GA PADA PASIEN PRECLAMPSIA

PR R4
• General anesthesia is less desirable than neuraxial
anesthesia because of the possibility of difficult tracheal
intubation secondary to airway edema and the transient
but severe hypertension that accompanies tracheal
intubation and extubation
• Clinical indications include severe ongoing maternal
hemorrhage, sustained fetal bradycardia with a reassuring
maternal airway examination, and severe
thrombocytopenia or other coagulopathy, or a combination
of these indications
• The platelet count can fall dramatically with rapidly
progressing severe preeclampsia or HELLP syndrome and
may mandate administration of general anesthesia.
Chestnut’s Obstetric Anesthesia, 2014
• Specific challenges for general anesthesia:
1. The potential difficulty of securing the airway
2. The hypertensive response to direct laryngoscopy
and tracheal intubation
3. The effects of magnesium sulfate on neuromuscular
transmission and uterine tone

Chestnut’s Obstetric Anesthesia, 2014

Chestnut’s Obstetric Anesthesia, 2014
Chestnut’s Obstetric Anesthesia, 2014
 Airway Consideration

• Before proceeding with general anesthesia  careful

airway examination
• Airway edema may be present even with a relatively
reassuring airway examination
• Endotracheal tubes in various sizes and difficult airway
equipment should be immediately available
• One of the dangers of repeated tracheal intubation
attempts is the risk for traumatic bleeding in the airway,
which may make ventilation difficult or even impossible

Chestnut’s Obstetric Anesthesia, 2014

 Airway Consideration

• It is wise to avoid repeated attempts and proceed with

insertion of a supraglottic airway device (e.g., laryngeal
mask airway) before the airway is irretrievably lost
• The supraglottic airway devices do not protect the
patient from pulmonary aspiration of gastric contents 
the obstetrician should be encouraged to complete the
procedure as quickly as possible.
• If indicated, an awake fiberoptic tracheal intubation
should be used to secure the airway  effective topical
anesthesia of the airway with nebulized or atomized
lidocaine can enhance patients’ comfort and decrease
the hypertensive response to airway manipulation
Chestnut’s Obstetric Anesthesia, 2014
 Hypertensive Response to Laryngoscopy

• The hemodynamic instability associated with rapid-

sequence induction and tracheal intubation presents a
serious problem
• The transient but severe hypertension that may
accompany tracheal intubation can result in cerebral
hemorrhage or pulmonary edema, both potentially fatal
complications
• Medications that have been used to blunt the
hemodynamic response to laryngoscopy include
labetalol, esmolol, nitroglycerin, sodium nitroprusside,
and remifentanil.
Chestnut’s Obstetric Anesthesia, 2014
 Hypertensive Response to Laryngoscopy

• The goal of treatment is to reduce the arterial blood pressure

to approximately 140/90 mm Hg before the induction of
general anesthesia and to maintain the systolic blood pressure
between 140 to 160 mm Hg and the diastolic blood pressure
between 90 to 100 mm Hg throughout laryngoscopy and
tracheal intubation
• Labetalol is drug of choice for attenuating the hypertensive
response to laryngoscopy in women with severe preeclampsia
 mean arterial blood pressure increased after tracheal
intubation but hypertensive response was significantly less
pronounced
• Labetalol can be administered using either a bolus technique
or a continuous intravenous infusion, or both
Chestnut’s Obstetric Anesthesia, 2014
 Hypertensive Response to Laryngoscopy

• Esmolol can be safely used to dampen the hemodynamic

response to laryngoscopy and tracheal intubation  2 mg/kg
intravenous
• Nitroglycerin has many desirable properties for blunting the
hypertensive response to tracheal intubation
 It is a direct vasodilator with a rapid onset, is rapidly
metabolized, and has no apparent maternal or fetal toxicity
 intravenous nitroglycerin (200 μg/mL)  decrease mean
arterial blood pressure by approximately 20%, before the
induction of general anesthesia.
• Sodium nitroprusside infusions can be initiated at 0.5
μg/kg/min and titrated to blood pressure response

Chestnut’s Obstetric Anesthesia, 2014

 Hypertensive Response to Laryngoscopy

• The short-acting opioid remifentanil is rapidly metabolized by

both mother and neonate by nonspecific blood and tissue
esterases and has been administered to preeclamptic women
• The advantage of remifentanil  the rapid onset and short
duration of the drug
• The disadvantage of remifentanil  remifentanil crosses the
placenta
• Dose  0.5 μg/kg

Chestnut’s Obstetric Anesthesia, 2014

Chestnut’s Obstetric Anesthesia, 2014
 Effects of Magnesium Sulfate

• The primary anesthetic considerations for women receiving

magnesium sulfate are (1) interaction with nondepolarizing
muscle relaxants, (2) effects on uterine tone, and (3)
interaction with calcium entry–blocking agents
• Magnesium inhibits the release of acetylcholine at the
neuromuscular junction, decreases the sensitivity of the
neuromuscular junction to acetylcholine, and depresses the
excitability of the muscle fiber membrane
• Magnesium sulfate increases the potency and duration of
vecuronium, rocuronium, and mivacurium  administered in
very small doses and the response should be monitored
carefully with a peripheral nerve stimulator

Chestnut’s Obstetric Anesthesia, 2014

 Effects of Magnesium Sulfate

• Succinylcholine (1 to 1.5 mg/kg for RSI)  onset and duration

of a single intubating dose is not prolonged when
administered concurrently with a magnesium sulfate infusion
• Magnesium depresses smooth muscle contractions and
inhibits CNS catecholamine release  the risk for uterine
atony and excessive blood loss might be increased in women
receiving magnesium sulfate  ready for blood and
uterotonic agents
• Some reports have suggested that coadministration of a
calcium entry–blocking agent and magnesium may cause
hypotension and/or neuromuscular blockade, more recent
information suggests that these medications can be used
safely together.
Chestnut’s Obstetric Anesthesia, 2014
TERIMA KASIH