SPINA BIFIDA : #Anesthesia IMPLICATIONS

💥Incidence of Spina bifida occulta is 10%–25% of the population. 

💥Associated with cord abnormalities (spinal dysraphism)

💥70% of those with cord abnormalities have dimpling or a hairy naevus at the base of the spine. 

💥30% of patients with spinal dysraphism have neurological signs. 

💥If such a patient comes for surgery, an MRI scan should be done to rule out a tethered cord. 

💥Once this is excluded, it may be appropriate to proceed with regional analgesia at a site above the lesion. 

💥The patient should be explained about the higher incidence of dural puncture because of abnormal ligamental structure. 

💥Another point is, there may be incomplete spread of anaesthetic to sites below the lesion and consequently a suboptimal block may occur. 

💥The epidural space volume is usually reduced and so, the epidural should be established with small aliquots of local anaesthetic to prevent a high block. 

💥Spina bifida is also associated with a difficult intubation.

💥Spina bifida is a risk factor for latex allergy

Ref: Ali L, Stocks GM. Spina bifida, tethered cord and regional anaesthesia. Anaesthesia. 2005; 60(11): 1149–1150. Griffiths S, Durbridge JA. Anaesthetic implications of neurological disease in pregnancy. Contin Educ Anaesth Crit Care Pain. 2011; 11(5): 157–161. D’Astous J,Drouin MA, Rhine E 1992 Intraoperative anaphylaxis secondary to allergy to latex in children who have spina bifida. Report of two cases. Journal of Bone & Joint Surgery 74: 1084–6.

CLINICAL GUIDELINES FOR #Opioid ROUTE CONVERSION AND ROTATION

Reference: Opioid Equianalgesic Tables: Are They All Equally Dangerous? Philip E. Shaheen, Declan Walsh, Wael Lasheen, Mellar P. Davis and Ruth L. Lagman (Journal of Pain and Symptom Management, Vol. 38 No. 3 September 2009)

👄Rotation of an opioid, secondary to uncontrolled pain requires equianalgesic doses.

👄If you are rotating an opioid secondary to toxicity, it  requires a dose 30% 50% lower than the equivalent dose of the second opioid. This is because of incomplete analgesic cross-tolerance.

👄Thirty percent of patients who are on opioids need an alternative route, as in severe nausea or mucositis. 

👄Once toxicity occurs, before doing rotation, consider treating side effects, lowering the dose of the current opioid(if pain is controlled), and use of adjuvant analgesics. 

👄Whenever we start or titrate opioid dose, always  consider the pharmacokinetic alterations due to age, comorbid conditions, gender, other simultaneously administered medications, and organ failure etc

👄Opioids that are partial agonists have less analgesia per dose increment at higher doses than full agonists or opioids with high intrinsic efficacy (e.g., methadone); therefore, equianalgesic ratios will change with dose. 

👄Rotating to a new opioid before reaching steady-state of the first opioid is pharmacologically meaningless.

👄Rotation in the setting of organ dysfunction is dangerous even if we use  the recommended doses from equianalgesic tables. 

👄Note that, opioids may worsen intestinal colic. Dexamethasone, glycopyrrolate, or octreotide are better options for such pains. 

👄Opioid-induced toxicity takes some time to resolve. If symptoms related to toxicity are persisting after rotation, it can be because of slow clearance of the first opioid and not the new opioid. 

👄Be cautious while rotating between short and long-acting opioids and do it in a careful way, so as to avoid withdrawal or overdosing.

#pharmacology , #anesthesia , #PainAndPalliativeCare , #OpioidRotation , #CriticalCare , #pharmacy , #PainPhysician , #anaesthesia

GESTATIONAL DIABETES : INFO WE GET FROM THE #ACOG 2013 GUIDELINES

✔️Increased blood sugars 4-6 h prior to delivery leads to increased rates of hypoglycemia in the neonate. A maternal blood glucose value of more than 180 mg/dl has been conclusively proven to be associated with high risk of neonatal hypoglycemia.

✔️The American College of Obstetrics and Gynecology and the American College of Endocrinology recommends maintenance of blood glucose between 70 and 110 mg/dl during labor (3.9-6.1 mmol/L) this goal is the same irrespective of whether the women has type 1 diabetes, type 2 diabetes or GDM. 

✔️The hepatic glucose supply is sufficient during the latent phase of labor, but during the active phase of labor the hepatic glucose supply is depleted so calorie supplementation is required. 

✔️During labor in a case with GDM controlled only on life-style modification it is not compulsory to monitor blood sugars periodically and monitoring once in every 4-6 h is sufficient during labor 

✔️In patients on insulin it is mandatory to monitor the blood sugar every 2-4 h during the latent phase, every 1-2 h during the active phase 

✔️In patients for whom cesarean is planned, it always preferred to do the procedure early morning. 

✔️Patient needs to take her usual night dose of intermediate-acting insulin and the morning dose of insulin has to be withheld and patient needs to be kept nil by mouth. 

✔️If surgery is delayed it is needed to start basal and corrective regimen (DNS with short acting insulin) with one-third of the morning intermediate insulin dose with a 5% dextrose infusion to avoid ketosis. Blood glucose has to be monitored second hourly and if required subcutaneous dose of corrective dose of short acting insulin to be given. 

✔️After delivery, the requirement of insulin shows a sharp decline and in GDM it is advisable to continue the monitoring to see if the sugars have become normal in the postpartum period 

✔️In cases with type 1 and type 2 DM it is prudent to decrease the dose of insulin by 20-40% of the pregnancy dose as the requirement of insulin during lactation is less. During the breast-feeding, sometimes the requirement of insulin can fall drastically and these women may develop hypoglycemia, so the dose of insulin needs to be adjusted accordingly

Reference: ACOG Practice Bulletin, 137, 2013

Indian Journal of Endocrinology and Metabolism: Peripartum management of diabetes, Pramila Kalra and Manjunath Anakal

#anesthesia , #diabetes , #gdm , #insulin , #acog ,#labor ,