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EVIDENCE BASED DATA
Year : 2009  |  Volume : 53  |  Issue : 3  |  Page : 367-368 Table of Contents     

Tetanus: Anaesthetic Management


Senior Prof. & Head, Department of Anaesthesiology, R.N.T.Medical College, Udaipur (Raj.), India

Date of Web Publication3-Mar-2010

Correspondence Address:
Pramila Bajaj
25, Polo Ground, Udaipur (Raj.)
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Bajaj P. Tetanus: Anaesthetic Management. Indian J Anaesth 2009;53:367-8

How to cite this URL:
Bajaj P. Tetanus: Anaesthetic Management. Indian J Anaesth [serial online] 2009 [cited 2020 Apr 4];53:367-8. Available from: http://www.ijaweb.org/text.asp?2009/53/3/367/60307

Tetanus is a rare condition in the western world, primarily due to widespread vaccination programs, from infancy to adulthood.

Clostridium tetani spores usually enter the tissue through a penetrating contaminated wound, and after a period of anaeroi incubation, they become bacilli that release tetanus toxin. The toxin enters peripheral neu­rons and travels retrograde up axons to the central ner­vous system. It can enter motor, sensory, and auto­nomic neurons, although radiolabelled assays have shown a predilection for inhibitory neurons. Most of the clinical disease results from motor and autonomic inhibition. Tetanospasmin is a metalloprotease substance which acts at the presynaptic membrane to cleave synaptobrevin, a protein that allows fusion of neu­rotransmitter vesicles to nerve membranes. When this fusion process is prevented , neurotransmitters are not released into the synapse and neurotransmission is blocked. Centrally, transmission along the inhibitory gamma-amino butyric acid (GABA) and glycinergic neurons is interrupted, and at the level of the spinal cord, inhibitory interneurons are blocked [1] .

Initial management of muscle spasms involves se­dation and a dark, quiet room. Numerous approaches are reported in the literature to relieving spasms, in­cluding benzodiazepines, barbiturates, anticonvulsants, narcotics, baclofen, dantrolene [2] , and propofol [3] . Pre­treatment with sedatives and analgesics may be neces­sary prior to nursing care and procedures to avoid trig­gering paroxysms. Benzodiazepines are often used as first-line treatment. Baclofen has been shown in a few case series to completely relieve spasms when given via the intrathecal route but carries a significant risk of respiratory depression [4] .

The anaesthesiologists may be consulted for man­agement of emergent acute respiratory failure from laryngospasm or subacute respiratory failure. The dia­phragm and the laryngeal and pharyngeal muscles are all affected, and in combination with the profuse bron­chial and oral secretions seen in tetanus, management of an unsecured airway is difficult. Accompanied by increased abdominal pressures and gastrointestinal sta­sis, even the awake patient is at increased risk of aspi­ration, which is a common complication [4] . It should be noted that the literature does not report trismus to be a problem during tracheal intubation after neuromuscular relaxation. The response to depolarizing and non-de­polarizing neuromuscular blockade is normal in teta­nus [5] , although use of depolarizing agents, such as succinlycholine, should be carefully considered. Re­peated administration of intramuscular succinylcholine with complication has been documented for the treat­ment of tetanic contractures [6] . However, there are at least two reports of hyperkalemic cardiac arrest after succinylcholine administration late in the course of teta­nus [7] . Pancuronium carries the theoretical risk of in­creased adrenergic activity but has been shown not to increase complications when compared to other agents [4] . Hypoxemia is a common problem, even in the intubated patient, because of a restrictive defect from chest wall rigidity leading to atelectasis and increased bronchial secretions obstructing the airways [4] . Hypox­emia from ventilation-perfusion mismatch may occur without chest radiograph abnormalities [4] . Prolonged ventilation puts the patient at increased risk of pneu­monia, which often complicates the course of severe tetanus, as does sepsis and acute respiratory distress syndrome [4],[8].

Surgical procedures in tetanus patients are occa­sionally necessary, such as debridement of the injury and tracheostomy. Little evidence exists to recommend specific anaesthetic protocols. Similar to the recom­mendation to pretreat patients prior to nursing care [5] .

Patients should be deeply anaesthetized and possibly paralyzed to prevent triggering hypertensive crises and spasms during the procedure. Most intravenous anaes­thetic agents and sedatives have been used in tetanus patients. Epidural mepivicaine and high continuous spi­nal bupivacaine [4] have been used successfully to treat autonomic instability without complications related to the neuraxial technique, but norepinephrine infusions were required to maintain mean arterial pressure. Spi­nal anaesthesia has been used for lower extremity de­bridement in a patient with mild tetanus who was not tracheally intubated [9] . There is no literature examining the safety of volatile anaesthetics.

Electrolyte derangements from tetanus-induced renal dysfunction should be corrected preoperatively [4] . Appropriate invasive monitoring should be secured, and titrable drug infusions for intra-operative management of autonomic storms should be prepared before pro­ceeding with a surgical procedure. Ideally, patients be­ing considered for debridement and tracheostomy should undergo anaesthesia and surgery before severe autonomic dysfunction develops.



 
   References Top

1.Mellanh J, Green J. How does tetanus toxin act? Neuro­science 81; 6: 281-300.  Back to cited text no. 1      
2.Bleck TP. Pharmacology of tetanus. Clinical Neuropharmacol 1986; 9: 103-20.  Back to cited text no. 2      
3.Cook TM, Protheroe RT, Handel JM. Tetanus: a review of the literature. Br J Anaesth 2001; 87: 477-87.  Back to cited text no. 3      
4.Cumberland P, Shulman CE, Maple PA, et al. Maternal HIV infection and placental malaria reduce transplacen­tal antibody transfer and tetanus antibody levels in new­borns in Kenya. J Infect Dis 2007; 196: 550-7.  Back to cited text no. 4      
5.Azar I. The response of patients with neuromuscular disorders to muscle relaxants: a review. Anesthesiology 1984: 61: 173-87.  Back to cited text no. 5      
6.Curran FJ, Smith WE, Lauro S. Report of a severe case of tetanus managed with large doses of intramuscular succinylcholine. Anesth Analg 1968; 47: 218-21.  Back to cited text no. 6      
7.Roth F, Wuthrich H. The clinical importance of hyperkalaemia following suxamethonium administration. Br J Anaesth 1969; 41: 311-6.  Back to cited text no. 7      
8.Trujillo MH, Castillo A, Espana J, Manzo A, Zerpa R. Impact of intensive care management on the prognosis of tetanus. Analysis of 641 cases. Chest 1987: 92: 63-5.  Back to cited text no. 8      
9.Tobias JD. Anaesthetic implications of tetanus. South Med J 1998;91:384-7.  Back to cited text no. 9      




 

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