evan G. Pivalizza, MD (Distinguished Teaching Professor)⁎ Department of Anesthesiology University of Texas Health Science Center–Houston MSB 5.020, 6431 Fannin St, Houston, TX, 77030 ⁎Corresponding author. Tel.: +1 713 500 6251 fax: +1 713 500 6270 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jclinane.2014.11.014
References [1] Emereuwaonu I. Fetal heart rate misrepresented by maternal heart rate: a case of signal ambiguity. Am J Clin Med 2012;9–1:52-7. [2] Murray ML. Maternal or fetal heart rate? Avoiding intrapartum misidentification. J Obstet Gynecol Neonatal Nurs 2004;33:93-104.
We write to you to report a case that happened in our institution, and that made us raise questions about the possibility of using sugammadex in pregnant women and to have an answer from the scientific community. The case involves a 19-year-old and 27-week gestation pregnant admitted to emergency surgery for ovarian torsion. The induction was standard with fentanyl, propofol, and rocuronium; and surgery was performed laparoscopically without incident. The total dose of rocuronium was 50 mg (0.9 mg/kg). The surgery lasted 120 minutes, and at that time, train of four was 1/4. We made a search in PubMed with the terms “sugammadex” and “pregnancy” and found nothing published about safety of use for sugammadex in pregnant women. All articles found referred to the use of sugammadex for blockade reversal after cesarean sections. We contacted the pharmaceutical representative of sugammadex (Bridion; Merck Sharp & Dohme Inc., Madrid, Spain) who told us she had never heard of any similar case. She then contacted the national expert reference for sugammadex (whose name we do not know). The latter told her that no safety studies had been conducted in humans, and therefore, unless it was a case of vital necessity, he discouraged its use because of potential harm, not only for patient but particularly for the fetus. By the time we got this answer, the train of four was 4/4 (21%) and proceeded to the reversal of Neuromuscular Blockade (NMB) with neostigmine (2 mg) and atropine (0.5 mg). The patient was extubated without incident and later discharged from the postanesthesia care unit within 120 minutes with a strictly normal postoperative course. The patient is still in the last months of pregnancy without having had any complications. This case has made us raise a doubt about the safety of sugammadex use in pregnancy, and we therefore write to you. We have no casuistry in our hospital about the use of sugammadex in pregnant women and could not find any reported case, but it is more than likely that it may have been used in situations, where the benefit from its use may exceed the potential risk (eg, “cannot ventilate, cannot intubate” situations in pregnant patients in whom rocuronium may have been used, residual NMB situations, etc). We understand that it may never have been used routinely without proper safety studies, but it is likely that, in these extreme cases of life-threatening emergency situations, it may have. We hope that this letter may stimulate readers to report cases if there are any. Nevertheless, we expect to encourage the scientific community to perform safety studies regarding the use of sugammadex in pregnant women [1-3].
Correspondence Sonia Vaida, MD1 Department of Anesthesia Penn State Hershey Medical Center Hershey, PA,USA Corresponding author. Department of Anesthesia Penn State Hershey Medical Center PO Box 850, H187 Hershey, PA 17033 Tel.: +1 717 531 8433; fax: +1 717 531 6221 1
Conflicts of interest: None
http://dx.doi.org/10.1016/j.jclinane.2014.11.013
Fig. 1
Previous version of LMA Supreme.
References [1] Eschertzhuber S, Brimacombe J, Hohlrieder M, Keller C. The laryngeal mask airway Supreme–a single use laryngeal mask airway with an oesophageal vent. A randomised, cross-over study with the laryngeal mask airway ProSeal in paralysed, anaesthetised patients. Anaesthesia 2009;64:79-83. [2] Cook T, Lee G, Nolan GP. The ProSeal™ laryngeal mask airway: a review of the literature. Can J Anaesth 2005;52:739-60. [3] Brimacombe J, Kennaugh S, Berry A, Keller C. Malposition of the ProSeal laryngeal mask (Letter,reply). Anesth Analg 2001;93:1367. [4] http://www.lmana.com/files/lma8972_r01_011209supreme.pdf. [last accessed 10.20.2014].
Whose deceleration is it?☆,☆☆
Fig. 2
The new version of LMA Supreme.
Letter to the Editor,
were made using an Ohaus Pioneer analytical balance; Ohaus Corporation, Parsippany, NJ). We also found differences in the thickness of the distal cuff. Comparative measures are: (1) new version: superior part, 1.5 mm; inferior part, 1 mm; lateral left and right, 1.2 mm; and (2) previous version: superior part, 2.5 mm; inferior part, 1.5 mm; lateral left and right, 1.4 mm (measurements were made using a Mitutoyo 530-108 Vernier Micrometer Caliper [Mitutoyo Corporation, Kawasaki, Japan]). We wonder if the softer, thinner, redesigned tip could potentially lead to an increased incidence of the fold-over malposition. Is this change an advantage or a disadvantage? Obviously, clinical evidence is needed to detect a possible increased incidence of fold-over malposition. The purpose of this letter is to increase our colleagues' awareness of such a possible complication.
An otherwise healthy 31-year-old primigravida parturient had an uneventful intrapartum course with placement of an L4/5 epidural for labor analgesia. After an initial 10 mL 0.1% ropivicane + 2 μg/mL fentanyl bolus, patient-controlled epidural analgesia was commenced with a basal infusion of 8 mL/h and a 6-mL bolus available every 8 minutes. One hour after epidural placement, a nonreassuring fetal heart rate (FHR) with variable and late decelerations on the external FHR monitor prompted placement of an intrauterine fetal scalp monitor, which also allowed for continuous maternal heart rate (MHR) monitoring. Unexpectedly, MHR mimicked fetal nonreassuring patterns with profound, cyclical bradycardia (from 120-90 beats per minute) corresponding to each uterine contraction (Figure—fetal strip upper, yellow; maternal strip middle, white). We postulated that the bradycardia was due to relative hypovolemia induced by epidural analgesia, with contraction-induced increase in venous return triggering the
Luis Gaitini, MD (Former Director)1 Department of Anaesthesia, B'nai Zion Medical Center Haifa, Israel E-mail address: [email protected]
Supported only by department resources. Presented as a medically challenging case at the American Society of Anesthesiologists annual meeting, October 2014, New Orleans, LA.
☆
☆☆
Correspondence
183 Sugammadex and pregnancy, is it safe? To the Editor:
Figure Intrauterine FHR (yellow, upper line) and MHR (white, second line) corresponding to uterine contractions (lower strip). Maternal heart rate baseline 120, decreasing to below 90.
Bezhold-Jarisch reflex. Stimulation of these cardiac receptors by stretch resulted in increased parasympathetic activity and maternal bradycardia. Administration of 500 mL colloid resulted in resolution of both maternal bradycardia and fetal decelerations. Labor continued uneventfully with a normal abdominal delivery. Potential confusion of maternal and FHRs has been reported [1,2], and maternal decelerations may predict nonreassuring fetal status [3]. We present an image of significant contraction-related maternal bradycardia, which caused consternation to nursing and obstetric colleagues and suggest a possible physiologic explanation.
Kaitlin J. Herald, DO (Resident) Evan G. Pivalizza, MD (Distinguished Teaching Professor)⁎ Department of Anesthesiology University of Texas Health Science Center–Houston MSB 5.020, 6431 Fannin St, Houston, TX, 77030 ⁎Corresponding author. Tel.: +1 713 500 6251 fax: +1 713 500 6270 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jclinane.2014.11.014
References [1] Emereuwaonu I. Fetal heart rate misrepresented by maternal heart rate: a case of signal ambiguity. Am J Clin Med 2012;9–1:52-7. [2] Murray ML. Maternal or fetal heart rate? Avoiding intrapartum misidentification. J Obstet Gynecol Neonatal Nurs 2004;33:93-104.
We write to you to report a case that happened in our institution, and that made us raise questions about the possibility of using sugammadex in pregnant women and to have an answer from the scientific community. The case involves a 19-year-old and 27-week gestation pregnant admitted to emergency surgery for ovarian torsion. The induction was standard with fentanyl, propofol, and rocuronium; and surgery was performed laparoscopically without incident. The total dose of rocuronium was 50 mg (0.9 mg/kg). The surgery lasted 120 minutes, and at that time, train of four was 1/4. We made a search in PubMed with the terms “sugammadex” and “pregnancy” and found nothing published about safety of use for sugammadex in pregnant women. All articles found referred to the use of sugammadex for blockade reversal after cesarean sections. We contacted the pharmaceutical representative of sugammadex (Bridion; Merck Sharp & Dohme Inc., Madrid, Spain) who told us she had never heard of any similar case. She then contacted the national expert reference for sugammadex (whose name we do not know). The latter told her that no safety studies had been conducted in humans, and therefore, unless it was a case of vital necessity, he discouraged its use because of potential harm, not only for patient but particularly for the fetus. By the time we got this answer, the train of four was 4/4 (21%) and proceeded to the reversal of Neuromuscular Blockade (NMB) with neostigmine (2 mg) and atropine (0.5 mg). The patient was extubated without incident and later discharged from the postanesthesia care unit within 120 minutes with a strictly normal postoperative course. The patient is still in the last months of pregnancy without having had any complications. This case has made us raise a doubt about the safety of sugammadex use in pregnancy, and we therefore write to you. We have no casuistry in our hospital about the use of sugammadex in pregnant women and could not find any reported case, but it is more than likely that it may have been used in situations, where the benefit from its use may exceed the potential risk (eg, “cannot ventilate, cannot intubate” situations in pregnant patients in whom rocuronium may have been used, residual NMB situations, etc). We understand that it may never have been used routinely without proper safety studies, but it is likely that, in these extreme cases of life-threatening emergency situations, it may have. We hope that this letter may stimulate readers to report cases if there are any. Nevertheless, we expect to encourage the scientific community to perform safety studies regarding the use of sugammadex in pregnant women [1-3].
