Case 13: Laparoscopic Appendectomy for the pregnant patient

Question 1

Pregnant woman at 22 weeks pregnancy presents of laparoscopic appendectomy. Mother is very concerned about fetal neurotoxicity. What would you say?

Answer 1

While there is some animal based evidence that exposure of the developing brain can lead to long term neurocognitive deficits affecting memory, there is inadequate research on humans to change current clinical practice. I would reassure her by letting her now that the available human evidence suggests that a single exposure to anesthesia is very unlikely to increase risk of neurodevelopment.

Question 2

What are your concerns regarding non-obstetric surgery for a pregnant patient?

Answer 2

In addition to the risks associated w/ underlying disease process and planned surgery, the obstetric patient is exposed to increased risk of morbidity and mortality when undergoing surgery or anesthesia due to physiologic changes associated with pregnancy. The mother is expose to increased risk of 1. failed intubation 2. pulmonary aspiration 3. hemorrhage 4. infection 5. Thromboembolism Baby is exposed to risk such as 1. pre term labor/delivery 2. teratogenesis 3. IUGR 4. miscarriage 5. neurotoxicity

Question 3

When is the best time to perform semi-elective surgery for a pregnant patient?

Answer 3

The optimal time is the 2nd trimester due to the increased risk of miscarriage and teratogenesis in the first trimester and the increased risk of preterm labor/delivery in the 3rd trimester.

Question 4

Which anesthetics are teratogenic?

Answer 4

Benzodiazepines - cleft lip/palate N2O

Question 5

Would you administer steroids in obstetric patient presenting for non-elective surgery?

Answer 5

I would administer dexamethasone to prevent post operative nausea and vomiting. However, i recognize it could complicate blood sugar management. It would also aid in fetal lung maturity if baby has reached age of viability (24 weeks).

Question 6

What is diabetic stiff joint syndrome?

Answer 6

• Due to glycosylation of proteins, may develop in patients with long standing type 1 diabetes.
• Syndrome can result in
  
  • limited movement of alanto occiptal join, teporomandibular, and cervical spine joints - increasing risk of difficult direct laryngoscopy and intubation
• use “prayer sign” to screen for syndrome

Question 7

How would you manage insulin dependant diabetic patient with blood sugar of 356 in preoperative holding area?

Answer 7

1. Notify surgeon of potential risks associated with perioperative hyperglycemia; ie. poor wound healing, abdominal pain, nausea vomiting.
2. Administer IV insulin bolus + normal saline
3. check serum and urinary ketones
4. obtain arterial blood gas, blood urea nitrogen, creatinine, electrolytes
5. determine anion gap (DKA)

If patient in DKA

1. continue fluids
2. start insulin infusion w/ goal for reducing 50-100 per hour
3. replace potassium, phosphate, and magnesium
4. continue to closely monitor serum potassium, blood glucose, ketones, anion gap