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LETTER TO EDITOR
Year : 2012  |  Volume : 6  |  Issue : 1  |  Page : 83-84

Anesthetic problems in patient with paralyzed and pulse less extremity: A case of aortoarteritis


Department of Neuroanesthesiology, Neurosciences Center, 7th Floor, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Tumul Chowdhury
Department of Neuroanesthesiology, Neurosciences Center, 7th Floor, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.93073

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Date of Web Publication21-Feb-2012
 


How to cite this article:
Chowdhury T, Dube SK, Bharati SJ, Goyal K. Anesthetic problems in patient with paralyzed and pulse less extremity: A case of aortoarteritis. Saudi J Anaesth 2012;6:83-4

How to cite this URL:
Chowdhury T, Dube SK, Bharati SJ, Goyal K. Anesthetic problems in patient with paralyzed and pulse less extremity: A case of aortoarteritis. Saudi J Anaesth [serial online] 2012 [cited 2019 Dec 13];6:83-4. Available from: http://www.saudija.org/text.asp?2012/6/1/83/93073

Sir,

Aortoarteritis is a chronic inflammatory condition that can produce a wide array of manifestations. The common manifestation is pulseless extremity. Here we highlighted the anesthetic concerns in the patient with one paralyzed limb and other with pulseless.

A 23-year-old male patient presented with weakness of right upper and lower limb since 15 days and difficulty in speaking since 1 day. Magnetic resonance imaging showed large, chronic hemorrhagic infarction in the left temporoparietal region and Doppler study demonstrated left side thrombosis of common carotid, internal carotid, subclavian, and vertebral artery. The patient was diagnosed as a case of aortoarteritis. On examination, the patient has no palpable pulse in left side of the limb and 2/5 power in right limb. The patient was scheduled for encephaloduroarteriomyosynangiosis. The patient was premedicated with glycopyrrolate 0.2 mg 1 h before shifting to the operation theater. The pulseless extremity was chosen for intravenous cannula. He was shifted to operating room and routine monitors were attached, including pulse oximeter, electrocardiogram, and noninvasive blood pressure (NIBP). NIBP is applied on paralyzed arm and was set an interval of 3 min initially for 15 min and 10 min afterward. The patient was given 200 mg hydrocortisone preinduction. The patient was induced with injection fentanyl 100 μg and propofol 100 mg and rocuronium 50 mg intravenously. Trachea was intubated with 8.5 mm portex cuffed endotracheal tube. Invasive blood pressure monitoring with right radial artery cannulation and central venous catheterization of right subclavian vein (7 FR, double lumen) were also done. Baseline heart rate was 80 beats/min, mean arterial pressure was 85 mmHg. The patient was maintained on isoflurane with O2 and N2 O (40:60) with endtidal concentration of 1%-1.5%. The mean arterial pressure was maintained around 85-90 mmHg with the help of dopamine infusion. PCO2 was kept around 35-37 mmHg. At the end of surgery, neuromuscular blockade was reversed with neostigmine and glycopyrrolate. The patient was fully conscious and following verbal commands. Trachea was extubated and the patient was shifted to postanesthesia care unit. The patient was discharged on the 4 th postoperative day with no neurologic deficit.

Cannulation in paralyzed limb should be avoided so as to minimize thromboembolic episodes, while intravenous access can be established in pulseless extremity. On the other hand, arterial cannulation should not be put in the pulseless limb to avoid the risks of inflammation and thereby, thrombosis. The noninvasive blood pressure cuff must not attach on the pulseless limb that can decrease the capillary perfusion. However, over the paralyzed limb, cuff pressure should be set for an adequate interval in which capillary perfusion may return to normal. Although automatic NIBP can be used to record blood pressure in patients with weak or absent pulses in the extremities, in our opinion it is best to avoid. [1] A plan for the management of anesthesia must take into account the drugs used for treatment of this disease, such as chronic corticosteroid therapy may result in suppression of adrenocortical function, indicating the need for supplemental exogenous corticosteroids before induction. [2] The other most important concern in this disease is to maintain the mean arterial pressure on the higher normal side during the intraoperative period. Therefore, anesthetic-induced decreased blood pressure caused by decreased cardiac output or systemic vascular resistance must be recognized promptly and treated by either adjusting the concentration of anesthetic drugs or expanding the intravascular fluid volume, or both. The administration of a sympathomimetic to maintain perfusion pressure may be helpful until the underlying cause of the decrease in blood pressure can be corrected. Hyperventilation should be avoided to favor maintenance of cerebral blood flow, especially in patients in whom the disease process involves the carotid arteries. [3] Careful examination of patient in the preanesthetic check up, selection of proper site for arterial and venous cannulation, NIBP attachment maintenance of cerebral perfusion pressure, and avoidance of hyperventilation are key anesthetic goals in such patients.

 
  References Top

1.Kathirvel S, Chavan S, Arya VK, Rehman I, Babu V, Malhotra N, et al. Anesthetic management of patients with Takayasu's arteritis: A case series and review. Anesth Analg 2001;93:60-5.  Back to cited text no. 1
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2.Ishikawa k, Yonekawa Y. Regression of carotid stenosis after corticosteroid therapy in occlusive thromboaortopathy (Takayasu's disease). Stroke 1987;18:677-9.  Back to cited text no. 2
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3.Warner MA, Hughes DR, Messick JM. Anesthetic management of a patient with pulse less disease. Anesth Analg 1983;62:532-5.  Back to cited text no. 3
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