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Lesson 278: PreAnesthetic Assessment of
the Parturient With Obstructive Hydrocephalus |
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Course Author:
Shibrah Jamil, MD, Anesthesia attending physician,
Department of Anesthesiology, New York Hospital Queens, New York,
New York
Reviewed By:
Isaac Lowenwirt, MD, Director of
obstetrical anesthesia, Department of Anesthesia, New York
Hospital Queens; clinical assistant professor of anesthesiology,
Weill Medical College of Cornell University, New York, New York
Review Date: October, 2008
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Registration Fee: $15.00
2.0 AMA PRA Category 1 CreditsTM
available until February 28, 2010
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REGISTRATION INFORMATION:
Participants who do not possess a copy of Anesthesiology News
can download and print the course material in an easy to read
convenient format. Participants must reflect on the information
presented, and then register to complete the exam and course evaluation
online before the availability date listed above. (CME credit is not valid past this
date).
Click on the link below to download and print the course material
and post-test exam.
Register for the exam to enter your responses to receive CME credit. There are ten questions in the examination and you must achieve
a score of 80% or better to earn CME credit. Following successful
completion, your certificate will be immediately available online.
In addition, a historical record of completed CME courses is
maintained online in an individualized profile. This includes
copies of course certificates which can be printed at any time.
The registration fee for this course is $15.00
Physicians are provided with two opportunities to successfully complete the
exam presented here.
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NEEDS STATEMENT
Controversy has arisen as to which anesthetic technique is
preferred in the parturient with neurologic dysfunction, either
active or latent. Questions have been raised as to whether good pain
control during labor should be denied a patient with a history of
hydrocephalus, established perhaps during childhood. Committee has
identified the need to present and discuss topics for which a review
of the literature and evaluation of evidence-based consensus are
indicated.
CASE HISTORY
A 24-year-old woman, gravida 2 para 0010, with a history of
Arnold-Chiari type 1 malformation and syringomyelia, presented for
urgent primary cesarean delivery. Her case had been referred to the
obstetric anesthesia high-risk clinic by the maternal–fetal medicine
division at 7 months’ gestation to plan her anesthetic management.
As a 13-year-old, the patient had undergone a suboccipital
craniotomy, laminectomy of the first cervical vertebra, duraplasty,
and placement of a syringo-subarachnoid shunt—also termed a Chiari
decompression. Three months later, the patient’s symptoms returned;
she reported severe suboccipital headaches, gait disturbances, and
sensory and motor deficits of the upper extremities. She immediately
underwent emergency revision of the syringo-subarachnoid shunt and
experienced dramatic improvement.
Since that time, the patient had been active with only occasional
headaches. The rest of her medical history was negative with the
exception of mild thoracolumbar scoliosis. She denied respiratory
difficulties or exercise limitations. At the time of the anesthesia
interview, she reported mild headaches unchanged by pregnancy.
Physical examination findings, including the neurologic examination
findings, were normal. The patient’s airway was class 2 with mild
restriction in neck extension, the thyromental distance was 5 cm,
and the interdental distance was adequate. Recent magnetic resonance
imaging of the brain and cervical spine revealed a small syrinx of
the cervical cord, with ample cerebrospinal fluid dorsal to the
cerebellar tonsils, and no hydrocephalus.
LEARNING OBJECTIVES
At the end of this activity, the participant should be able to:
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Summarize the anesthetic
considerations in the management of a patient with obstructive
hydrocephalus.
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Differentiate between obstructive
and nonobstructive hydrocephalus.
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Define intracranial hypertension.
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Review the physiology of
cerebrospinal fluid.
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Describe typical changes in
neurophysiology that occur during pregnancy.
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List the causes of obstructive
hydrocephalus.
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Present to the parturient the
treatment options available for various types of obstructive
hydrocephalus with different causes.
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Explain how changes that normally
occur during pregnancy affect the parturient with obstructive
hydrocephalus.
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Outline the effects on the fetus of
alterations in maternal neurophysiology.
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Identify the role of regional
anesthesia in pregnant patients with hydrocephalus.
TARGET AUDIENCE: Anesthesiologists
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Accreditation Statement
Mount Sinai School of Medicine is accredited by the Accreditation
Council for Continuing Medical Education (ACCME) to provide continuing
medical education for physicians.
Credit Designation: The Mount Sinai School of Medicine designates
each educational activity for a maximum of 2 AMA PRA Category 1 CreditsTM.
Physicians should only claim credit commensurate with the extent of
their participation in the activity.
It is the policy of Mount Sinai School of Medicine to ensure objectivity,
balance, independence, and scientific rigor in all CME-sponsored educational
activities. All faculty participating in the planning or implementation
of a sponsored activity are expected to disclose to the audience any
relevant financial relationships and to assist in resolving any conflict
of interest that may arise from the relationship. Presenters must
also make a meaningful disclosure to the audience of their discussions
of unlabeled or unapproved drugs or devices.
Disclosures
The author, reviewer, and editor have no relationships with
pharmaceutical companies or manufacturers of products to disclose.
This educational activity may contain discussion of published
and/or investigational uses of agents for the treatment of
disease. Some uses of these agents have not been approved by the
FDA. Please refer to the official prescribing information for each
product for approved indications, contraindications, and warnings.
CONTACT INFORMATION
Questions regarding course content may be directed to Dr. Elizabeth
Frost: ElzFrost@aol.com.
If you require technical assistance with completing this
course, please contact Continuing Education Online Customer Service
at 718-648-8080 or send e-mail to
ceo.contact7@proceo.com.
CALL FOR WRITERS
If you would like to write a CME lesson in Anesthesiology News,
please send an e-mail to Elizabeth A.M. Frost, MD, at
ElzFrost@aol.com
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