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Regional vs GeneralFrom: BUCKY_C@TSJC.Colorado.EDUFri Mar 29 17:24:53 1996
>I have never seen the term "pre-toxemic." Also, I don't see how epidural >can alter the seizure thresshold in a patient. It is my understanding that >the big concern with regional anesthesia is the risk of rapid BP drop with >subsequent uteroplacental insufficiency and this is more likely with spinal >than epidural. The type of anesthesia and seizure prevention are two >independent variables (unless the patient is in status epilepticus). Then I was unclear in my posting. 1. Pregnancy itself generally lowers the seizure threshold (at least to lidocaine) for patients exposed to seizure producing situations. 2. Eclampsia fosters a seizurable pathophysiology. 3. Epidural anesthesia (for C-section) requires a goodly dose of local anesthetic to achieve sufficient level to allow comfortable surgery. 4. That goodly dose of local pushes the maximum safe dose in folks with normal threshold for seizure. 5. Truly, the biggest fear in giving spinal anesthesia for C-section is a rapid chemical sympathectomy with resulting hypotension. In my experience this is quite easily (and better) treated with vasopressors without apparent ill effect to the fetus, which is the only outcome measure of significance (even if a relative surrogate), than with massive volume preloading. (I've noticed something interesting about volume preloading we can talk about separately, and which I've been playing with for 5 years). The big advantage of spinal over epidural anesthesia for eclamptic patients undergoing C-section is the relatively tiny dose of local anesthetic drug needed to produce generally very good surgical and patient comfort conditions. Lastly, I disagree that type of anesthesia and seizure prevention in eclamptic parturients are independent of each other (see above). Since performing the human research to definitely show this would be wholly unethical, the animal cohort studies would have to suffice at this time. The anecdotal case reports parallel closely the animal results described. Pre-toxemia was a term introduced to me by an OB-GYN physician in 1970. I'll grant you that no one uses it anymore. Bucky PS - we miss your input over on Fidonet.
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